Derivatives of prostate-specific antigen as predictors of incidental prostate cancer

Prevalence and risk factors of incidental prostate cancer in certain surgeries for benign prostatic hyperplasia: A systematic review and meta-analysis

BACKGROUND

This study aimed to explore the prevalence and clinical risk factors in patients diagnosed with incidental prostate cancer (IPC) during certain surgeries (transurethral resection of the prostate [TURP], open prostatectomy [OP], and holmium laser enucleation of the prostate [HoLEP]) after clinically suspected benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Literature search of the MEDILINE, Web of Science, Embase, and Cochrane Library databases was performed to identify eligible studies published before June 2021. Multivariate adjusted odds ratios (ORs) and associated 95% confidence intervals (CIs) of the prevalence and clinical risk factors of IPC were calculated using random or fixed-effect models.

RESULTS

Twenty-three studies were included in the meta-analysis. Amongst the 94.783 patients, IPC was detected in 24.715 (26.1%). Results showed that the chance of IPC detection (10%, 95% CI: 0.07-4.00; P<0.001; I2=97%) in patients treated with TURP is similar to that of patients treated with HoLEP (9%, 95% CI: 0.07-0.11; P<0.001; I2=81.4%). However, the pooled prevalence estimate of patients treated with OP was 11% (95% CI: -0.03-0.25; P=0.113; I2=99.1%) with no statistical significance. We observed increased incidence of IPC diagnosis after BPH surgery amongst patients with higher prostate-specific antigen (PSA) level (OR: 1.13, 95% CI: 1.04-1.23; P=0.004; I2=89%), whereas no effect of age (OR: 1.02, 95% CI: 0.97-1.06; P=0.48; I2=78.8%) and prostate volume (OR: 0.99, 95% CI: 0.96-1.03; P=0.686; I2=80.5%) were observed.

CONCLUSIONS

The prevalence of IPC was similar amongst patients undergoing TURP, HoLEP, and OP for presumed BPH. Interestingly, increased PSA level was the only independent predictor of increasing risk of IPC after BPH surgery rather than age and prostate volume. Hence, future research should focus on predictors which accurately foretell the progression of prostate cancer to determine the optimal treatment for managing patients with IPC after BPH surgery.

Using clinical parameters to predict prostate cancer and reduce the unnecessary biopsy among patients with PSA in the gray zone

The gold standard for prostate cancer (PCa) diagnosis is prostate biopsy. However, it remines controversial as an invasive mean for patients with PSA levels in the gray zone (4–10 ng/mL). This study aimed to develop strategy to reduce the unnecessary prostate biopsy. We retrospectively identified 235 patients with serum total PSA testing in the gray zone before prostate biopsy between 2014 and 2018. Age, PSA derivates, prostate volume and multiparametric magnetic imaging (mpMRI) examination were assessed as predictors for PCa and clinically significant PCa with Gleason score ≥ 7 (CSPCa). Univariate analysis showed that prostate volume, PSAD, and mpMRI examination were significant predictors of PCa and CSPCa (P < 0.05). The differences of diagnostic accuracy between mpMRI examination (AUC = 0.69) and other clinical parameters in diagnostic accuracy for PCa were not statistically significant. However, mpMRI examination (AUC = 0.79) outperformed prostate volume and PSAD in diagnosis of CSPCa. The multivariate models (AUC = 0.79 and 0.84 for PCa and CSPCa) performed significantly better than mpMRI examination for detection of PCa (P = 0.003) and CSPCa (P = 0.036) among patients with PSA level in the gray zone. At the same level of sensitivity as the mpMRI examination to diagnose PCa, applying the multivariate models could reduce the number of biopsies by 5% compared with mpMRI examination. Overall, our results supported the view that the multivariate model could reduce unnecessary biopsies without compromising the ability to diagnose PCa and CSPCa. Further prospective validation is required.

Re-examining Prostate-specific Antigen (PSA) Density: Defining the Optimal PSA Range and Patients for Using PSA Density to Predict Prostate Cancer Using Extended Template Biopsy

OBJECTIVE

To compare the predictive accuracy of prostate-specific antigen (PSA) density vs PSA across different PSA ranges and by prior biopsy status in a prospective cohort undergoing prostate biopsy.

