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Šimánek V, Vrzáková R, Viták R, Jirásko M, Fürst T, Topolčan O, Pecen L, Vurm V, Kučera R. Preanalytical stability of molecular forms of prostate-specific antigen in serum samples (PSA, free PSA, [-2]proPSA) and their impact on fPSA/tPSA ratio and PHI. Prostate 2024; 84:656-665. [PMID: 38414098 DOI: 10.1002/pros.24681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/04/2024] [Accepted: 02/14/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Prostate cancer is a common cancer in men. Detection methods include the measurement of biomarkers: prostate-specific antigen (PSA), free PSA, [-2]proPSA, and the calculated indices: fPSA/tPSA ratio and Prostate Health Index (PHI). Proper preanalytical conditions are crucial for precise measurement and failure to adhere to protocols or regulations can influence the diagnostic algorithm. We assessed the stability of the above-mentioned biomarkers, fPSA/tPSA ratio and PHI, under various pre-analytical conditions. METHODS Serum samples from 45 males were collected and stored under specific conditions before tPSA, fPSA, and [-2]proPSA were measured. Subsequently, the fPSA/tPSA and PHI were calculated. RESULTS tPSA, fPSA, and [-2]proPSA remained stable during the two freeze-thaw cycles. Storage at 4°C and 22°C resulted in stable tPSA concentrations. However, fPSA levels decreased and [-2]proPSA levels increased over time. The fPSA/tPSA ratio remained stable for 72 h, at which point a decrease was observed in the samples kept at 4°C and 22°C. A gradual increase in PHI was observed in the samples kept at 4°C and 22°C. CONCLUSIONS All biomarkers remained stable during two freeze-thaw cycles. tPSA was the most stable analyte when stored at 4°C, as well as at RT. A gradual increase of [-2]proPSA and a slight decrease in fPSA were observed during the storage test. This led to a decrease in the fPSA/tPSA ratio and an elevation in the PHI. We therefore recommend measuring prostate biomarkers promptly following blood collection. IMPACT Understanding the pre-analytical stability of prostate biomarkers helps prevent false positive results and improve the accuracy of diagnostics for prostate cancer.
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Affiliation(s)
- Václav Šimánek
- Department of Immunochemistry Diagnostics, University Hospital and Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Radana Vrzáková
- Department of Medical Chemistry and Biochemistry, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Roman Viták
- Department of Pharmacology and Toxicology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Michal Jirásko
- Department of Immunochemistry Diagnostics, University Hospital and Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Department of Pharmacology and Toxicology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Tomáš Fürst
- Faculty of Science, c, Palacky University in Olomou, Olomouc, Czech Republic
| | - Ondřej Topolčan
- Department of Immunochemistry Diagnostics, University Hospital and Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Ladislav Pecen
- Department of Immunochemistry Diagnostics, University Hospital and Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Vladimír Vurm
- Department of Immunochemistry Diagnostics, University Hospital and Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Radek Kučera
- Department of Immunochemistry Diagnostics, University Hospital and Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Department of Pharmacology and Toxicology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
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2
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Meehan J, Gray M, Martínez-Pérez C, Kay C, McLaren D, Turnbull AK. Tissue- and Liquid-Based Biomarkers in Prostate Cancer Precision Medicine. J Pers Med 2021; 11:jpm11070664. [PMID: 34357131 PMCID: PMC8306523 DOI: 10.3390/jpm11070664] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/06/2021] [Accepted: 07/13/2021] [Indexed: 12/24/2022] Open
Abstract
Worldwide, prostate cancer (PC) is the second-most-frequently diagnosed male cancer and the fifth-most-common cause of all cancer-related deaths. Suspicion of PC in a patient is largely based upon clinical signs and the use of prostate-specific antigen (PSA) levels. Although PSA levels have been criticised for a lack of specificity, leading to PC over-diagnosis, it is still the most commonly used biomarker in PC management. Unfortunately, PC is extremely heterogeneous, and it can be difficult to stratify patients whose tumours are unlikely to progress from those that are aggressive and require treatment intensification. Although PC-specific biomarker research has previously focused on disease diagnosis, there is an unmet clinical need for novel prognostic, predictive and treatment response biomarkers that can be used to provide a precision medicine approach to PC management. In particular, the identification of biomarkers at the time of screening/diagnosis that can provide an indication of disease aggressiveness is perhaps the greatest current unmet clinical need in PC management. Largely through advances in genomic and proteomic techniques, exciting pre-clinical and clinical research is continuing to identify potential tissue, blood and urine-based PC-specific biomarkers that may in the future supplement or replace current standard practices. In this review, we describe how PC-specific biomarker research is progressing, including the evolution of PSA-based tests and those novel assays that have gained clinical approval. We also describe alternative diagnostic biomarkers to PSA, in addition to biomarkers that can predict PC aggressiveness and biomarkers that can predict response to certain therapies. We believe that novel biomarker research has the potential to make significant improvements to the clinical management of this disease in the near future.
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Affiliation(s)
- James Meehan
- Translational Oncology Research Group, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Edinburgh EH4 2XU, UK; (C.M.-P.); (C.K.); (A.K.T.)
- Correspondence:
| | - Mark Gray
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Midlothian EH25 9RG, UK;
| | - Carlos Martínez-Pérez
- Translational Oncology Research Group, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Edinburgh EH4 2XU, UK; (C.M.-P.); (C.K.); (A.K.T.)
- Breast Cancer Now Edinburgh Research Team, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Edinburgh EH4 2XU, UK
| | - Charlene Kay
- Translational Oncology Research Group, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Edinburgh EH4 2XU, UK; (C.M.-P.); (C.K.); (A.K.T.)
- Breast Cancer Now Edinburgh Research Team, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Edinburgh EH4 2XU, UK
| | - Duncan McLaren
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh EH4 2XU, UK;
| | - Arran K. Turnbull
- Translational Oncology Research Group, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Edinburgh EH4 2XU, UK; (C.M.-P.); (C.K.); (A.K.T.)
- Breast Cancer Now Edinburgh Research Team, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Edinburgh EH4 2XU, UK
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3
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Dittadi R, Fabricio ASC, Rainato G, Peroni E, Di Tonno F, Vezzù B, Mazzariol C, Squarcina E, Tammone L, Gion M. Preanalytical stability of [-2]proPSA in whole blood stored at room temperature before separation of serum and plasma: implications to Phi determination. Clin Chem Lab Med 2019; 57:521-531. [PMID: 30218601 DOI: 10.1515/cclm-2018-0596] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/11/2018] [Indexed: 12/26/2022]
Abstract
Background [-2]proPSA seems to outperform free/total prostate-specific antigen (PSA) ratio in prostate cancer diagnosis. However, [-2]proPSA stability remains an underestimated issue. We examined [-2]proPSA stability over time in whole blood before separation of serum and plasma and its implications for prostate health index (Phi) determination. Total PSA (tPSA) and free PSA (fPSA) stabilities were also assessed. Methods Blood was drawn from 26 patients and separated in two tubes for plasma (K2EDTA and K2EDTA plus protease inhibitors - P100) and one for serum (clot activator plus gel separator). Tubes were stored at room temperature before centrifugation 1, 3 and 5 h for serum and EDTA plasma or 1 and 5 h for P100 plasma. To investigate the influence of gel separator on markers' stability, blood was collected from 10 patients in three types of tubes to obtain serum: tubes with clot activator plus gel separator, with silica particles or glass tubes. Biomarkers were assayed with chemiluminescent immunoassays. Results [-2]proPSA and Phi levels significantly and progressively increased over time in serum (+4.81% and +8.2% at 3 h; +12.03% and +14.91% at 5 h, respectively, vs. 1 h; p<0.001). Conversely, [-2]proPSA levels did not change in plasma (EDTA or P100). tPSA levels did not change over time in serum or plasma, whereas fPSA decreased in serum. All markers were higher in plasma than in serum at any time point. This difference did not seem to be attributable to the use of gel for serum preparation. Conclusions EDTA prevented spurious in vitro modifications in PSA-related isoforms, confirming that a stabilized blood sample is a prerequisite for [-2]proPSA measurement and Phi determination.
