Postoperative Nomogram for Disease Recurrence After Radical Prostatectomy for Prostate Cancer Michael W. Kattan, Thomas M. Wheeler, and Peter T. Scardino Purpose: Although models exist that place patients into discrete groups at various risks for disease recur- rence after surgery for prostate cancer, we know of no published work that combines pathologic factors to predict an individual’s probability of disease recur- rence. Because clinical stage and biopsy Gleason grade only approximate pathologic stage and Gleason grade in the prostatectomy specimen, prediction of prognosis should be more accurate when postoperative infor- mation is added to preoperative variables. Therefore, we developed a postoperative nomogram that allows more accurate prediction of probability for disease recurrence for patients w ho have received radical pros- tatectomy as treatment for prostate cancer, compared with the preoperative nomogram we previously pub- lished. Patients and Methods: By Cox proportional hazards regression analysis, w e modeled the clinical and patho- logic data and disease follow-up for 996 men with clinical stage T1a-T3c NXM0 prostate cancer w ho w ere treated with radical prostatectomy by a single surgeon at our institution. Prognosticvariablesincluded pretreat- ment serum prostate-specific antigen level, specimen Gleason sum, prostaticcapsular invasion, surgical mar- gin status, seminal vesicle invasion, and lymph node status. Treatment failure w as recorded w hen there w as either clinical evidence of disease recurrence, a rising serum prostate-specific antigen level (two measure- ments of 0.4 ng/ mL or greater and rising), or initiation of adjuvant therapy. Validation w as performed on this set of men and a separate sample of 322 men from five other surgeons’ practicesfrom our institution. Results: Cancer recurrence was noted in 189 of the 996 men, and the recurrence-free group had a median follow -up period of 37 months(range, 1 to 168 months). The 7-year recurrence-free probability for the cohort was 73% (95% confidence interval, 68% to 76%). The predictions from the nomogram appeared to be accu- rate and discriminating, w ith a validation sample area under the receiver operating characteristic curve (ie, a comparison of the predicted probability w ith the actual outcome) of 0.89. Conclusion: A postoperative nomogram has been developed that can be used to predict the 7-year prob- ability of disease recurrence among men treated with radical prostatectomy. J Clin Oncol 17:1499-1507.  1999 by American Society of Clinical Oncology. T HE MOST COMMON definitive therapy for the treat- ment of clinically localized prostate cancer is radical prostatectomy. Unfortunately, approximately one third of men treated with radical prostatectomy later experience progression of their disease. Typically, the first indication that the disease has progressed is a detectable level of serum prostate-specific antigen (PSA) measured months or years after surgery. Early identification, before detectable PSA is measured, of men likely to ultimately experience disease progression would be useful in considering early adjuvant therapy. Accurate identification of the risk of disease recur- rence would also be particularly useful in clinical trials to assure comparability of treatment and control groups or to identify appropriate candidates for investigational treatment, such as gene therapy. The purpose of this study was to develop a nomogram, based on the follow-up of men treated at our institution, that would predict the probability that a man will experience progression of prostate cancer after radical prostatectomy. The nomogram uses data that are routinely collected and available immediately postopera- tively, so that it can be applied before the PSA level begins to rise in most men. To develop this nomogram, we used methods similar to those that we used previously to con- struct a preoperative nomogram based on clinical stage, Gleason grade, and serum PSA levels. 1 Because clinical stage and Gleason grade in a biopsy sample only approxi- mate pathologic stage and Gleason grade in the radical prostatectomy specimen, we anticipated that a nomogram that incorporated these pathologic variables would provide more accurate prediction than our previous nomogram, which utilized only those clinical variables known before definitive treatment. From the Departments of Epidemiology and Biostatistics and Sur- gery, Memorial Sloan-Kettering Cancer Center, New York, NY; Depart- ment of Pathology, Baylor College of Medicine; and The Methodist Hospital, Houston, TX. Submitted July 2, 1998; accepted January 19, 1999. Supported in part by a Specialized Program of Research Excellence (SPORE) grant in prostate cancer (CA58204) from the National Cancer Institute. A PalmPilot version of this nonogram is available free of charge at http://nomograms.org. Address reprint requests to Peter T. Scardino, MD, c/o Brenna Nichols, Urology Service, Department of Surgery, Memorial Sloan- Kettering Cancer Center, 1275 York Avenue, New York, NY 10021; email nicholsb@mskcc.org.  1999 by American Society of Clinical Oncology. 0732-183X/99/1705-1499 Journal of Clinical Oncology, Vol 17, No 5 (May), 1999: pp 1499-1507 1499 Downloaded from jco.ascopubs.org on June 1, 2014. For personal use only. No other uses without permission. Copyright © 1999 American Society of Clinical Oncology. All rights reserved.