Biopsy and treatment decisions in the initial management of prostate cancer and the role of PCA3; a systematic analysis of expert opinion

Urinary markers aiding in the detection and risk stratification of prostate cancer

The purpose of this review is to highlight the role of existing and promising urinary biomarkers for the detection and prognostication of prostate cancer (PCa). A number of novel urinary biomarkers have been introduced into the clinical space, which in combination with clinical variables, have demonstrated an increased ability to select patients for biopsy and identify men at risk of harboring clinically significant PCa. Though a number of assays require further validation, initial data is promising and forthcoming results will ultimately determine their clinical utility and commercial availability. For the past 30 years, first-line screening for PCa has relied on measurement of serum prostate-specific antigen (PSA) levels and the results from a digital rectal exam (DRE). A large body of evidence from the last 3 decades indicates that these screening methods are problematic, and often inadequate for detecting clinically significant PCa. Extensive efforts have recently been made to identify and commercialize novel PCa biomarkers for more effective detection of PCa, either alone or in combination with current screening methods. This review article highlights problems with current screening standards, and discusses 6 urinary biomarker assays in terms of their ability to detect and risk-stratify PCa: prostate cancer antigen 3 (PCA3), TMPRSS2-ERG, second chromosome locus associated with prostate-1 (SChLAP1), ExoDx, SelectMDx, and Michigan Prostate Score (MiPS).

LncRNAs in pancreatic cancer

Pancreatic cancer (PC) is one of the most common causes of cancer-related death. The underlying mechanism of PC is not completely understood at present. Studies in recent years have demonstrated that long non-coding RNAs (lncRNAs) have multiple biological functions in cell growth, differentiation and proliferation. Notably, expressions of some lncRNAs undergo significant changes in the initiation and progression of cancers. In addition, lncRNAs are reported to be involved in various steps of PC development and have a potential value in the diagnosis, treatment and prognostic prediction of PC. In this review, we highlight recent evidence related to the molecular mechanism of lncRNAs in growth, survival, invasion, metastasis, angiogenesis and apoptosis of PC cells, and discuss the potential clinical application of lncRNAs to the diagnosis, treatment and prognostic prediction of PC.

The clinical effectiveness and cost-effectiveness of the PROGENSA® prostate cancer antigen 3 assay and the Prostate Health Index in the diagnosis of prostate cancer: a systematic review and economic evaluation

BACKGROUND

There is no single definitive test to identify prostate cancer in men. Biopsies are commonly used to obtain samples of prostate tissue for histopathological examination. However, this approach frequently misses cases of cancer, meaning that repeat biopsies may be necessary to obtain a diagnosis. The PROGENSA(®) prostate cancer antigen 3 (PCA3) assay (Hologic Gen-Probe, Marlborough, MA, USA) and the Prostate Health Index (phi; Beckman Coulter Inc., Brea, CA, USA) are two new tests (a urine test and a blood test, respectively) that are designed to be used to help clinicians decide whether or not to recommend a repeat biopsy.

OBJECTIVE

To evaluate the clinical effectiveness and cost-effectiveness of the PCA3 assay and the phi in the diagnosis of prostate cancer.

DATA SOURCES

Multiple publication databases and trial registers were searched in May 2014 (from 2000 to May 2014), including MEDLINE, EMBASE, The Cochrane Library, ISI Web of Science, Medion, Aggressive Research Intelligence Facility database, ClinicalTrials.gov, International Standard Randomised Controlled Trial Number Register and World Health Organization International Clinical Trials Registry Platform.

REVIEW METHODS

The assessment of clinical effectiveness involved three separate systematic reviews, namely reviews of the analytical validity, the clinical validity of these tests and the clinical utility of these tests. The assessment of cost-effectiveness comprised a systematic review of full economic evaluations and the development of a de novo economic model.

SETTING

The perspective of the evaluation was the NHS in England and Wales.

PARTICIPANTS

Men suspected of having prostate cancer for whom the results of an initial prostate biopsy were negative or equivocal.

INTERVENTIONS

The use of the PCA3 score or phi in combination with existing tests (including histopathology results, prostate-specific antigen level and digital rectal examination), multiparametric magnetic resonance imaging and clinical judgement.