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Affiliation(s)
- Ruggero Dittadi
- Laboratory Analysis Unit, Department of Clinical Pathology and Transfusion Medicine, Dell'Angelo Hospital, Mestre-Venice (VE), Italy
| | - Aline S C Fabricio
- Regional Center for Biomarkers, Department of Clinical Pathology and Transfusion Medicine, SS Giovanni e Paolo Regional Hospital, Venice (VE), Italy
| | - Giulia Rainato
- Istituto Oncologico Veneto (IOV), IRCCS, Padua (PD), Italy
| | - Edoardo Peroni
- Istituto Oncologico Veneto (IOV), IRCCS, Padua (PD), Italy
| | - Fulvio Di Tonno
- Unit of Urology, dell'Angelo Regional General Hospital, Mestre-Venice (VE), Italy
| | - Beatrice Vezzù
- Unit of Urology, dell'Angelo Regional General Hospital, Mestre-Venice (VE), Italy
| | - Chiara Mazzariol
- Unit of Urology, dell'Angelo Regional General Hospital, Mestre-Venice (VE), Italy
| | - Elisa Squarcina
- Regional Center for Biomarkers, Department of Clinical Pathology and Transfusion Medicine, SS Giovanni e Paolo Regional Hospital, Venice (VE), Italy
| | - Laura Tammone
- Endoscopy Ward, dell'Angelo Hospital, dell'Angelo Regional General Hospital, Mestre-Venice (VE), Italy
| | - Massimo Gion
- Centro Regionale Biomarcatori, AULSS3 Serenissima, Department of Clinical Pathology and Transfusion Medicine, SS Giovanni e Paolo Regional Hospital, Campo SS Giovanni e Paolo 6777, Ospedale Civile, 30122 Venezia, Italy
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4
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Higgins CE, Neybold P, Holdridge MB, Barnes CR, Dong Y, Reeve M, Mathur V, Weisberger J, Linder V. Performance of the 4Kscore Test in Plasma and Serum and Stability of the Component Analytes in Clinical Samples. J Appl Lab Med 2019; 3:185-199. [PMID: 33636931 DOI: 10.1373/jalm.2017.024612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/27/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND The 4Kscore Test determines a personalized risk score for aggressive prostate cancer by combining the blood sample measurements of total prostate-specific antigen (tPSA), free PSA (fPSA), intact PSA (iPSA), and human kallikrein-related peptidase 2 (hK2) with patient clinical information to generate the patient risk's score; thus, accuracy and precision of the 4Kscore depend on the reliability of these measurements. Although tPSA and fPSA are measured on a Food and Drug Administration (FDA)-approved platform, the performance of the iPSA and hK2 assays in the clinical setting has not previously been reported. METHODS Analytical performance was determined for the iPSA and hK2 assays in both serum and EDTA plasma, according to Clinical and Laboratory Standards Institute guidelines. Equivalence of the 4Kscore in both sample matrices was demonstrated in a 353-patient clinical cohort, and the stability of endogenous iPSA and hK2 for at least 3 days was demonstrated in a smaller subset. RESULTS Intralaboratory and interlaboratory precision of the iPSA and hK2 assays in both matrices was comparable with that of FDA-approved tPSA and fPSA assays (<18% for iPSA; <8% for hK2). The picogram per milliliter sensitivity and wide dynamic range of the iPSA and hK2 assays allowed for accurate measurements in the target population. The 4Kscore generated in either matrix up to 3 days after collection is equivalent to that measured within 24 h of collection (Passing-Bablok slope 95% CI: plasma, 0.999-1.034; serum, 0.997-1.040). CONCLUSIONS The robust performance of component assays and reliable stability of the endogenous analytes in clinical samples proven here ensures an accurate 4Kscore Test result.
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Affiliation(s)
| | | | | | | | - Yan Dong
- OPKO Diagnostics, LLC, Woburn, MA
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5
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Allard WJ, Cheli CD, Morris DL, Goldblatt J, Pierre Y, Kish L, Chen Y, Dai J, Vessella RL, Chan DW, Schwartz MK, Zhou Z, Yeung KK. Multicenter Evaluation of the Performance and Clinical Utility in Longitudinal Monitoring of the Bayer Immuno 1™ Complexed PSA Assay. Int J Biol Markers 2018; 14:73-83. [PMID: 10399626 DOI: 10.1177/172460089901400204] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We conducted a multicenter evaluation of the analytical and clinical performance of the automated Bayer Immuno 1™ complexed PSA (cPSA) assay, and compared assay performance to the Bayer Immuno 1™ PSA assay. We sought to determine whether measurements of cPSA could be of clinical utility in the management of patients with prostate cancer. Results of the 10–day imprecision across three evaluation sites produced total CV < 2.50% and an analytical sensitivity of 0.02μg/L. There was an increased trend in clinical sensitivity for prostate cancer with increasing stage of disease (71–86%). Clinical specificity for patients with benign urogenital disease was 74.8%, and for other nonprostate diseases ranged from 91.1–100%. Retrospective serial monitoring of 155 patients with prostate cancer demonstrated concordance of cPSA measurements to clinical status for 97% of the patients analyzed. Results from the clinical studies using the Bayer Immuno 1 cPSA assay were comparable to results obtained with the Bayer Immuno 1 PSA assay. The Bayer Immuno 1 cPSA assay demonstrates analytical performance and clinical effectiveness in the management of prostate cancer patients during the course of disease and therapy.
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Affiliation(s)
- W J Allard
- Bayer Corporation, Tarrytown, New York, USA.
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6
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Scaramuzzino D, Schulte K, Mack B, Soriano T, Fritsche H. Five-Year Stability Study of Free and Total Prostate-Specific Antigen Concentrations in Serum Specimens Collected and Stored at – 70°C or Less. Int J Biol Markers 2018; 22:206-13. [DOI: 10.1177/172460080702200308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The stability of total (t) and free (f) prostate-specific antigen (PSA) in male serum specimens stored at –70°C or lower temperature for 4.7 to 4.9 years was studied. Until now, the stability of these analytes in serum has not been evaluated systematically beyond 2 years of storage at –70°C. Aliquots of frozen serum were thawed in 2001 and 2006 and assayed for tPSA and fPSA using a Dade Behring Dimension(r) RxL analyzer and reagents. tPSA values ranged from 0.07 to 69.94 and 0.00 to 69.83 ng/mL in 2001 and 2006, respectively, whereas fPSA values for the tested specimens ranged from 0.02 to 5.72 and 0.00 to 5.92, respectively. Deming regression analyses showed agreement in assay values over time as tPSA values yielded a slope of 1.0112 and a y-intercept of 0.0195; fPSA values produced a slope 1.0538 and a y-intercept of –0.0442; f/tPSA values yielded a slope of 0.9631 and a y-intercept of 0.1195. A Bland-Altman analysis of the data demonstrated analyte and ratio stability over this time period. We conclude that serum, when collected properly and stored at –70°C or lower temperature, may be used for tPSA and fPSA clinical studies for at least 5 years after collection.
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Affiliation(s)
| | - K. Schulte
- Ellis Hospital Laboratory, Schenectady, NY
| | | | | | - H.A. Fritsche
- Department of Laboratory Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX - USA
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7
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Agrawal L, Engel KB, Greytak SR, Moore HM. Understanding preanalytical variables and their effects on clinical biomarkers of oncology and immunotherapy. Semin Cancer Biol 2017; 52:26-38. [PMID: 29258857 DOI: 10.1016/j.semcancer.2017.12.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/07/2017] [Accepted: 12/13/2017] [Indexed: 12/20/2022]
Abstract
Identifying a suitable course of immunotherapy treatment for a given patient as well as monitoring treatment response is heavily reliant on biomarkers detected and quantified in blood and tissue biospecimens. Suboptimal or variable biospecimen collection, processing, and storage practices have the potential to alter clinically relevant biomarkers, including those used in cancer immunotherapy. In the present review, we summarize effects reported for immunologically relevant biomarkers and highlight preanalytical factors associated with specific analytical platforms and assays used to predict and gauge immunotherapy response. Given that many of the effects introduced by preanalytical variability are gene-, transcript-, and protein-specific, biospecimen practices should be standardized and validated for each biomarker and assay to ensure accurate results and facilitate clinical implementation of newly identified immunotherapy approaches.
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Affiliation(s)
- Lokesh Agrawal
- Biorepositories and Biospecimen Research Branch (BBRB), Cancer Diagnosis Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, 9609 Medical Center Drive, Bethesda, Maryland, USA
| | | | | | - Helen M Moore
- Biorepositories and Biospecimen Research Branch (BBRB), Cancer Diagnosis Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, 9609 Medical Center Drive, Bethesda, Maryland, USA.
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8
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Lazzeri M, Guazzoni G, Montorsi F. Total and Free PSA, PCA3, PSA Density and Velocity. Prostate Cancer 2016. [DOI: 10.1016/b978-0-12-800077-9.00010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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9
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Bryant RJ, Sjoberg DD, Vickers AJ, Robinson MC, Kumar R, Marsden L, Davis M, Scardino PT, Donovan J, Neal DE, Lilja H, Hamdy FC. Predicting high-grade cancer at ten-core prostate biopsy using four kallikrein markers measured in blood in the ProtecT study. J Natl Cancer Inst 2015; 107:djv095. [PMID: 25863334 PMCID: PMC4554254 DOI: 10.1093/jnci/djv095] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Many men with elevated prostate-specific antigen (PSA) levels in serum do not have aggressive prostate cancer and undergo unnecessary biopsy. Retrospective studies using cryopreserved serum suggest that four kallikrein markers can predict biopsy outcome. Methods: Free, intact and total PSA, and kallikrein-related peptidase 2 were measured in cryopreserved blood from 6129 men with elevated PSA (≥3.0ng/mL) participating in the prospective, randomized trial Prostate Testing for Cancer and Treatment. Marker levels from 4765 men providing anticoagulated plasma were incorporated into statistical models to predict any-grade and high-grade (Gleason score ≥7) prostate cancer at 10-core biopsy. The models were corrected for optimism by 10-fold cross validation and independently validated using markers measured in serum from 1364 men. All statistical tests were two-sided. Results: The four kallikreins enhanced prostate cancer detection compared with PSA and age alone. Area under the curve (AUC) for the four kallikreins was 0.719 (95% confidence interval [CI] = 0.704 to 0.734) vs 0.634 (95% CI = 0.617 to 0.651, P < .001) for PSA and age alone for any-grade cancer, and 0.820 (95% CI = 0.802 to 0.838) vs 0.738 (95% CI = 0.716 to 0.761) for high-grade cancer. Using a 6% risk of high-grade cancer as an illustrative cutoff, for 1000 biopsied men with PSA levels of 3.0ng/mL or higher, the model would reduce the need for biopsy in 428 men, detect 119 high-grade cancers, and delay diagnosis of 14 of 133 high-grade cancers. Models exhibited excellent discrimination on independent validation among men with only serum samples available for analysis. Conclusions: A statistical model based on kallikrein markers was validated in a large prospective study and reduces unnecessary biopsies while delaying diagnosis of high-grade cancers in few men.
