The Nottingham Prognostic Index applied to 9,149 patients from the studies of the Danish Breast Cancer Cooperative Group (DBCG)

Abstract

In primary, operable breast cancer, the Nottingham Prognostic Index (NPI) based on tumour size, lymph node stage and histological grade can identify three prognostic groups (PGs) with 10-year survival rates of 83%, 52%, and 13%. With the aim of defining a subset of patients having so good prognosis that adjuvant therapy can be withhold, the NPI was applied to a Danish population-based study group comprising 9,149 patients. As opposed to the British study, we used conventional axillary lymph-node staging. Histological grading was in both studies done by means of a similar slight modification of the Bloom and Richardson procedure, but in the Danish study only ductal carcinomas were graded. The 10-year crude survival was 68.1% for 4,791 patients with tumour size < or = 2 cm and 70.0% for 2,900 patients with grade I tumours. For 4,761 node-negative patients, the 10-year survival was also 70.0%, the expected survival being 89.3%. The relative mortality (observed:expected) was even at 10 years 2.1 demonstrating that more than 10 years observation time is necessary to estimate cumulated mortality. By application of the NPI, the Danish good PG comprising 27.3% of the patients had a 10-year survival of 79.0%. Thus, the index defined a subset with better survival than could be defined individually by each of its three components, but it did not succeed in defining a subset with survival similar to the expected; additional prognostic factors are therefore needed. The somewhat poorer survival of the Danish good PG may be ascribed to the British inclusion of non-ductal carcinomas, to interobserver variation present only in the Danish study, and to poorer expected survival of the Danish patients. The 10-year survival of the Danish moderate PG and poor PG was 56% and 25%, respectively. These improved survival rates are attributed to the administration of adjuvant therapies. There were virtually no node-positive patients in the good PG and no node-negative patients in the poor PG. Patients should therefore still be stratified initially by lymph-node status, but tumour size and histological grade are significant prognostic factors primarily within the node-negative group, and they should be included in future prognostication procedures.

Is Nottingham prognostic index useful after induction chemotherapy in operable breast cancer?

“…Our approach consisted of representing the 'amount' of residual disease by collecting the three recognised prognostic factors, that is, the node involvement, SBR grade and tumour size. This combination constitutes a score called NPI, a reference index of the literature (Haybittle et al, 1982;Galea et al, 1992;Balslev et al, 1994). Originally designed with a special three nodes dissection (Haybittle et al, 1982;Galea et al, 1992), it has been converted into more conventional axillary dissection by the Danish group (Balslev et al, 1992).…”

“…The NPI was based on tumour size, lymph-node status and histological grade (Balslev et al, 1994), as follows: NPI ¼ 0.2 Â tumour size (cm) þ lymph-node stage (1, node-negative; 2, 1 -3 positive lymph nodes; 3, X4 positive lymph nodes) þ SBR grade (1, good; 2, moderate; 3, poor).…”

“…The NPI was used to define three subsets of patients with different chances of dying from breast cancer. As opposed to the British study, the Danish group used conventional axillary lymph-node staging and SBR grade evaluated only in ductal carcinomas (Balslev et al, 1994). Paradoxical data have been published concerning the prognostic significance of the NPI ever since (Sauerbrei et al, 1997;Sundquist et al, 1999;D'Eredita et al, 2001;Malmstrom et al, 2001;Fredriksson et al, 2002).…”

Identification of fibroblast growth factor-8b target genes associated with early and late cell cycle events in breast cancer cells

“…NPI is a clinicopathological classification system based on tumor size, histological grade and lymph node status used for breast cancer prognostication (Balslev et al, 1994;Elston and Ellis, 1991;Galea et al, 1992;Sauerbrei et al, 1997;Todd et al, 1987). Patients with NPI ≤ 3.4 are considered to have a good prognosis, patients with 3.4 < NPI ≤ 5.4 a moderate prognosis and patients with NPI > 5.4 are considered to have a poor prognosis (Todd et al, 1987).…”

Vascular grading of angiogenesis: prognostic significance in breast cancer

“…However, the clinical decision process may be a hetero-geneous matter. The Nottingham Prognostic Index (NPI) is a validated index (Haybittle et al, 1982;Todd et al, 1987;Galea et al, 1992;Balslev et al, 1994), that has led to clinically useful grouping of breast cancer patients, based solely on tumour size, lymph node state and histological grading of malignancy. Thus, it can be used as a validated predefined tool for clinical decisions in order to investigate the accompanying clinical relevance of a new prognostic factor, i.e.…”