Tool Updated for Predicting Prostate Cancer Severity

Nick Mulcahy

January 09, 2013

An update of the staging nomogram known as the "Partin tables," which predicts the severity of prostate cancer and helps clinicians and patients make treatment decisions, has been published in the January 3 issue of the British Journal of Urology International.

The tool uses commonly available preoperative data — serum prostate-specific antigen (PSA) level, clinical stage, and biopsy Gleason score — to accurately predict pathologic stage, which can only be fully assessed once the prostate is surgically removed.

Pathologic stage reveals whether or not the cancer has spread outside of the gland and, thus, contributes to risk categorization, the authors explain.

The update reflects changes that have occurred in recent years in the field of prostate cancer. "As PSA screening became widespread, a continuously increasing proportion of men diagnosed with prostate cancer have presented with localized disease amenable to surgical therapy, making older nomograms progressively obsolete," write the authors, led by John B. Eifler, MD, from the James Buchanan Brady Urological Institute at Johns Hopkins Medical Institutions in Baltimore, Maryland. Dr. Eifler worked on the paper with the creator of the tables, Alan W. Partin, MD, PhD, and other Johns Hopkins staff.

The nomogram can also be used to help low- and intermediate-risk patients to decide about active surveillance, say the authors.

Some categories of disease that were previously not thought to have a good prognosis might now potentially be cured with surgery, according to the authors.

"We now have a better understanding of intermediate risk and see that more men fall into that category, instead of the higher-risk group," said Dr. Eifler in a press statement.

Specifically, the most important differences between the current nomogram and the 2007 version are that the risk for advanced-stage disease is higher for Gleason 9 and 10 tumors than for Gleason 8 tumors; Gleason 4+3 and 8 tumors exhibit similar risks for each category of clinical stage and PSA; and a PSA level above 10 ng/mL strongly predicts pT3 and N1 disease.

The update is based on a study of more than 5600 men treated at Johns Hopkins from 2006 to 2011. Earlier versions of the nomogram were also based on patients at the institution; this single-center data pool is a limitation of the tool.

Likelihood of Cure With Surgery

"The first thing most men want to know when they learn they have prostate cancer is their prognosis — whether it can be cured," said Dr. Partin in the press statement. The Partin tables show "the probability that the cancer is confined to the prostate and, therefore, likely to be cured with surgery," he explained.

However, as the authors of the update admit, the Partin nomograms are now most commonly used to decide whether to perform a lymphadenectomy at the time of radical prostatectomy — not for deciding about primary surgery itself.

They say that lymphadenectomy is not necessary in men with Gleason 6 disease unless they have a PSA level above 10 ng/mL and clinical stage T2b disease or greater. Men with Gleason 3+4 and clinical stage T1c disease can avoid lymphadenectomy unless PSA levels are above 10 ng/mL

"When patients have Gleason 3+4 and palpable disease, lymphadenectomy should be performed in most cases, and in our opinion, all men with Gleason 4+3 or greater disease should undergo lymphadenectomy regardless of clinical stage or serum PSA," they write.

By inputting the PSA, Gleason score, and clinical stage into the updated Partin tables and clicking the Find Results button, an individual can see the percentage chance that the cancer is confined to the prostate, has migrated to the edge of the gland, has invaded the seminal vesicles, or has spread to the lymph nodes.

BJU Int. 2013;111:22–29. Abstract