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Affiliation(s)
- Richard J Bryant
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Daniel D Sjoberg
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Andrew J Vickers
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Mary C Robinson
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Rajeev Kumar
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Luke Marsden
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Michael Davis
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Peter T Scardino
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Jenny Donovan
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - David E Neal
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Hans Lilja
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL).
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
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10
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Abstract
OBJECTIVES To provide clarity on the pros and cons of using prostate-specific antigen (PSA) as a screening tool for prostate cancer. METHODS Case scenarios and a literature review of recently published clinical trial data are presented to provide evidence of the controversy. RESULTS PSA is a sensitive biomarker for detecting diseases of the prostate, but it is limited in its ability to distinguish cancerous from noncancerous conditions or aggressive from indolent cancers and has resulted in a considerable amount of overdiagnosis and overtreatment. CONCLUSIONS The analytical methodology for total PSA testing is both reliable and cost-effective, but patients should be encouraged to talk to their providers to understand the benefits and harms associated with this testing.
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Affiliation(s)
- Jaime H. Noguez
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Corinne R. Fantz
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
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11
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Abstract
This article updates advances in prostate cancer screening based on prostate-specific antigen, its derivatives, and human kallikrein markers. Many men are diagnosed with indolent disease not requiring treatment. Although there is evidence of a survival benefit from screening, the numbers needed to screen and treat remain high. There is risk of exposing men to the side effects of treatment for nonthreatening disease. A screening test is needed with sufficiently good performance characteristics to detect disease at an early stage so treatment may be offered with curative intent, while reducing the number of negative or unnecessary biopsies.
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Affiliation(s)
- Richard J Bryant
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Hans Lilja
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK; Department of Laboratory Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue (Mailbox 213), New York, NY 10065, USA; Department of Surgery (Urology), Memorial Sloan-Kettering Cancer Center, 1275 York Avenue (Mailbox 213), New York, NY 10065, USA; Department of Medicine (GU-Oncology), Memorial Sloan-Kettering Cancer Center, 1275 York Avenue (Mailbox 213), New York, NY 10065, USA.
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12
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Cary KC, Cooperberg MR. Biomarkers in prostate cancer surveillance and screening: past, present, and future. Ther Adv Urol 2013; 5:318-29. [PMID: 24294290 DOI: 10.1177/1756287213495915] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The use of biomarkers for prostate cancer (PCa) screening, detection, and prognostication have revolutionized the diagnosis and management of the disease. Current clinical practice has been driven largely by the utilization of prostate-specific antigen (PSA). The lack of specificity of PSA for PCa has led to both unnecessary biopsies and overdiagnosis of indolent cancers. The recent controversial recommendation by the United States Preventive Services Task Force against PCa screening has highlighted the need for novel clinically useful biomarkers. We review the literature on PCa biomarkers in serum, urine, and tissue. While these markers show promise, none seems poised to replace PSA, but rather may augment it. Further validation and consideration of how these novel markers improve clinical outcome is necessary. The discovery of new genetic markers shows promise in stratifying men with aggressive PCa.
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Affiliation(s)
- K Clint Cary
- University of California, San Francisco, CA, USA
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13
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The number of tPSA tests continues to rise and variation in testing practices persists: a survey of laboratory services in Ireland 2008-2010. Ir J Med Sci 2013; 183:369-75. [PMID: 24072433 DOI: 10.1007/s11845-013-1022-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 09/17/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Ireland had the highest incidence of prostate cancer in Europe in 2008, due to widespread prostate specific antigen (PSA) testing. AIMS To investigate practices and costs of PSA testing in Ireland, 2008-2010. METHODS Postal laboratory questionnaire. Results were compared with 2006 and 2007 surveys. RESULTS Response rate was 95 % (42/44). In 2010, 37 laboratories measured total PSA (tPSA); 10 measured free PSA (fPSA). Eight assays were used and cut-offs to define 'normal' tPSA varied widely. There was a 9.9 % annual increase in the number of tPSA tests and a -31 % annual decrease in the number of fPSA, 2006-2010. A 100-fold difference in tPSA workload was observed across laboratories. In 2010, the estimated cost of PSA testing was <euro>3,649,984 (95 % CI <euro>2,532,745-<euro>4,767,222). CONCLUSIONS Health service costs of PSA testing are significant. The number of tPSA tests continues to rise; fPSA use fell by almost one-third. Inter-laboratory variation in testing practices persists. These have potentially important clinical consequences for men and need to be addressed.
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14
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Gallo MF, Snead MC, Black CM, Brown TM, Kourtis AP, Jamieson DJ, Carter M, Penman-Aguilar A, Macaluso M. Optimal methods for collecting and storing vaginal specimens for prostate-specific antigen testing in research studies. Contraception 2012; 87:830-5. [PMID: 23121826 DOI: 10.1016/j.contraception.2012.09.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 09/27/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Prostate-specific antigen (PSA) detected in vaginal fluid can be used in studies of HIV/sexually transmitted infection (STI) and pregnancy prevention as an alternative to relying on participant reports of exposure to semen. Optimal methods for collecting and storing specimens for this testing have not been determined. STUDY DESIGN We conducted a controlled, in vitro experiment of 550 specimens spiked with semen to determine the effects of swab type (five types), storage conditions of the swabs (room temperature with or without desiccant or at -80°C without desiccant) and time from collection to testing (seven intervals over the course of 12 months) on the identification of PSA. We performed factorial analysis of variance to identify factors influencing PSA detection. RESULTS Concentrations of PSA detected in the swabs declined with time of storage over the 1-year experiment (p<.01). The 1-mL, rayon-tipped swab stored immediately at -80°C following collection performed best. CONCLUSIONS If immediate testing or freezer storage is not feasible, investigators should use a swab with 1-mL capacity with processing and testing as soon as possible after specimen collection.
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Affiliation(s)
- Maria F Gallo
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, Mail Stop K-34, Atlanta, GA 30341-3724, USA.
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15
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Kumari GR, Malati T. Stability of total and free prostate specific antigen in serum samples at different storage conditions. Indian J Clin Biochem 2012; 19:10-3. [PMID: 23105449 DOI: 10.1007/bf02894250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The present preliminary study was performed to find out stability of total prostate specific antigen (PSA) and free prostate specific antigen (FPSA) in serum of healthy males as well as in patients of benign and malignant disorders of prostate at various freezing and nonfreezing temperatures and at different duration of time.The results of our study indicated long-term stability of both the analytes in frozen serum. Serum total and free PSA were stable only for three to four days in regular refrigerators in unfrozen states. Clotted blood kept at room temperature (25°C-30°C) did not cause change in concentrations of both the analytes for twenty four hours.
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Affiliation(s)
- G Rajani Kumari
- Department of Biochemistry, Nizam's Institute of Medical Sciences, Punjagutta, 500 082 Hyderabad, India
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16
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Prensner JR, Rubin MA, Wei JT, Chinnaiyan AM. Beyond PSA: the next generation of prostate cancer biomarkers. Sci Transl Med 2012; 4:127rv3. [PMID: 22461644 DOI: 10.1126/scitranslmed.3003180] [Citation(s) in RCA: 332] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Since the introduction of serum prostate-specific antigen (PSA) screening 25 years ago, prostate cancer diagnosis and management have been guided by this biomarker. Yet, PSA has proven controversial as a screening assay owing to several inherent limitations. The next wave of prostate cancer biomarkers has emerged, introducing new assays in serum and urine that may supplement or, in time, replace PSA because of their higher cancer specificity. This expanding universe of biomarkers has been facilitated, in large part, by new genomic technologies that have enabled an unbiased look at cancer biology. Such efforts have produced several notable success stories that involve rapidly moving biomarkers from the bench to the clinic. However, biomarker research has centered on disease diagnostics, rather than prognosis and prediction, which would address disease management. The development of biomarkers to stratify risk of prostate cancer aggressiveness at the time of screening remains the greatest unmet clinical need in prostate cancer. We review the current state of prostate cancer biomarker research, including the PSA revolution, its impact on early cancer detection, the recent advances in biomarker discovery, and the future efforts that promise to improve clinical management of this disease.