RESULTS

In addition to documents published by the manufacturers, six studies were identified for inclusion in the analytical validity review. The review identified issues concerning the precision of the PCA3 assay measurements. It also highlighted issues relating to the storage requirements and stability of samples intended for analysis using the phi assay. Fifteen studies met the inclusion criteria for the clinical validity review. These studies reported results for 10 different clinical comparisons. There was insufficient evidence to enable the identification of appropriate test threshold values for use in a clinical setting. In addition, the implications of adding either the PCA3 assay or the phi to clinical assessment were not clear. Furthermore, the addition of the PCA3 assay or the phi to clinical assessment plus magnetic resonance imaging was not found to improve discrimination. No published papers met the inclusion criteria for either the clinical utility review or the cost-effectiveness review. The results from the cost-effectiveness analyses indicated that using either the PCA3 assay or the phi in the NHS was not cost-effective.

LIMITATIONS

The main limitations of the systematic review of clinical validity are that the review conclusions are over-reliant on findings from one study, the descriptions of clinical assessment vary widely within reviewed studies and many of the reported results for the clinical validity outcomes do not include either standard errors or confidence intervals.

CONCLUSIONS

The clinical benefit of using the PCA3 assay or the phi in combination with existing tests, scans and clinical judgement has not yet been confirmed. The results from the cost-effectiveness analyses indicate that the use of these tests in the NHS would not be cost-effective.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014009595.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Screening for Prostate Cancer-Beyond Total PSA, Utilization of Novel Biomarkers

Urology has been beset by several major trends that have shifted the entire paradigm for prostate cancer screening. These stem from a backlash against overdiagnosis and overtreatment due to prostate-specific antigen (PSA)-based screening efforts and have led national societies to modify their guidelines. More importantly, the public outcry has shifted the focus of early detection from an effort to diagnose any and all prostate cancers to an effort to diagnose clinically significant prostate cancers at an early stage. This review provides an update on contemporary biomarkers for prostate cancer that may be used to supplement PSA-based screening approaches.

Urinary biomarkers for prostate cancer

PURPOSE OF REVIEW

The field of urology has been beset by several major trends that have affected the early detection of prostate cancer. These stem primarily from a backlash against overdiagnosis due to prostate specific antigen-based screening efforts and are epitomized by the US Preventive Services Task Force giving prostate specific antigen-based prostate cancer screening a 'D' recommendation. Consequently, the active surveillance strategy for low-risk prostate cancer has become commonplace, leading many to ask how best to follow these patients. More importantly, this public outcry has shifted the focus of early detection from an effort to diagnose any and all prostate cancers to an effort to diagnose only 'high-risk' cancer. Along with a trend for minimally invasive procedures, these forces have challenged the early detection field to more efficiently identify clinically significant prostate cancers at an early stage while limiting the number of biopsies.

RECENT FINDINGS

With US Food and Drug Administration approval, prostate cancer antigen 3 has emerged as the first bona-fide urinary biomarker for prostate cancer. Using the same platform, investigators have developed a second urinary test based on TMPRSS2:erg fusion. Recent literature supports the use of these biomarkers as a combined panel that improves risk evaluation in the setting of prostate cancer detection. Early works for applying urinary biomarkers for active surveillance are underway. Other biomarkers in the pipeline will require further prevalidation and validation work.

SUMMARY

Recent literature would support that urinary biomarkers have a clear role to supplement risk evaluation for men undergoing prostate biopsy and for prognostication.

Breast Implant-associated Anaplastic Large Cell Lymphoma: Updated Results from a Structured Expert Consultation Process

Background:

Despite increased cases published on breast implant–associated anaplastic large cell lymphoma (BIA-ALCL), important clinical issues remain unanswered. We conducted a second structured expert consultation process to rate statements related to the diagnosis, management, and surveillance of this disease, based on their interpretation of published evidence.

Methods:

A multidisciplinary panel of 12 experts was selected based on nominations from national specialty societies, academic department heads, and recognized researchers in the United States.

Results:

Panelists agreed that (1) this disease should be called “BIA-ALCL”; (2) late seromas occurring >1 year after breast implantation should be evaluated via ultrasound, and if a seroma is present, the fluid should be aspirated and sent for culture, cytology, flow cytometry, and cell block to an experienced hematopathologist; (3) surgical removal of the affected implant and capsule (as completely as possible) should occur, which is sufficient to eradicate capsule-confined BIA-ALCL; (4) surveillance should consist of clinical follow-up at least every 6 months for at least 5 years and breast ultrasound yearly for at least 2 years; and (5) BIA-ALCL is generally a biologically indolent disease with a good prognosis, unless it extends beyond the capsule and/or presents as a mass. They firmly disagreed with statements that chemotherapy and radiation therapy should be given to all patients with BIA-ALCL.