MATERIALS AND METHODS

Men from a prospective trial underwent an extended template biopsy to evaluate for prostate cancer at 26 sites throughout the United States. The area under the receiver operating curve assessed the predictive accuracy of PSA density vs PSA across 3 PSA ranges (<4 ng/mL, 4-10 ng/mL, >10 ng/mL). We also investigated the effect of varying the PSA density cutoffs on the detection of cancer and assessed the performance of PSA density vs PSA in men with or without a prior negative biopsy.

RESULTS

Among 1290 patients, 585 (45%) and 284 (22%) men had prostate cancer and significant prostate cancer, respectively. PSA density performed better than PSA in detecting any prostate cancer within a PSA of 4-10 ng/mL (area under the receiver operating characteristic curve [AUC]: 0.70 vs 0.53, P < .0001) and within a PSA >10 mg/mL (AUC: 0.84 vs 0.65, P < .0001). PSA density was significantly more predictive than PSA in detecting any prostate cancer in men without (AUC: 0.73 vs 0.67, P < .0001) and with (AUC: 0.69 vs 0.55, P < .0001) a previous biopsy; however, the incremental difference in AUC was higher among men with a previous negative biopsy. Similar inferences were seen for significant cancer across all analyses.

CONCLUSION

As PSA increases, PSA density becomes a better marker for predicting prostate cancer compared with PSA alone. Additionally, PSA density performed better than PSA in men with a prior negative biopsy.

PSA density improves the rate of prostate cancer detection in Chinese men with a PSA between 2.5-10.0 ng ml (-1) and 10.1-20.0 ng ml (-1) : a multicenter study

Chinese men should have a higher prostate-specific antigen (PSA) “gray zone” than the traditional value of 2.5–10.0 ng ml⁻¹ since the incidence of prostate cancer (PCa) in Chinese men is relative low. We hypothesized that PSA density (PSAD) could improve the rate of PCa detection in Chinese men with a PSA higher than the traditional PSA “gray zone.” A total of 461 men with a PSA between 2.5 and 20.0 ng ml⁻¹, who had undergone prostatic biopsy at two Chinese centers were included in the analysis. The men were then further divided into groups with a PSA between 2.5–10.0 ng ml⁻¹ and 10.1–20.0 ng ml⁻¹. Receiver operating characteristic (ROC) curve was used to evaluate the efficacy of PSA and PSAD for the diagnosis of PCa. In men with a PSA of 2.5–10.0 ng ml⁻¹ or 10.1–20.0 ng ml⁻¹, the areas under the ROC curve were higher for PSAD than for PSA. This was consistent across both centers and the cohort overall. When the entire cohort was considered, the optimal PSAD cut-off for predicting PCa in men with a PSA of 2.5–10.0 ng ml⁻¹ was 0.15 ng ml⁻¹ ml⁻¹, with a sensitivity of 64.4% and specificity of 64.6%. The optimal cut-off for PSAD in men with a PSA of 10.1–20.0 ng ml⁻¹ was 0.33 ng ml⁻¹ ml⁻¹, with a sensitivity of 60.3% and specificity of 82.7%. PSAD can improve the effectiveness for PCa detection in Chinese men with a PSA of 2.5–10.0 ng ml⁻¹ (traditional Western PSA “gray zone”) and 10.1–20.0 ng ml⁻¹ (Chinese PSA “gray zone”).

Screening for prostate cancer: an updated review

Prostate cancer is the most frequently diagnosed malignancy in men and its incidence has been increasing in the last decades. Diagnosis and treatment of prostate cancer were radically improved after the discovery of prostatic-specific antigen. Early detection rates increased, especially in asymptomatic individuals, confirmed by recent published randomized trials. The impact of screening in overdiagnosis and overtreatments is discussed, since benefits in overall mortality rates were not clearly demonstrated. Perhaps younger patients with a longer life expectancy would be the ones with the most benefits from screening. This study presents an update of the most important screening methods for prostate cancer as well as the recent recommendations for screening.