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Affiliation(s)
- John R Prensner
- Michigan Center for Translational Pathology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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17
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Pal RP, Maitra NU, Mellon JK, Khan MA. Defining prostate cancer risk before prostate biopsy. Urol Oncol 2012; 31:1408-18. [PMID: 22795499 DOI: 10.1016/j.urolonc.2012.05.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 05/29/2012] [Accepted: 05/31/2012] [Indexed: 12/24/2022]
Abstract
Prostate cancer is the most commonly diagnosed cancer in men. At present, patients are selected for prostate biopsy on the basis of age, serum prostate specific antigen (PSA), and prostatic digital rectal examination (DRE) findings. However, due to limitations in the use of PSA and DRE, many patients undergo unnecessary prostate biopsy. A further problem arises as many patients are diagnosed and treated for indolent disease. This review of the literature highlights the strengths and weaknesses of existing methods of prebiopsy risk stratification and evaluates promising serum, urine, and radiologic prostate cancer biomarkers, which may improve risk stratification for prostate biopsy in the future.
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Affiliation(s)
- Raj P Pal
- University Hospitals of Leicester NHS Trust, Department of Urology, Leicester General Hospital, Leicester, LE5 4PW, UK.
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18
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Baden J, Adams S, Astacio T, Jones J, Markiewicz J, Painter J, Trust C, Wang Y, Green G. Predicting prostate biopsy result in men with prostate specific antigen 2.0 to 10.0 ng/ml using an investigational prostate cancer methylation assay. J Urol 2011; 186:2101-6. [PMID: 21944123 DOI: 10.1016/j.juro.2011.06.052] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Indexed: 11/20/2022]
Abstract
PURPOSE The inadequacies of prostate specific antigen testing have created a need for novel markers for prostate cancer screening. The investigational ProCaM™ prostate cancer methylation assay detects aberrant methylation of DNA in cells associated with prostate cancer. We describe a large, prospective, multicenter study done to verify the performance of this assay. MATERIALS AND METHODS The assay is designed to detect epigenetic modifications in the 3 markers GSTP1, RARβ2 and APC, which are indicative of prostate cancer. A total of 232 men with cancer and 283 without cancer from 18 clinical sites were evaluated by trained operators at central testing laboratories. Study inclusion criteria were age 40 to 75 years, total prostate specific antigen between 2.0 and 10.0 ng/ml, and a digital rectal examination result. All participants signed an informed consent form and underwent transrectal ultrasound guided needle biopsy with 10 or more cores. RESULTS Assay sensitivity was 60%, specificity was 80% and the informative rate was 97%. Assay predictive accuracy was higher than that of age, digital rectal examination, family history, prostate specific antigen, prior negative biopsy and prostate volume (AUC 0.73 vs 0.52 to 0.66, p <0.038). Risk factors plus the assay improved overall predictive power (AUC 0.79, p = 0.001). A man with a positive prostate cancer methylation result was 7.7 times more likely to have high grade cancer. CONCLUSIONS The prostate cancer methylation assay correlated with positive biopsy and with Gleason score. This assay has the potential to add value to the biopsy decision making process by improving current prostate cancer screening algorithms to more accurately identify men with prostate cancer.
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Affiliation(s)
- Jonathan Baden
- Ortho Clinical Diagnostics, Johnson&Johnson Co, Raritan, New Jersey 08869, USA.
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19
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Djavan B, Kazzazi A, Dulabon L, Margreiter M, Farr A, Handl MJ, Lepor H. Diagnostic Strategies for Prostate Cancer. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.eursup.2011.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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20
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Duffy MJ. Prostate-specific antigen: does the current evidence support its use in prostate cancer screening? Ann Clin Biochem 2011; 48:310-6. [DOI: 10.1258/acb.2011.010273] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Although widely used, the value of prostate-specific antigen (PSA) in screening asymptomatic men for prostate cancer is controversial. Reasons for the controversy relate to PSA being less than an ideal marker in detecting early prostate cancer, the possibility that screening for prostate cancer may result in the overdetection and thus overtreatment of indolent disease and the lack of clarity as to the definitive or best treatment for men diagnosed with localized prostate cancer. Although the results from some randomized prospective trials suggest that screening with PSA reduces mortality from prostate cancer, the overall benefit was modest. It is thus currently unclear as to whether the modest benefit of reduced mortality outweighs the harms of overdetection and overtreatment. Thus, prior to undergoing screening for prostate cancer, men should be informed of the risks and benefits of early detection. Newly emerging markers that may complement PSA in the early detection of prostate cancer include specific isoforms of PSA and PCA3.
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Affiliation(s)
- Michael J Duffy
- Department of Pathology and Laboratory Medicine, St Vincent's University Hospital, Dublin and UCD School of Medicine and Medical Science, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
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21
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Gupta A, Lilja H. Editorial comment. Urology 2011; 77:903-4; author reply 904. [PMID: 21477718 DOI: 10.1016/j.urology.2010.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 08/11/2010] [Accepted: 08/21/2010] [Indexed: 10/18/2022]
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22
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Peltola MT, Niemelä P, Väisänen V, Viitanen T, Alanen K, Nurmi M, Pettersson K. Intact and Internally Cleaved Free Prostate-Specific Antigen in Patients With Prostate Cancer With Different Pathologic Stages and Grades. Urology 2011; 77:1009.e1-8. [DOI: 10.1016/j.urology.2010.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Revised: 10/26/2010] [Accepted: 11/04/2010] [Indexed: 10/18/2022]
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23
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Serum-based ALYGNSA immunoassay for the prostate cancer biomarker, total prostate-specific antigen (tPSA). Anal Bioanal Chem 2010; 397:3151-4. [PMID: 20556365 DOI: 10.1007/s00216-010-3827-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Revised: 05/03/2010] [Accepted: 05/04/2010] [Indexed: 10/19/2022]
Abstract
Prostate-specific antigen (PSA) is a serum glycoprotein overproduced by the prostate in prostate cancer (> or = 4 ng/mL in the bloodstream). An immunoassay for total PSA (tPSA) was developed using the ALYGNSA method to enhance capture antibody orientation and a limit of detection of 0.63 ng/mL was reported, a limit 15-fold lower than a commercial tPSA ELISA assay. This ALYGNSA assay, however, was performed using only buffer-based proteins and blocking agents (Mackness et al., Anal Bioanal Chem 396:681-686, 2010). To improve the clinical application of this system, a serum-based tPSA ALYGNSA was developed employing human serum. This assay also resulted in a limit of detection of 0.63 ng/mL of tPSA protein. The findings reported here provide support for the clinical application of this assay for diagnosis, progression, treatment, and possible recurrence of prostate cancer.
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24
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Swoboda A, Luboldt HJ, Rübben H, Börgermann C. Der Quotient f/t-PSA in klinischer und ambulanter Anwendung. Urologe A 2009; 48:1002, 1004, 1006-7. [DOI: 10.1007/s00120-009-2075-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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25
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The f/t-PSA ratio in diagnosis of in-patients and out-patients: a unitary cutoff value is not useful! World J Urol 2009; 27:581-5. [PMID: 19562347 DOI: 10.1007/s00345-009-0441-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Accepted: 06/15/2009] [Indexed: 10/20/2022] Open
Abstract
PURPOSE In the prostate specific antigen (PSA) range of 4-10 ng/ml after a negative digital rectal examination, the PSA value indicates a lack of specificity with a carcinoma detection rate of roughly 20%. To improve the biopsy/carcinoma ratio, the interdisciplinary consensus recommends free PSA (fPSA) measurement. This does not take into account the pre-analysis when the cutoff value is established for biopsy indication. METHODS In the present study, an in-patient cohort whose blood samples were immediately analysed was compared with an out-patient cohort whose sample processing was delayed by between 24 and 48 h. RESULTS The in-patient cohort comprises 382 patients with 99 prostate carcinomas, the out-patient cohort 987 patients with 235 carcinomas. In the in-patient cohort a sensitivity of 90% with a cutoff value of 25% for the f/t-PSA ratios is achieved with the theoretical possibility of reducing the number of punch biopsies by 34.6%. A sensitivity of 90% in the out-patient cohort necessitates a cutoff value of 18% for the f/t-PSA ratios. The specificity is 35.3% with a possible biopsy reduction of 29.1%. CONCLUSIONS The cutoff values from cohorts with an immediate fPSA measurement cannot be adopted for a typical out-patient cohort whose analyses are delayed. On the contrary, an individual adjustment is necessary which corresponds to the pre-analysis.
