The University of California, San Francisco (UCSF) Cancer of the Prostate Risk Assessment (CAPRA) score was initially introduced in 2005 and validated in 2006 as a pre-treatment tool that could be used to assess risk for prostate cancer recurrence after first-line treatment. We have previously described the use of the CAPRA scoring system, and the fact that at UCSF it is now being used to assess patients who may be suitable for management under active surveillance.
In a new paper, Cooperberg et al. have described a comparable post-surgical tool to be known as the CAPRA-S (the Cancer of the Prostate Risk Assessment Post-Surgical) score, which can also be used to project risk of prostate cancer recurrence after first-line surgery.
In a manner similar to the original CAPRA score, the CAPRA-S score is a number from 1 to 12 that is calculated for each individual patient. However, the CAPRA-S score is based on data available before and after the surgical excision of the prostate:
- The pre-surgical PSA level
- The pathologic Gleason score
- The presence or absence of positive surgical margins
- Whether there was extracapsular extension
- Whether cancer extended into the seminal vesicles
- Whether cancer extended into the regional lymph nodes
The following table provides the data necessary for an individual patient to be able to assess his CAPRA-S score:
Use of the CAPRA-S scores was correlated to actual biochemical recurrence data for > 3,800 radical prostatectomy patients in the CAPSURE database treated after 1992, of whom 644 had subsequent disease recurrence. The model allows for the following predictive output at 3 and at 5 years after surgery:
Let’s look at a couple of examples:
- JRK is 58 years of age. He had a robot-assisted laparoscopic prostatectomy (RALP) in May this year. His PSA pre-surgery was 6.4 ng/ml. After surgery, his pathologic Gleason score was 3 + 3 = 6; he had a positive surgical margin; and he had no sign of extracapsular disease or extension of the cancer into his seminal vesicles or his lymph nodes. We can calculate his CAPRA-S score as 1 + 0 + 2 + 0 + 0 + 0 = 3. This gives him a probability of biochemical progression-free survival of about 70 percent at 5 years.
- ASR is also 64 years old and had an open radical prostatectomy in May. Before surgery, his PSA was 3.8 ng/ml. After surgery his pathologic Gleason score was also 3 + 3 = 6; he had negative surgical margins, but (unusually for someone with a Gleason score of 6) he did have cancer that was evident in one of his seminal vesicles. We can calculate ASR’s CAPRA-S score as 0 + 0 + 0 + 0 + 2 + 0 = 2. This gives a probability of biochemical progression-free survival of about 83 percent at 5 years.
Cooperberg et al. note carefully that “the CAPRA-S score is meant to be used primarily as a measure of relative risk” of biochemical progression. They further state that, “Additional validations studies will be required to determine how consistently the absolute risk predictions are calibrated across different clinical contexts.”
It is important to note that the CAPRA-S projections are based on data from a wide spectrum of data from community-based urologists (as compared to data from the Kattan nomograms, which are based on experience from a high-volume, high-skill academic setting). It will be interesting to see whether the CAPRA-S score projections can be validated using data sets such as the SEARCH database, which has been developed from experience in a group of VA medical centers. We understand that such a validation study is ongoing.
Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk, Treatment | Tagged: CAPRA, CAPRA-S, prognosis, recurrence, risk, surgery |
THE "NEW" PROSTATE CANCER INFOLINK 
I don’t see that knowing your CAPRA-S score provides any sort of useful information. Your score will not have any value in future decision making, it might actually lull a man into not being vigilant about follow-up PSA tests post-treatment. My feeling is that it does no good other than allow someone to charge more money for no real value.
Joel … You have lost me completely.
First, there is no charge associated with use of the CAPRA-S score. (Where did you get that idea?) It is just a prognostic tool like the Kattan nomograms or the Han tables. Anyone can now print out the data above and use them to estimate their risk for biochemical progression post-surgery. (Although I would again emphasize that the model needs to be independently validated.)
Second, if you are correct, then use of the Kattan post-treatment nomogram (and many other nomograms) would also potentially “lull a man into not being vigilant about follow-up PSA tests post-treatment,” but I have never seen any indication that that was the case.
Mike,
I stand corrected about the cost, but I remain concerned about people becoming less vigilant.
I do not have hard data, but I know from my support groups that men do become more complacent as time goes on. For the careful man it is OK, but for many others it could lull them into a false confidence.
My score indicated that I was statistically “home free.” but I still had a recurrence. Would low scores have made me less vigilant, I don’t know. I do know that there are individuals who would become less careful. That could lead only to problems.
Joel:
Any use of prognostic tools like the CAPRA-S score or the Kattan nomograms needs to be taken in conjunction with a clear message that no one can tell any prostate cancer patient with absolute certainty that he has been “cured” by any type of first- or second-line therapy. Prognostic tools can, however, make it easier for a lot of patients to live with a better sense of their clinical risk for progressive disease.
“Less vigilant”?
How hard is it to get a PSA test once yearly? That doesn’t require much in the way of vigilance. That is about one-third the number of times I have to think about getting my oil changed in my car.
The CAPRA-S scale attempts to refine the standard method. The Cooperberg paper explicitly discusses the conundrum of the current system, in which a patient with a Gleason score of 4 + 3, PSA > 10, and 6/12 needle aspirations positive for cancer is rated at the same risk at that of a patient with a Gleason score of 3 + 4, PSA < 4.0, and 1/12 aspirations positive for cancer. The latter is precisely my situation! Under the Johns Hopkins active surveillance protocol, I do not qualify because my single positive aspiration had 65% of the core with cancer cells, of which 5% were graded Gleason 4. Apart from Cooperberg, I can find nothing that helps me evaluate my real risk — and two doctors have so far said, based on the classic scores alone, that I should be treated immediately. It is extremely frustrating, as I cannot understand why the extremely small amount of Gleason pattern 4 in a very low volume prostate cancer shifts my risk profile so profoundly. Can you help?
Dear FDAmaven:
The problem with your situation is a problem I have been seeking a resolution to for years … but we simply don’t have good enough data to make “logical” decisions, and most of the urology community is inevitably going to “hedge their bets” and say that anyone with a life expectancy of 10+ years and any amount of Gleason pattern 4 disease should be treated.
The Hopkins active surveillance protocol is probably the most conservative one under active study today. My suspicion is that if you went to see Dr. Klotz in Toronto (or perhaps even Dr. Carroll at UCSF), they would be perfectly willing to discuss active surveillance with you. Is your risk slightly higher than that of a man with Gleason 6 disease? Well sure it is! On the other hand, if you are willing to take that risk and monitor your cancer for at least a while, why wouldn’t you do that? Terry Herbert (who runs the Yananow web site and just monitored his cancer for nearly 15 years from his late 40s) would probably tell you to just “go for it”. I am going to be neutral and simply say that I think this is your decision, but if you want to try it, just make sure you track your PSAs assiduously and get another biopsy in a year’s time (or less if the PSA starts to rise).
Prognostic tools may “make it easier for a lot of patients to live with a better sense of their clinical risk for progressive disease,” or they may provide no useful information to the individual patient. I am a UCSF patient with biochemical recurrence 20 months after prostatectomy. My CAPRA-S score is 1 because I have 3 + 4 = 7 pathology and otherwise scored 0. According to the chart, it appears my odds of progression-free survival at 3 years after RP were 95.3%. I don’t think my CAPRA-S score told me anything about me and the favorable odds had no impact on my treatment, which consisted of regular PSA tests. Perhaps CAPRA-S is clinically useful in some other context, but for guiding post-RP treatment, not so much?