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Journal of Clinical Oncology, Vol 26, No 4 (February 1), 2008: pp. 691-693 © 2008 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.14.6282
In ReplyCancer Prognostics and Health Outcomes Unit, University of Montreal, Montreal, Quebec, Canada
Department of Urology, University of Texas, Southwestern Medical School, Dallas, TX We wish to thank Drs Froehner and Mohan for their interest in our manuscript entitled, "A Nomogram Predicting 10-Year Life Expectancy in Candidates for Radical Prostatectomy or Radiotherapy for Prostate Cancer," and for their pertinent questions and observations. In reply to Froehner's question, we performed an external validation of our nomogram in 2,123 assessable patients, who were exposed to radical prostatectomy (RP; n = 1,023) or external-beam radiotherapy (EBRT; n = 1,100) in combination with neoadjuvant hormonal therapy (HT). Their characteristics are presented in Table 1. The survival curves of these two cohorts, relative to the original RP and EBRT validation cohorts, are plotted in Figure 1. As was suspected by Froehner, the survival of patients exposed to neoadjuvant HT and EBRT is better than that of patients exposed to EBRT alone (median, 7.2 v 4.7 years; log-rank P < .001). Conversely, RP patients treated with neoadjuvant HT demonstrate worse survival (P < .001). Despite these survival differences, the accuracy of the nomogram was 82.3% in patients treated with neoadjuvant HT versus 84.3% in the original validation.1 In consequence, we believe that it is safe to generalize the statement that the nomogram "accurately identifies those individuals who do not have sufficient life expectancy to warrant definitive prostate cancer treatment." Mohan raises two pertinent issues: (1) We do need more nomograms that predict health-adjusted life-expectancy (HALE) that do not rely on stage and grade criteria, and (2) despite the existence of some 40 prostate cancer nomograms, treatment decisions are still fraught with difficulty, and the development of a nomogram of nomograms has been suggested.2 Indeed life expectancy (LE) predictions are difficult and HALE predictions are even more difficult. We have recently demonstrated that clinicians are poor in rating LE. The accuracy of clinician-derived LE predictions (10-year LE) was 69%, which sharply contrasts with our nomogram's 84% accuracy.3 Although our nomogram quantifies HALE, its methodology (requires the Charlson comorbidity index) and its accuracy (84%) are not perfect. It is probably safe to assume that more detailed assessment of comorbidity, its extent, and its recorded duration might yield more informative, more accurate, and more meaningful predictions. Despite its limitations, our nomogram represents a springboard towards better HALE prognostication. Besides, it might help physicians, urologists, and nonurologists with the complexity of treatment decision-making. For urologists and radiation oncologists, Mohan mentions the existence of some 40 different nomograms that are based on cancer characteristics to better predict optimal treatment. In their editorial, Drs Ross and Kantoff addressed the relatively florid proliferation of new nomograms and suggested the development of a nomogram of nomograms to predict the all–prostate cancer outcomes.2 Although at first glance, the rapidly proliferating field of PCa nomograms may suggest overlap and redundancy, the existing nomograms (www.nomogram.org and www.nomograms.org) do not exhibit these unfavorable characteristics. The number of existing nomograms is defined by the natural history of treated PCa, which is characterized by many transitions. At virtually every transition, from diagnosis until death from hormone refractory prostate cancer, a transition-specific nomogram is available to assist with risk estimation. The number of some transition-specific nomograms has been multiplied by 2, as population-specific versions have been devised for European and North American patients, especially when population differences preclude valid application of the nomograms across the Atlantic.4
AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest.
ACKNOWLEDGMENTS Pierre I. Karakiewicz is partially supported by the University of Montreal Health Center Urology Associates, Fonds de la Recherche en Santé du Québec, the University of Montreal Department of Surgery and the University of Montreal Health Center (CHUM) Foundation. REFERENCES
1. Walz J, Gallina A, Saad F, et al: A nomogram predicting 10-year life expectancy in candidates for radical prostatectomy or radiotherapy for prostate cancer. J Clin Oncol 25:3576-3581, 2007 2. Ross RW, Kantoff PW: Predicting outcomes in prostate cancer: How many more nomograms do we need? J Clin Oncol 25:3563-3564, 2007 3. Walz J, Gallina A, Perrotte P, et al: Clinicians are poor raters of life expectancy prior to radical prostatectomy or definitive radiotherapy for localized prostate cancer. BJU Int, [in press] 4. Steuber T, Graefen M, Haese A, et al: Validation of a nomogram for prediction of side specific extracapsular extension at radical prostatectomy. J Urol 175:939-944, 2006[CrossRef][Medline] Related Correspondence
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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