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26
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EL Ezzi AA, EL-Saidi MA. Stability of total and free prostate specific antigen in serum submitted to intermittent cold storage conditions. Indian J Clin Biochem 2009; 24:166-74. [DOI: 10.1007/s12291-009-0030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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27
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Affiliation(s)
- Danil V. Makarov
- The James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland; ; ;
| | - Stacy Loeb
- The James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland; ; ;
| | - Robert H. Getzenberg
- The James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland; ; ;
| | - Alan W. Partin
- The James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland; ; ;
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28
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Park JT, Kim SJ, Ahn HS, Kim YS, Choi JB, Kim SI. Short-term Prostate-Specific Antigen Velocity Measurement before Prostate Biopsy. Korean J Urol 2009. [DOI: 10.4111/kju.2009.50.6.553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Jong Tak Park
- Department of Urology, Ajou University School of Medicine, Suwon, Korea
| | - Se Joong Kim
- Department of Urology, Ajou University School of Medicine, Suwon, Korea
| | - Hyun Soo Ahn
- Department of Urology, Ajou University School of Medicine, Suwon, Korea
| | - Young Soo Kim
- Department of Urology, Ajou University School of Medicine, Suwon, Korea
| | - Jong Bo Choi
- Department of Urology, Ajou University School of Medicine, Suwon, Korea
| | - Sun Il Kim
- Department of Urology, Ajou University School of Medicine, Suwon, Korea
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29
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Wenske S, Korets R, Cronin AM, Vickers AJ, Fleisher M, Scher HI, Pettersson K, Guillonneau B, Scardino PT, Eastham JA, Lilja H. Evaluation of molecular forms of prostate-specific antigen and human kallikrein 2 in predicting biochemical failure after radical prostatectomy. Int J Cancer 2008; 124:659-63. [PMID: 19003994 DOI: 10.1002/ijc.23983] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Most pretreatment risk-assessment models to predict biochemical recurrence (BCR) after radical prostatectomy (RP) for prostate cancer rely on total prostate-specific antigen (PSA), clinical stage, and biopsy Gleason grade. We investigated whether free PSA (fPSA) and human glandular kallikrein-2 (hK2) would enhance the predictive accuracy of this standard model. Preoperative serum samples and complete clinical data were available for 1,356 patients who underwent RP for localized prostate cancer from 1993 to 2005. A case-control design was used, and conditional logistic regression models were used to evaluate the association between preoperative predictors and BCR after RP. We constructed multivariable models with fPSA and hK2 as additional preoperative predictors to the base model. Predictive accuracy was assessed with the area under the ROC curve (AUC). There were 146 BCR cases; the median follow up for patients without BCR was 3.2 years. Overall, 436 controls were matched to 146 BCR cases. The AUC of the base model was 0.786 in the entire cohort; adding fPSA and hK2 to this model enhanced the AUC to 0.798 (p=0.053), an effect largely driven by fPSA. In the subgroup of men with total PSA<or=10 ng/ml (48% of cases), adding fPSA and hK2 enhanced the AUC of the base model to a similar degree (from 0.720 to 0.726, p=0.2). fPSA is routinely measured during prostate cancer detection. We suggest that the role of fPSA in aiding preoperative prediction should be investigated in further cohorts.
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Affiliation(s)
- Sven Wenske
- Department of Surgery (Urology Service), Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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30
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Sturgeon CM, Duffy MJ, Stenman UH, Lilja H, Brünner N, Chan DW, Babaian R, Bast RC, Dowell B, Esteva FJ, Haglund C, Harbeck N, Hayes DF, Holten-Andersen M, Klee GG, Lamerz R, Looijenga LH, Molina R, Nielsen HJ, Rittenhouse H, Semjonow A, Shih IM, Sibley P, Sölétormos G, Stephan C, Sokoll L, Hoffman BR, Diamandis EP. National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for Use of Tumor Markers in Testicular, Prostate, Colorectal, Breast, and Ovarian Cancers. Clin Chem 2008; 54:e11-79. [DOI: 10.1373/clinchem.2008.105601] [Citation(s) in RCA: 458] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Background: Updated National Academy of Clinical Biochemistry (NACB) Laboratory Medicine Practice Guidelines for the use of tumor markers in the clinic have been developed.
Methods: Published reports relevant to use of tumor markers for 5 cancer sites—testicular, prostate, colorectal, breast, and ovarian—were critically reviewed.
Results: For testicular cancer, α-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase are recommended for diagnosis/case finding, staging, prognosis determination, recurrence detection, and therapy monitoring. α-Fetoprotein is also recommended for differential diagnosis of nonseminomatous and seminomatous germ cell tumors. Prostate-specific antigen (PSA) is not recommended for prostate cancer screening, but may be used for detecting disease recurrence and monitoring therapy. Free PSA measurement data are useful for distinguishing malignant from benign prostatic disease when total PSA is <10 μg/L. In colorectal cancer, carcinoembryonic antigen is recommended (with some caveats) for prognosis determination, postoperative surveillance, and therapy monitoring in advanced disease. Fecal occult blood testing may be used for screening asymptomatic adults 50 years or older. For breast cancer, estrogen and progesterone receptors are mandatory for predicting response to hormone therapy, human epidermal growth factor receptor-2 measurement is mandatory for predicting response to trastuzumab, and urokinase plasminogen activator/plasminogen activator inhibitor 1 may be used for determining prognosis in lymph node–negative patients. CA15-3/BR27–29 or carcinoembryonic antigen may be used for therapy monitoring in advanced disease. CA125 is recommended (with transvaginal ultrasound) for early detection of ovarian cancer in women at high risk for this disease. CA125 is also recommended for differential diagnosis of suspicious pelvic masses in postmenopausal women, as well as for detection of recurrence, monitoring of therapy, and determination of prognosis in women with ovarian cancer.
Conclusions: Implementation of these recommendations should encourage optimal use of tumor markers.
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Affiliation(s)
- Catharine M Sturgeon
- Department of Clinical Biochemistry, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael J Duffy
- Department of Pathology and Laboratory Medicine, St Vincent’s University Hospital and UCD School of Medicine and Medical Science, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
| | - Ulf-Håkan Stenman
- Department of Clinical Chemistry, Helsinki University Central Hospital, Helsinki, Finland
| | - Hans Lilja
- Departments of Clinical Laboratories, Urology, and Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Nils Brünner
- Section of Biomedicine, Department of Veterinary Pathobiology, Faculty of Life Sciences, University of Copenhagen, Denmark
| | - Daniel W Chan
- Departments of Pathology and Oncology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Richard Babaian
- Department of Urology, The University of Texas Anderson Cancer Center, Houston, TX
| | - Robert C Bast
- Department of Experimental Therapeutics, University of Texas Anderson Cancer Center, Houston, Texas, USA
| | | | - Francisco J Esteva
- Departments of Breast Medical Oncology, Molecular and Cellular Oncology, University of Texas M.D. Anderson Cancer Center, Houston TX
| | - Caj Haglund
- Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Nadia Harbeck
- Frauenklinik der Technischen Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Daniel F Hayes
- Breast Oncology Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
| | - Mads Holten-Andersen
- Section of Biomedicine, Department of Veterinary Pathobiology, Faculty of Life Sciences, University of Copenhagen, Denmark
| | - George G Klee
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN
| | - Rolf Lamerz
- Department of Medicine, Klinikum of the University of Munich, Grosshadern, Germany
| | - Leendert H Looijenga
- Laboratory of Experimental Patho-Oncology, Erasmus MC-University Medical Center Rotterdam, and Daniel den Hoed Cancer Center, Rotterdam, the Netherlands
| | - Rafael Molina
- Laboratory of Biochemistry, Hospital Clinico Provincial, Barcelona, Spain
| | - Hans Jørgen Nielsen
- Department of Surgical Gastroenterology, Hvidovre Hospital, Copenhagen, Denmark
| | | | - Axel Semjonow
- Prostate Center, Department of Urology, University Clinic Muenster, Muenster, Germany
| | - Ie-Ming Shih
- Departments of Pathology and Oncology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Paul Sibley
- Siemens Medical Solutions Diagnostics, Glyn Rhonwy, Llanberis, Gwynedd, UK
| | | | - Carsten Stephan
- Department of Urology, Charité Hospital, Universitätsmedizin Berlin, Berlin, Germany
| | - Lori Sokoll
- Departments of Pathology and Oncology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Barry R Hoffman
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, and Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada
| | - Eleftherios P Diamandis
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, and Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada
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Reed AB, Ankerst DP, Leach RJ, Vipraio G, Thompson IM, Parekh DJ. Total Prostate Specific Antigen Stability Confirmed After Long-Term Storage of Serum at −80C. J Urol 2008; 180:534-7; discussion 537-8. [DOI: 10.1016/j.juro.2008.04.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Indexed: 10/22/2022]
Affiliation(s)
- Amanda Beth Reed
- Department of Urology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | - Donna Pauler Ankerst
- Department of Urology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | - Robin J. Leach
- Department of Urology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | - Gilbert Vipraio
- Department of Urology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | - Ian M. Thompson
- Department of Urology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | - Dipen J. Parekh
- Department of Urology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
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Vickers AJ, Cronin AM, Aus G, Pihl CG, Becker C, Pettersson K, Scardino PT, Hugosson J, Lilja H. A panel of kallikrein markers can reduce unnecessary biopsy for prostate cancer: data from the European Randomized Study of Prostate Cancer Screening in Göteborg, Sweden. BMC Med 2008; 6:19. [PMID: 18611265 PMCID: PMC2474851 DOI: 10.1186/1741-7015-6-19] [Citation(s) in RCA: 179] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 07/08/2008] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Prostate-specific antigen (PSA) is widely used to detect prostate cancer. The low positive predictive value of elevated PSA results in large numbers of unnecessary prostate biopsies. We set out to determine whether a multivariable model including four kallikrein forms (total, free, and intact PSA, and human kallikrein 2 (hK2)) could predict prostate biopsy outcome in previously unscreened men with elevated total PSA. METHODS The study cohort comprised 740 men in Göteborg, Sweden, undergoing biopsy during the first round of the European Randomized study of Screening for Prostate Cancer. We calculated the area-under-the-curve (AUC) for predicting prostate cancer at biopsy. AUCs for a model including age and PSA (the 'laboratory' model) and age, PSA and digital rectal exam (the 'clinical' model) were compared with those for models that also included additional kallikreins. RESULTS Addition of free and intact PSA and hK2 improved AUC from 0.68 to 0.83 and from 0.72 to 0.84, for the laboratory and clinical models respectively. Using a 20% risk of prostate cancer as the threshold for biopsy would have reduced the number of biopsies by 424 (57%) and missed only 31 out of 152 low-grade and 3 out of 40 high-grade cancers. CONCLUSION Multiple kallikrein forms measured in blood can predict the result of biopsy in previously unscreened men with elevated PSA. A multivariable model can determine which men should be advised to undergo biopsy and which might be advised to continue screening, but defer biopsy until there was stronger evidence of malignancy.
