ROUNDY PROSTATE CANCER RISK NOMOGRAM USER GUIDE

  This Nomogram is a software tool to stratify a patient’s risk of prostate cancer progression from Very Low Risk to Very High Risk. The user is not required to understand the significance of the various medical terms such as Gleason Grade Group or Clinical Stage. Using the medical diagnosis details, the Nomogram calculates the patient’s risk of prostate cancer progression by computing the patient’s risk stratification using the well known CAPRA 1 and NCCN 2 Risk analysis software tools.

  That information helps the patient and his doctors to make informed treatment decisions with the goal to cure or at least control the cancer, with the minimum of unwanted side effects such as incontinence, impotence, urinary stricture, and bowel bother.

  The Nomogram is only designed for men with localized prostate cancer, Stage T1 through T4. The Nomogram is not for men with advanced disease Stage N1 positive lymph nodes, and/or Stage M1 distant metastasis. Those men are at very high risk and should find a team of prostate cancer specialists to aggressively deal with their cancer. The team should include a Urologic Surgical Oncologist, a Radiation Oncologist, and a Medical Oncologist.

  For men believed to have localized disease, prostate cancer treatment should be proportional to the cancer diagnosis risk stratification. Those diagnosed with Very low risk stratification probably do not need treated, at least not until Active Surveillance indicates the cancer shows signs of becoming more aggressive. That avoids or delays treatment side effects that reduce quality of life.

Side effects can include:
  1. urinary incontinence – inability to control urine leakage
  2. sexual impotence – inability to achieve or maintain an erection for sex
  3. urinary stricture – difficulty to drain the bladder
  4. bowel bother – frequent bowel movements, blood in stool, pain
  5. infection - rare, but can be life threatening
  6. anesthesia risk – some treatments require anesthesia
  Some men will be diagnosed with a very aggressive variant of prostate cancer that grows quickly, has the potential to spread around the body, and is life threatening. Those aggressive cancers may have better prognosis with multiple, aggressive therapies, applied early. Those Very High Risk men accept the treatment side effects in hopes of cure or at least long term prostate cancer control.
  Patients with Intermediate Risk have a more difficult treatment decision because IntermediatIntermediate Risk has more options and personal preferences to consider and discuss with their doctors. Additional genomic testing may assist with the decision making about cancer risk and treatment aggressiveness.
  With accurate risk stratification, the patient and his doctors can make informed treatment decisions to control the cancer with the fewest side effects.

Diagnosis Data Requirements Entered into The Nomogram
  1. AGE at the time of diagnosis
  2. PSA at the time of diagnosis
  3. CLINICAL STAGE Clinical Stage refers to where cancer is in and around the prostate, as determined by the Digital Rectal Exam (DRE) that is typically performed by the urologist who determines the diagnosis. Ask the doctor or phone the doctor’s office to obtain the Clinical Stage. Note: biopsy and imaging staging is not included in Clinical Stage. It is DRE data only.
    T1cT2aT2bT2cT3aT3bT4
    Cannont be felt with the finger1/2 of one side onlyTumor invades more than 1/2 of one side only Tumor felt on both sidesFelt outside the prostate capsuleInvades the seminal vesiclesInvades local tissues - bladder, rectum, etc.
  4. PROSTATE SIZE Measured in cubic centimeters (cc) or milliliters (ml), or grams (gm). This is important for choosing some therapy options such as radiation, and useful for determining the PSA Density calculation that predicts risk of cancer already outside the prostate. PSA density = PSA/Size. If density is >0.15 it raises the question from where the extra PSA is coming. Prostate size can be found in the Trans Rectal UltraSound (TRUS) report written by the urologist, or from imaging tests such as the Multi Parametric MRI.
  5. BIOPSY CORE DATA The biopsy core data may be the most important risk stratification information from the original diagnosis. It can also be the most difficult to understand. This Nomogram does not require the user to understand the medical terms in the biopsy report, such as what is the significance of a Gleason score. It only requires the user to get a copy of the written report from the doctor or pathologist and to enter the data for each biopsy core. Then the Nomogram displays the data in simple spreadsheet format, and the raw data from all the cores is evaluated into CAPRA and NCCN risk stratification. Because there is no agreed universal format for writing the biopsy report, it can be difficult for the lay person to identify the data for each core.
    • At the doctor’s office appointment, ask the doctor to help enter the core data.
    • Prostate Cancer Support groups often have members who are very well informed about prostate cancer and they can assist in entering the biopsy core data. One can usually find a local support group ** at the Us Too web site **
    • Contact the UCSF Prostate Cancer Support Group facilitator, Nathan Roundy, at email prostateguy@gmail.com for assistance.

NCCN Risk Stratification

Very High Risk Factors

Stage T3b - T4
More than 4 cores with Grade Group 4 or 5
Primary Gleason has pattern 5
Has 2-3 high risk factors

High Risk Factors

Stage T3a
Grade Group 4 or 5
PSA is greater than 20 ng/ml

Unfavorable Intermediate Risk Factors

50% or more of biopsy cores positive
Has 2 or 3 Intermediate Risk Factors
Grade Group 3

Favorable Intermediate Risk Factors

Less than 50% of biopsy cores positive
Has 1 Intermediate Risk Factor
Grade Group 1 or 2

Intermediate Risk Factors

Stage T2b-T2c
Grade Group 2 or 3
PSA 10-20 ng/ml

Low Risk FactorsData

Stage T1-T2a
Grade Group 1
PSA is less than 10 ng/ml

Very Low Risk Factors

Stage T1c
Grade Group 1
PSA less than 10-20 ng/ml
PSA density less than 0.15 ng/ml/g
Fewer than 3 cores positive, each with less than 50% involved
Using the Nomogram
  1. Enter the Age, PSA, Clinical Stage (from the DRE) and prostate size in ml, cc, or gm.
  2. Enter the biopsy core details.
  3. Index is the counter of the number of biopsy cores
  4. Core ID is the location in the prostate from which the core was extracted. This data is not used in the CAPRA and NCCN calculations, but is interesting for better understanding where the cancer is in the prostate. The prostate is labeled Base at the top, Mid Gland in the middle, and Apex at the bottom. The position is further broken down to Left, Center, and Right.
  5. Length is the measurement of the core in millimeters.
  6. Percent Involved is calculated by the pathologist and is an important indicator of risk that the cancer may already be outside the prostate.
  7. Primary is the primary Gleason Score from 3 to 5.
  8. Secondary is the secondary Gleason Score from 3 to 5.
  9. Sum is the Gleason sum calculated from the Primary and Secondary.
  10. Gleason Grade Group is calculated by the Nomogram