Cleveland Clinic, Cleveland, OH
Michael Austin Brooks , Sigrid V. Carlsson , Alexander Zajichek , Kevin M. Chagin , Jonas Hugosson , Michael W. Kattan , Andrew J. Stephenson
Background: Recommendations for PSA screening encourage shared decision making between patients and providers, rather than population-based screening. Nomograms provide individualized risk predictions potentially enhancing informed decisions to undergo screening. Our objective was to develop PSA screening nomograms using demographic and follow-up data from two large randomized screening trials: the Göteborg Screening Trial (Lancet Oncol. 2010;11:725-32) and Prostate, Lung, Colon, and Ovarian (PLCO) Cancer Screening Trial (N Engl J Med. 2009;360:1310-9). The endpoints of the models were PCDx, PCM, and ACM at 15 years. Methods: Patients with screening prior to trial entry were excluded, leaving 59,951 total subjects: 19,899 and 40,052 from Göteborg and PLCO, respectively. Demographic information including age, family history of PCDx, ethnicity, Charlson Comorbidity Index, marital status, education, and control vs. screening arm were used as predictive variables. If screened, baseline PSA was used as an additional continuous variable. Models for ACM were first developed, then models predicting PCDx and PCM using competing risk analysis. Predictive accuracy was assessed using the concordance index (c-index) and calibration plots. Results: On multivariable analysis, all variables were significant (P < 0.05) for predicting at least one outcome. Nomograms predicting PCDx, PCM, and ACM demonstrated reasonable discrimination: c-index 0.60, 0.65, 0.70, respectively. When a single baseline PSA was included, discriminative accuracy improved for PCDx and PCM, but remained the same for ACM: c-index 0.78, 0.74, 0.69, respectively. Estimates were well-calibrated for all endpoints. Conclusions: Using demographic information, we developed PSA screening nomograms, with good discrimination and calibration in predicting all three outcomes. A single baseline PSA improved nomogram discrimination substantially for PCDx and PCM. We will study the implementation of these nomograms into clinic practice to aid decisions for previously unscreened patients, or whether to continue PSA screening for patients with a known prior PSA.
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