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Affiliation(s)
- Andrew J Vickers
- Memorial Sloan-Kettering Cancer Center, Department of Epidemiology and Biostatistics, East 63rd Street, New York, NY 10021, USA.
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Effect of thrombin tube on PSA determination, a clue for false negative in screening for prostate cancer. J Thromb Thrombolysis 2008; 27:223-6. [PMID: 18297239 DOI: 10.1007/s11239-008-0200-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Accepted: 01/21/2008] [Indexed: 10/22/2022]
Abstract
Prostate cancer is an important male carcinoma. Laboratory screening for tumor marker is the routine preventive strategy for control of this cancer. For screening, prostate specific antigen (PSA) has been proposed as a marker in the serum. In this article, the author assesses the effect of new blood collection tube, thrombin tube, on the analysis of the PSA by bioinformatics technique. Using GoFigure server, the molecular functions of thrombin, PSA and thrombin-PSA were predicted. A significant change of molecular function due to the interaction between thrombin and PSA can be found. Increased of coagulation due to the synergistic clot activation can be expected. If this occurs, the false negative can be expected and it can bring the underdiagnosis of early prostate cancer. Therefore, the recommendation for usage of thrombin tube for PSA test should be modified from general usage. Shortening of the period between blood collection and sample analysis than general case must be done.
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Gao YC, Yuan ZB, Yang YD, Lu HK. Effect of freeze-thaw cycles on serum measurements of AFP, CEA, CA125 and CA19-9. Scand J Clin Lab Invest 2008; 67:741-7. [PMID: 17852813 DOI: 10.1080/00365510701297480] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AFP, CEA, CA125 and CA19-9 are commonly used serum tumour markers (TMs) in clinical practice, although their quantification by immunoassay may be influenced by pre-analytical sample handling. Though the effect of repetitive freeze-thaw cycles is generally recognized, it is not clear in detail. The present study measured (CLIA) these TMs in serum samples freshly separated and after each of five freeze-thaw cycles, in which the samples were frozen at -40 degrees C for 10 months at cycle 4 and 2 h at other cycles. Statistical analysis with the General Linear Model for Repeated Measures revealed significant decreases in the measurements of the four TMs, with the least decrease of 6.8 % for CA125 and the most decrease of 18.2 % for CA19-9 after the last cycle, and an overwhelming single cycle decrease of mean 7.7 % at cycle 4 for AFP, CEA and CA125, of 7.5 % and 9.3 % at cycles 4 and 5 for CA19-9. So it seems that measurements of AFP, CEA and CA125 are more readily affected by long-term frozen storage compared with frequent freezing-thawing, while CA19-9 is relatively unstable under both conditions.
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Affiliation(s)
- Y-C Gao
- The Immunoassay Laboratory, Department of Nuclear Medicine, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China.
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36
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Banfi G, Salvagno GL, Lippi G. The role of ethylenediamine tetraacetic acid (EDTA) as in vitro anticoagulant for diagnostic purposes. Clin Chem Lab Med 2007; 45:565-76. [PMID: 17484616 DOI: 10.1515/cclm.2007.110] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Anticoagulants are used to prevent clot formation both in vitro and in vivo. In the specific field of in vitro diagnostics, anticoagulants are commonly added to collection tubes either to maintain blood in the fluid state for hematological testing or to obtain suitable plasma for coagulation and clinical chemistry analyses. Unfortunately, no universal anticoagulant that could be used for evaluation of several laboratory parameters in a sample from a single test tube is available so far. Ethylenediamine tetraacetic acid (EDTA) is a polyprotic acid containing four carboxylic acid groups and two amine groups with lone-pair electrons that chelate calcium and several other metal ions. Calcium is necessary for a wide range of enzyme reactions of the coagulation cascade and its removal irreversibly prevents blood clotting within the collection tube. Historically, EDTA has been recommended as the anticoagulant of choice for hematological testing because it allows the best preservation of cellular components and morphology of blood cells. The remarkable expansion in laboratory test volume and complexity over recent decades has amplified the potential spectrum of applications for this anticoagulant, which can be used to stabilize blood for a variety of traditional and innovative tests. Specific data on the behavior of EDTA as an anticoagulant in hematology, including possible pitfalls, are presented. The use of EDTA for measuring cytokines, protein and peptides, and cardiac markers is described, with an outline of the protection of labile molecules provided by this anticoagulant. The use of EDTA in proteomics and in general clinical chemistry is also described in comparison with other anticoagulants and with serum samples. Finally, the possible uses of alternative anticoagulants instead of EDTA and the potential use of a universal anticoagulant are illustrated.
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Affiliation(s)
- Giuseppe Banfi
- IRCCS Galeazzi and Chair of Clinical Biochemistry, School of Medicine, University of Milan, Milano, Italy.
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Fall K, Garmo H, Andrén O, Bill-Axelson A, Adolfsson J, Adami HO, Johansson JE, Holmberg L. Prostate-Specific Antigen Levels as a Predictor of Lethal Prostate Cancer. J Natl Cancer Inst 2007; 99:526-32. [PMID: 17405997 DOI: 10.1093/jnci/djk110] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Rates of long-term survival among patients with untreated localized prostate cancer are high. To avoid unnecessary treatment, tools are needed to identify the small proportion of patients who are destined to develop lethal prostate cancer. METHODS To evaluate the accuracy of early changes in prostate-specific antigen (PSA) levels as predictors of prostate cancer outcome, we assessed serial measurements of PSA level among 267 men with localized prostate cancer in a Scandinavian cohort of men who were diagnosed between 1989 and 1999 and who were managed by watchful waiting. We then 1) fitted individual regression lines to the PSA values assessed for each patient during the first 2 years of follow-up by using three different models, 2) evaluated early PSA curve characteristics as determinants of the cumulative incidence of lethal prostate cancer and calculated hazard ratios for baseline PSA value and rate of change in PSA level to prostate cancer outcome, and 3) plotted time-dependent receiver operating characteristic (ROC) curves. All P values are two-sided. RESULTS During complete follow-up for a mean of 8.5 years, 34 patients (13%) died from prostate cancer, and 18 (7%) developed metastases but were still alive at end of follow-up. In a log-linear model, both PSA value at baseline (P = .05) and the rate of PSA change (P<.001) were associated with the development of lethal prostate cancer. In the ROC analysis, however, the accuracy of classifying the disease as either indolent or destined to progress was low, regardless of the cut point chosen for initial PSA level or rate of change in PSA level. CONCLUSIONS Although baseline PSA value and rate of PSA change are prognostic factors for lethal prostate cancer, they are poor predictors of lethal prostate cancer among patients with localized prostate cancer who are managed by watchful waiting.
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Affiliation(s)
- Katja Fall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Box 281, S-171 77 Stockholm, Sweden.
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Lilja H, Ulmert D, Björk T, Becker C, Serio AM, Nilsson JA, Abrahamsson PA, Vickers AJ, Berglund G. Long-Term Prediction of Prostate Cancer Up to 25 Years Before Diagnosis of Prostate Cancer Using Prostate Kallikreins Measured at Age 44 to 50 Years. J Clin Oncol 2007; 25:431-6. [PMID: 17264339 DOI: 10.1200/jco.2006.06.9351] [Citation(s) in RCA: 161] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposeWe examined whether prostate-specific antigen (PSA) forms and human kallikrein 2 (hK2) measured at age 44 to 50 years predict long-term risk of incident prostate cancer.MethodsFrom 1974 to 1986, 21,277 men age ≤ 50 years in Malmö, Sweden, enrolled onto a cardiovascular study (74% participation). The rate of PSA screening in this population is low. According to the Swedish Cancer Registry, 498 were later diagnosed with prostate cancer. We measured hK2, free PSA, and total PSA (tPSA) in archived blood plasma from 462 participants later diagnosed with prostate cancer and from 1,222 matched controls. Conditional logistic regression was used to test for association of prostate cancer with hK2 and PSA forms measured at baseline.ResultsMedian delay between venipuncture and prostate cancer diagnosis was 18 years. hK2 and all PSA forms were strongly associated with prostate cancer (all P < .0005). None of the 90 anthropometric, lifestyle, biochemical, and medical history variables measured at baseline was importantly predictive. A tPSA increase of 1 ng/mL was associated with an increase in odds of cancer of 3.69 (95% CI, 2.99 to 4.56); addition of other PSA forms or hK2 did not add to the predictive value of tPSA. tPSA remained predictive for men diagnosed ≥ 20 years after venipuncture, and the predictive value remained unchanged in an analysis restricted to palpable disease.ConclusionA single PSA test at age 44 to 50 years predicts subsequent clinically diagnosed prostate cancer. This raises the possibility of risk stratification for prostate cancer screening programs.
