Comparison of nomograms with other methods for predicting outcomes in prostate cancer: A critical analysis of the literature

Purpose: Accurate estimates of risk are essential for physicians if they are to recommend a specific management to patients with prostate cancer, Accurate risk estimates are also required for clinical trial design, to ensure homogeneous patient groups. Because there is more than one model available for prediction of most outcomes, model comparisons are necessary for selection of the best model. We describe the criteria based on which to judge predictive tools, describe the limitations of current predictive tools, and compare the different predictive methodologies that have been used in the prostate cancer literature. Experimental Design: Using MEDLINE, a literature search was done on prostate cancer decision aids from January 1966 to July 2007. Results: The decision aids consist of nomograms, risk groupings, artificial neural networks, probability tables, and classification and regression tree analyses. The following considerations need to be applied when the qualities of predictive models are assessed: predictive accuracy (internal or ideally external validation), calibration (i.e., performance according to risk level or in specific patient subgroups), generalizability (reproducibility and transportability), and level of complexity relative to established models, to assess whether the new model offers advantages relative to available alternatives. Studies comparing decision aids have shown that nomograms outperform the other methodologies. Conclusions: Nomograms provide superior individualized disease-related risk estimations that facilitate management-related decisions. Of currently available prediction tools, the nomograms have the highest accuracy and the best discriminating characteristics for predicting outcomes in prostate cancer patients.