Conclusions:

Our assessment yielded consistent results on a number of key, incompletely addressed issues regarding BIA-ALCL, but additional research is needed to support these statement ratings and enhance our understanding of the biology, treatment, and outcomes associated with this disease.

Projecting Benefits and Harms of Novel Cancer Screening Biomarkers: A Study of PCA3 and Prostate Cancer

BACKGROUND

New biomarkers for early detection of cancer must pass through several phases of development. Early phases provide information on diagnostic properties but not on population benefits and harms. Prostate cancer antigen 3 (PCA3) is a promising prostate cancer biomarker still in early development. We use simulation modeling to project the impact of adding PCA3 to prostate-specific antigen (PSA) screening on prostate cancer detection and mortality in the United States.

METHODS

We used data from a recent study of PCA3 in men referred for prostate biopsy to extend an existing simulation model of PSA growth, disease progression, and survival. We specified several PSA-PCA3 strategies designed to improve specificity and reduce overdiagnosis. Using these strategies to screen a cohort of men biennially between ages 50 and 74, we projected true- and false-positive tests, overdiagnoses, and lives saved relative to a PSA-based strategy with a cutoff of 4.0 ng/mL for biopsy referral.

RESULTS

We identified several PSA-PCA3 strategies that substantially reduced false-positive tests and overdiagnoses while preserving the majority of lives saved. PCA3>35 for biopsy referral in men with PSA between 4.0 and 10.0 ng/mL retained 85% of lives saved while approximately halving false positives and reducing overdiagnoses by 25%.

CONCLUSIONS

Adding PCA3 to PSA screening can significantly reduce adverse screening outcomes. Strategies can be identified that preserve most of the lives saved relative to PSA-based screening.

IMPACT

Simulation modeling provides advance projections of population outcomes of new screening biomarkers and may help guide early detection research.

Can urinary PCA3 supplement PSA in the early detection of prostate cancer?

PURPOSE

Given the limited sensitivity and specificity of prostate-specific antigen (PSA), its widespread use as a screening tool has raised concerns for the overdiagnosis of low-risk and the underdiagnosis of high-grade prostate cancer. To improve early-detection biopsy decisions, the National Cancer Institute conducted a prospective validation trial to assess the diagnostic performance of the prostate cancer antigen 3 (PCA3) urinary assay for the detection of prostate cancer among men screened with PSA.

PATIENTS AND METHODS

In all, 859 men (mean age, 62 years) from 11 centers scheduled for a diagnostic prostate biopsy between December 2009 and June 2011 were enrolled. The primary outcomes were to assess whether PCA3 could improve the positive predictive value (PPV) for an initial biopsy (at a score > 60) and the negative predictive value (NPV) for a repeat biopsy (at a score < 20).

RESULTS

For the detection of any cancer, PPV was 80% (95% CI, 72% to 86%) in the initial biopsy group, and NPV was 88% (95% CI, 81% to 93%) in the repeat biopsy group. The addition of PCA3 to individual risk estimation models (which included age, race/ethnicity, prior biopsy, PSA, and digital rectal examination) improved the stratification of cancer and of high-grade cancer.

CONCLUSION

These data independently support the role of PCA3 in reducing the burden of prostate biopsies among men undergoing a repeat prostate biopsy. For biopsy-naive patients, a high PCA3 score (> 60) significantly increases the probability that an initial prostate biopsy will identify cancer.

Impact of adoption of a decision algorithm including PCA3 for repeat biopsy on the costs for prostate cancer diagnosis in France

OBJECTIVE

A recent expert study (RAND Appropriateness Method (RAM)) including a panel of 12 European urologists reported that the PCA3 score may be instrumental in taking appropriate prostate biopsy (PBx) decisions, mainly for repeat PBx. This study determined the cost/benefit balance of introducing PCA3 in the decision-making for PBx in France.

METHODS

Two RAM models, without and with PCA3, were retrospectively applied to a sample of 808 French men who had PBx in 2010 (78% first, 22% repeat). Outcome measures included the proportion of PBx that could have been avoided (i.e., judged inappropriate) in the French sample according to both RAM models, and the estimated impact of application of these models on the annual number of PBx and associated costs for France (based on most recent published data).