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Affiliation(s)
- Hans Lilja
- Department of Laboratory Medicine, Lund University, University Hospital UMAS, Malmö, Sweden.
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Steuber T, Vickers A, Haese A, Kattan MW, Eastham JA, Scardino PT, Huland H, Lilja H. Free PSA isoforms and intact and cleaved forms of urokinase plasminogen activator receptor in serum improve selection of patients for prostate cancer biopsy. Int J Cancer 2007; 120:1499-504. [PMID: 17205511 DOI: 10.1002/ijc.22427] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Clinicians currently use simple cut-points, such as serum prostate-specific antigen (PSA) >or=4 ng/ml, to decide whether to recommend further work-up for prostate cancer (PCa). As an alternative strategy, we evaluated multivariable models giving probabilities of a PCa diagnosis based on PSA and several circulating novel biomarkers. We measured total PSA, free PSA (fPSA), fPSA subfractions (single-chain fPSA-I and multichain fPSA-N), total human glandular kallikrein 2 (hK2) and full-length and cleaved forms of soluble urokinase plasminogen activator receptor (suPAR) in pretreatment serum from 355 men referred for prostate biopsy. Age and total PSA were combined in a "base" regression model to predict biopsy outcome. We then compared this base model to models supplemented by various combinations of circulating markers, using concordance index (AUC) to measure diagnostic discrimination. PCa prediction was significantly enhanced by models supplemented by measurements of suPAR fragments and fPSA isoforms. Addition of these markers improved bootstrap-corrected AUC from 0.611 for a cut-point and 0.706 for the base model to 0.754 for the full model (p=0.005). This improved diagnostic accuracy was also seen in subanalysis of patients with PSA 2-9.99 ng/ml and normal findings on DRE (0.652 vs. 0.715, p=0.039). In this setting, hK2 did not add diagnostic information. Measurements of individual forms of suPAR and PSA isoforms contributed significantly to discrimination of men with PCa from those with no evidence of malignancy.
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Affiliation(s)
- Thomas Steuber
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Abstract
Screening for prostate cancer is currently based on the assessment of blood prostate specific antigen (PSA). Although PSA was shown to be an adequate tool in prostate cancer screening, beginning from 4.0 ng/mL, its specificity is less significant. In men with a PSA between 4.0 and 10 ng/mL its predictive value is low. Therefore, there is a need for new instruments likely to improve the specificity of blood PSA levels between 4.0 and 10 ng/mL and the screening for prostate cancer in subjects with low PSA. Recent data are reviewed.
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Affiliation(s)
- C Seitz
- Dept. of Urology, Medical University of Vienna, 18-20, Xähringer-Gürte, 1090 Vienna, Austria
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Steuber T, Vickers AJ, Haese A, Becker C, Pettersson K, Chun FKH, Kattan MW, Eastham JA, Scardino PT, Huland H, Lilja H. Risk assessment for biochemical recurrence prior to radical prostatectomy: significant enhancement contributed by human glandular kallikrein 2 (hK2) and free prostate specific antigen (PSA) in men with moderate PSA-elevation in serum. Int J Cancer 2006; 118:1234-40. [PMID: 16152616 PMCID: PMC1950472 DOI: 10.1002/ijc.21474] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Most models to predict biochemical recurrence (BCR) of prostate cancer use pretreatment serum prostate-specific antigen (PSA), clinical stage and prostate biopsy Gleason grade. We investigated whether human glandular kallikrein 2 (hK2) and free prostate-specific antigen (fPSA) measured in pretreatment serum enhance prediction. We retrospectively measured total PSA (tPSA), fPSA and hK2 in preoperative serum samples from 461 men with localized prostate cancer treated with radical prostatectomy between 1999 and 2001. We developed a regression model to predict BCR using preoperative tPSA, clinical stage and biopsy Gleason grade. We then compared the predictive accuracy of this "base" model with a model with fPSA and hK2 as additional predictors. BCR was observed in 90 patients (20%), including 48 patients with a pretreatment tPSA < or = 14 ng/ml (13%), and 28 patients (10%) with a pretreatment tPSA < or = 10 ng/ml. Overall, the predictive accuracy of the base model (bootstrap-corrected concordance index of 0.813) was not improved after the addition of fPSA or hK2 (0.818). However, for men with moderate tPSA-elevation (tPSA < or = 10 ng/ml), addition of fPSA and hK2 data increased predictive accuracy (from a base model concordance index of 0.756-0.815, p = 0.005). The improvement in accuracy was not sensitive to the threshold for "moderately elevated" PSA. For patients with a moderate tPSA-elevation (tPSA < or = 10 ng/ml), which closely corresponds to concurrent disease demographics, BCR-prediction was enhanced when fPSA and hK2 were added to the conventional model. Measurements of fPSA and hK2 improve on our ability to counsel patients prior to treatment as to their risk of BCR.
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Affiliation(s)
- Thomas Steuber
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Ulmert D, Becker C, Nilsson JA, Piironen T, Björk T, Hugosson J, Berglund G, Lilja H. Reproducibility and Accuracy of Measurements of Free and Total Prostate-Specific Antigen in Serum vs Plasma after Long-Term Storage at −20 °C. Clin Chem 2006; 52:235-9. [PMID: 16384894 DOI: 10.1373/clinchem.2005.050641] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background: Long-term frozen storage may alter the results of prostate-specific antigen (PSA) measurements, mainly because of degradation of free PSA (fPSA) in vitro. We compared the effects of long-term storage on fPSA, total PSA (tPSA), and complexed PSA (cPSA) in serum vs EDTA-plasma samples.
Methods: We measured fPSA and tPSA concentrations in matched pairs of archival serum and EDTA-plasma samples (stored frozen at −20 °C for 20 years) from a large population-based cohort in Malmö, Sweden. We also compared concentrations in age-matched men with those in samples not subjected to long-term storage, obtained from participants in a population-based study of prostate cancer screening in Göteborg, Sweden. These contemporary samples were handled according to standardized preanalytical and analytical protocols aimed at minimizing in vitro degradation. tPSA and fPSA measurements were performed with a commercial assay (Prostatus Dual Assay; Perkin-Elmer Life Sciences).
Results: Concentrations of tPSA and fPSA and calculated cPSA (tPSA − fPSA) in archival plasma were not significantly different from those in contemporary serum from age-matched men. In archival serum, however, random variability of fPSA was higher vs plasma than in contemporary samples, whereas systematic error of fPSA analyses was similarly small in archival and contemporary serum and plasma.
Conclusions: Concentrations of tPSA and calculated cPSA were highly stable in plasma and serum samples subjected to long-term storage at −20 °C. Greater random variability, rather than a systematic decrease, may explain differences in fPSA analyses observed in archival serum.
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Affiliation(s)
- David Ulmert
- Department of Laboratory Medicine, Division of Clinical Chemistry, Lund University, University Hospital (UMAS), Malmö, Sweden.
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Nakano Y, Okamura K, Takamura S, Okamoto N, Narishima M, Yoshino Y, Hattori R, Ono Y, Ohshima S, Nagasaka T. Measurement of prostate specific antigen complexed to alpha1-antichymotrypsin to avoid unnecessary biopsy in patients with serum prostate specific antigen levels 4-20 ng/mL. Int J Urol 2005; 12:721-7. [PMID: 16174045 DOI: 10.1111/j.1442-2042.2005.01167.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To investigate whether measuring prostate specific antigen complexed to alpha1-Antichymotrypsin (PSA-ACT) can increase sensitivity and specificity in detecting prostate cancer. METHODS In this prospective study, we measured serum total PSA, PSA-ACT, free PSA, prostate volume and transition zone volume on 210 patients with total PSA level of 4-20 ng/mL. From fitted curves between positive predictive values for prostate cancer and age, prostate volume, transition zone volume, total PSA, PSA-ACT or F/T ratio, each function predicting prostate cancer was determined. Relative probabilities for prostate cancer (RPpca) which were defined by combined functions of age, F/T ratio, prostate volume or transition zone volume, and total PSA or PSA-ACT were calculated. Furthermore, using logistic regression, analysis was performed to determine the probability of prostate cancer. Receiver-operating characteristic analysis was performed to clarify the areas under the curve (AUC) for conventional single parameters, RPpca and logistic regression probability. RESULTS F/T ratio showed the largest AUC among conventional parameters. The AUC of RPpca was larger than those of F/T ratio and logistic regression probability. RPpca using the functions of age, transition zone volume, PSA-ACT and F/T ratio showed the largest AUC and highest specificity at sensitivity 95% level, however, specificities at sensitivity 90% and 85% were identical to those of RPpca using the functions of age, prostate volume, total PSA and F/T ratio. CONCLUSIONS RPpca using the functions of age, transition zone volume, PSA-ACT and F/T ratio was the best way to detect prostate cancer, however, the usefulness of PSA-ACT appears limited, considering the cost.