RESULTS

Complete profiles were available for 698 men. In the model without PCA3, 2% of PBx were deemed inappropriate. Knowledge of PCA3 would have avoided another 7% of PBx. Repeat PBx would have been avoided in 5% of cases without PCA3 and in 37% with PCA3. For France, application of the RAM model including PCA3 would result in 18,345 fewer repeat PBx. It would be budget-neutral in the unlikely hypothesis of no complications or no costs incurred by complications and would save €1.7 million for a mean cost for complications of €100/procedure or €5 million for a mean cost for complications of €280/procedure, calculated based on US and Canadian data.

LIMITATIONS

Limitations of the study are the theoretical nature of the analysis and the fact that PCA3 distributions had to be derived from other sources.

CONCLUSIONS

Adoption of RAM expert recommendations including PCA3 for repeat PBx decisions in clinical practice in France would reduce the number of repeat PBx and control costs.

Combination of real-time elastography and urine prostate cancer gene 3 (PCA3) detects more than 97% of significant prostate cancers

OBJECTIVE

The prostate cancer gene 3 (PCA3) score in urine is a promising biomarker for prostate cancer. Real-time elastography (RTE) is a well-documented ultrasound modality. The objective of this study was to evaluate the ability to detect significant cancer foci in the prostate with these methods alone and in combination.

MATERIAL AND METHODS

From September 2009 to September 2010, 40 patients planned for radical prostatectomy underwent a PCA3 urine test and RTE before operation. A Hitachi EUB-8500 with prostate end-fire transrectal probe was used. The PCA3 score was evaluated with a standard cut-off value of 35. RTE was evaluated in correlation with whole-mount section pathology. Three patients fulfilled the criteria for insignificant prostate cancer and were excluded from the study.

RESULTS

The PCA3 score was increased in 26 patients (70%). RTE identified at least one tumour in 33 out of 37 patients (89%). RTE detected the largest tumour in 27 out of 37 patients (73%). More than one cancer was present in 29 patients and RTE identified more than one tumour in 13 of these. The RTE was false positive in four patients. The PCA3 score was increased in three out of four false-negative RTE patients. By combining both methods, 36 out of 37 patients (97%) with significant prostate cancer were detected.

CONCLUSIONS

The combination of PCA3 score and RTE detected 97% of significant prostate cancers. The combinative use of RTE and PCA3 will be further investigated in an unselected series of men with suspected prostate cancer.

Age-specific PCA3 score reference values for diagnosis of prostate cancer

PURPOSE

We evaluated the impact of age on PCA3 score and the utility of age-specific reference values in predicting initial prostate biopsy (pBx) outcomes.

PATIENTS AND METHODS

This single-center, retrospective study included 205 men who underwent an initial 14-core TRUS-guided pBx due to PSA > 3.0 ng/ml or suspicious digital-rectal examination (DRE). PCA3 scores were measured with the Progensa assay. Linear regression models were fit to identify factors that impact PCA3 score and to determine age-specific reference values. Predictive accuracies of logistic regression models predicting presence of prostate cancer (PCa) were analyzed.

RESULTS

The positive biopsy rate was 37%. In multivariable linear regression, age (P < 0.001), presence of PCa (P < 0.001), and multifocal HG-PIN (P = 0.012) were independent predictors of PCA3 score. Age showed the strongest impact on PCA3 score (T = 4.77). The upper 95% confidence interval of PCA3 score in each age category was defined as the age-specific limit. A PCA3-score over the age-specific limit (PCA3-age) was associated with an 4.17-fold increased odds of being diagnosed with PCa (P < 0.001). In multivariable logistic regression models predicting the presence of PCa, predictive accuracy of a base model (age, DRE, PSA, volume) increased from 69.6 to 75.4% (P = 0.037) by adding the continuous PCA3 score, to 73.9% (P = 0.098) with the 35 cutoff (PCA3-35) and to 77.1% (P = 0.008) with PCA3-age.

CONCLUSIONS

PCA3 score increases with age, independent of PCa presence. Age-specific PCA3 score reference values are superior to PSA, continuous PCA3 score, and PCA3-35 in predicting initial pBx outcome. Therefore, an age-adjusted PCA3 score should be used for interpretation of the results.