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Bruun L, Becker C, Hugosson J, Lilja H, Christensson A. Assessment of intra-individual variation in prostate-specific antigen levels in a biennial randomized prostate cancer screening program in Sweden. Prostate 2005; 65:216-21. [PMID: 15948137 PMCID: PMC1951509 DOI: 10.1002/pros.20286] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The degree of variability in prostate-specific antigen (PSA) measurements is important for interpreting test results in screening programs, and particularly for interpreting the significance of changes between repeated tests. This study aimed to determine the long-term intra-individual variation for PSA in healthy men. METHODS A randomly selected cohort of men in a biennial prostate cancer screening program (ERSPC) conducted in Sweden from 1995-1996 to 2001-2002. We studied men who had total PSA (tPSA) levels < 2.0 ng/ml in 2001-2002. This included 791 men with tPSA < or = 0.61 ng/ml (group A), 1,542 men with tPSA < or = 0.99 ng/ml (group B), and 1,029 men with tPSA 1.00-1.99 ng/ml (group C). The intra-individual variability of free PSA (fPSA) and tPSA was assessed by calculating coefficients of variation (CV) for each individual's PSA measurements from the first and second round of screening (1995-1996 and 1997-1998). RESULTS Intra-individual CV (geometric means) for tPSA were 13.7%, 12.7%, and 11.5% in groups A, B, and C, respectively. Corresponding CVs for fPSA were significantly lower, ranging from 12.1% to 10.4%. The estimated biological variation of tPSA and fPSA in groups A to C were 12.5%, 11.4%, 10.0% and 9.7%, 7.8%, 7.5%, respectively. CONCLUSIONS In healthy men with PSA levels less than 2 ng/ml, the natural long-term variability for tPSA was less than 14%, and with 95% probability, a change in tPSA greater than 30% indicates a change beyond normal random variation.
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Affiliation(s)
- Laila Bruun
- Department of Nephrology and Transplantation, Lund University, University Hospital (UMAS), Malmö, Sweden.
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Sävblom C, Malm J, Giwercman A, Nilsson JA, Berglund G, Lilja H. Blood levels of free-PSA but not complex-PSA significantly correlates to prostate release of PSA in semen in young men, while blood levels of complex-PSA, but not free-PSA increase with age. Prostate 2005; 65:66-72. [PMID: 15880475 DOI: 10.1002/pros.20254] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The proportion of free- and complex-prostate specific antigen (PSA) in serum is used for differentiating between benign and malignant prostate disease. To further understand the physiological relationship between PSA in seminal plasma and blood, we have analyzed free-PSA (fPSA) and complex-PSA (cPSA) in blood and PSA in seminal plasma in young healthy men. We also compared age-related changes of PSA-forms in blood from young versus older men. METHODS Total-PSA (tPSA), fPSA, and cPSA were measured in (i) blood and semen from 289 male conscripts (mean age 18.1 years) and in (ii) blood from a representative population of 1,389 men (mean age 46.5 years) without diagnosis of prostate cancer (PCa) during long-term follow-up. RESULTS fPSA in serum (r = 0.40, P < 0.0001) but not cPSA (r = 0.09, P = 0.11), correlates to PSA in seminal fluid. fPSA levels in blood in young (geometric mean: 0.20 ng/ml) versus middle-aged men (geometric mean: 0.18 ng/ml) was not different (P = 0.06), whereas cPSA in middle-aged men (geometric mean: 0.38 ng/ml) was higher (P < 0.0001) than in young men (geometric mean: 0.28 ng/ml). CONCLUSIONS fPSA in blood, but not cPSA, is associated to PSA in semen ( approximately 17% co-variation). In blood cPSA, but not fPSA, increase with age in healthy men, which may reflect an increasing incidence of prostate disease.
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Affiliation(s)
- Charlotta Sävblom
- Department of Laboratory Medicine, Division of Clinical Chemistry, Lund University, Malmö University Hospital, Malmö, Sweden.
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Donohue MJ, Satterfield MB, Dalluge JJ, Welch MJ, Girard JE, Bunk DM. Capillary electrophoresis for the investigation of prostate-specific antigen heterogeneity. Anal Biochem 2005; 339:318-27. [PMID: 15797573 DOI: 10.1016/j.ab.2005.01.043] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2004] [Indexed: 11/23/2022]
Abstract
Prostate-specific antigen (PSA) is a single-chain glycoprotein that is used as a biomarker for prostate-related diseases. PSA has one known posttranslational modification, a sialylated diantennary N-linked oligosaccharide attached to the asparagine residue N45. In this study capillary electrophoresis (CE) was employed to separate the isoforms of seven commercially available free PSA samples, two of which were specialized: enzymatically active PSA and noncomplexing PSA. The free PSA samples examined migrated as four to nine distinct, highly resolved peaks, indicating the presence of several isoforms differing in their oligosaccharide compositions. Overall, the use of CE provides a rapid, reproducible method for separation of PSA into its individual isoforms.
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Affiliation(s)
- Maura J Donohue
- Department of Chemistry, American University, Washington, DC 20016, USA.
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48
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Herrmann W, Stöckle M, Sand-Hill M, Hübner U, Herrmann M, Obeid R, Wullich B, Loch T, Geisel J. The measurement of complexed prostate-specific antigen has a better performance than total prostate-specific antigen. Clin Chem Lab Med 2005; 42:1051-7. [PMID: 15497472 DOI: 10.1515/cclm.2004.211] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study was to compare the diagnostic utility of complexed prostate-specific antigen (cPSA) with total PSA (tPSA) in screening for prostate cancer. Serum concentrations of tPSA and cPSA were measured in 4479 adult men during the prostate cancer screening program in the Saarland region (Germany). The percentage of men with c/tPSA ratio above the cut-off value of 0.75 increased with increasing tPSA intervals: tPSA 0-0.9 microg/l, 4.4%; 1.0-1.9 microg/l, 24.3%; 2.0-2.9 microg/l, 43.9%; 3.0-3.9 microg/l, 50.4%; and 4.0-20 microg/l, 60.2%. The commonly accepted tPSA cut-off value of 3.9 microg/l matched to the 93rd percentile of the overall population (corresponding cPSA value, 2.9 microg/l). A total of 202 men out of 313 with increased cPSA had increased c/tPSA ratio (cut-off > or = 0.75) vs. 186 out of 312 men with increased tPSA. Thus, an additional 16 men at high risk for prostate cancer were selected only if cPSA was utilised as a first line parameter. Our data show that, compared to tPSA, cPSA measurement will always detect more high-risk patients, independent of the cut-off levels utilised for cPSA, tPSA and c/tPSA ratio. cPSA is more effective than tPSA in selecting subjects with an elevated c/tPSA ratio who are at high risk of prostate cancer. Thus, cPSA might be seen as the superior first-line parameter in screening for prostate cancer. Using lower cut-off values for tPSA or cPSA than the commonly accepted values seems reasonable for screening purposes.
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Affiliation(s)
- Wolfgang Herrmann
- Department of Clinical Chemistry/Central Laboratory, University Hospital of Saarland, Homburg/Saar, Germany.
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Steuber T, Niemela P, Haese A, Pettersson K, Erbersdobler A, Felix Chun KH, Graefen M, Kattan MW, Huland H, Lilja H. Association of free-prostate specific antigen subfractions and human glandular kallikrein 2 with volume of benign and malignant prostatic tissue. Prostate 2005; 63:13-8. [PMID: 15378521 DOI: 10.1002/pros.20156] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND We investigated the association of different subfractions of prostate specific antigen (PSA) and human glandular kallikrein 2 (hK2), such as total PSA (tPSA), complexed PSA (cPSA), free PSA (fPSA), "single-chain Intact fPSA" (fPSA-I), "multi-chain nicked fPSA" (fPSA-N), and total hK2 with volumes of total prostate gland, transition zone (tz), and prostate cancer (PCa) tissue in patients with benign and malignant prostatic disease. METHODS Serum samples were collected from men with negative biopsy (n=164) and PCa (n=252). Total and fPSA were measured using a commercially immunoassay. We measured hK2 and fPSA-I by previously reported in-house research assays specific for hK2 and single-chain, non-cleaved fPSA, respectively. Levels of fPSA-N (=fPSA-fPSA-I) and cPSA (=tPSA-fPSA) were calculated. Total prostate and tz volume were measured using transrectal ultrasound (TRUS); PCa volume was calculated using a computer assisted volumetric program. Association with tz and cancer volumes (CaVols) was performed by linear regression analysis. RESULTS All PSA subfractions and hK2 were associated with tz volume in multivariable linear regression analysis. Only hK2, fPSA, and fPSA-N were significantly associated with CaVol in multivariable analysis, fPSA-I seemed to be cancer related. CONCLUSIONS The multi-chain fPSA-N subfractions of fPSA may be a valuable predictor of both benign prostate hyperplasia (BPH) and CaVol that is likely to be more useful in predicting tz volumes than CaVols. fPSA-I may provide information on cancer without being influenced by the presence of BPH.
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Affiliation(s)
- Thomas Steuber
- Department of Urology, University of Hamburg Eppendorf, Hamburg, Germany.
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Djavan B, Fong YK, Remzi M, Fakhari M, Marberger M. New Serum and Urinary Markers for Prostate Cancer Detection in the New Millennium. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/j.eursup.2004.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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