Preoperative clinical factors for diagnosis of incidental prostate cancer in the era of tissue-ablative surgery for benign prostatic hyperplasia: a korean multi-center review

PURPOSE

To identify potential predictive factors of incidental prostate cancer (IPca) in patients considering tissue-ablation treatment for benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

From the 11 centers, 1,613 men who underwent transurethral resection of the prostate (TURP) or open prostatectomy were included. Before surgery, prostate biopsy was performed in all patients with prostate-specific antigen (PSA) ≥4.0 ng/ml or with abnormal digital rectal examination (DRE) findings. The patients with prostate cancer preoperatively or with PSA >20 ng/ml were excluded. As predictive factors of IPca, age, body mass index, PSA, DRE, and transrectal ultrasonography (TRUS) findings, including total prostate volume (TPV), transition zone volume (TZV), and the presence of hypoechoic lesions, were reviewed. PSA density (PSAD) and PSAD in the transition zone (PSAD-TZV) were calculated.

RESULTS

IPca was diagnosed in 78 patients (4.8%). DRE findings, PSA, and TZV were independent predictive factors in the multivariate analysis. In the receiver operating characteristic curve analysis of PSA, PSAD, and PSAD-TZV, the area under the curve (AUC) was the largest for PSAD-TZV (AUC, 0.685).

CONCLUSIONS

IPca was detected in 4.8% of the population studied. In addition to DRE findings, the combination of TZV and PSA can be useful predictive factors of IPca in patients considering tissue-ablation treatment as well as TURP.

An improved prognostic model for stage T1a and T1b prostate cancer by assessments of cancer extent

Treatment decisions on prostate cancer diagnosed by trans-urethral resection (TURP) of the prostate are difficult. The current TNM staging system for pT1 prostate cancer has not been re-evaluated for 25 years. Our objective was to optimise the predictive power of tumor extent measurements in TURP of the prostate specimens. A total of 914 patients diagnosed by TURP of the prostate between 1990 and 1996, managed conservatively were identified. The clinical end point was death from prostate cancer. Diagnostic serum prostate-specific antigen (PSA) and contemporary Gleason grading was available. Cancer extent was measured by the percentage of chips infiltrated by cancer. Death rates were compared by univariate and multivariate proportional hazards models, including baseline PSA and Gleason score. The percentage of positive chips was highly predictive of prostate cancer death when assessed as a continuous variable or as a grouped variable on the basis of and including the quintiles, quartiles, tertiles and median groups. In the univariate model, the most informative variable was a four group-split (≤10%, >10-25%, >25-75% and >75%); (HR=2.08, 95% CI=1.8-2.4, P<0.0001). The same was true in a multivariate model (ΔX(2) (1 d.f.)=15.0, P=0.0001). The current cutoff used by TNM (<=5%) was sub-optimal (ΔX(2) (1 d.f.)=4.8, P=0.023). The current TNM staging results in substantial loss of information. Staging by a four-group subdivision would substantially improve prognostication in patients with early stage disease and also may help to refine management decisions in patients who would do well with conservative treatments.

Serum early prostate cancer antigen (EPCA) as a significant predictor of incidental prostate cancer in patients undergoing transurethral resection of the prostate for benign prostatic hyperplasia

BACKGROUND

Early prostate cancer antigen (EPCA), a nuclear matrix protein, has been recently suggested as a novel biomarker in malignant lesions of the prostate. This study was to determine whether preoperative serum EPCA levels predicted the presence of incidental prostate cancer (IPCa) in patients undergoing TURP for BPH.

METHODS

Serum EPCA levels were measured by ELISA in 449 consecutive patients with symptomatic BPH treated with TURP and 112 healthy men. Predictive performance of serum EPCA levels for IPCa were evaluated.

RESULTS

With a cutoff of 10ng/ml, serum EPCA protein had a 100% specificity for the healthy men and a 98% specificity and a 100% sensitivity in separating men with IPCa from those without. Serum EPCA levels in patients with IPCa were significantly higher than in those without and in healthy controls (17.63±2.42ng/ml vs. 5.58±1.61 ng/ml and 4.95±1.43 ng/ml, all P<0.001), whereas an indwelling transurethral catheter presence and 5α-reductase inhibitor therapy had no effect on EPCA levels (P=0.144 and P=0.238, respectively). The area under ROC curves (AUC) showed that serum EPCA level had the best predictive accuracy of all IPCa (AUC: 0.952, 95% CI: 0.912-0.981, P<0.001). Univariate and multivariate Cox regression analyses further demonstrated the independently predictive performance by preoperative serum EPCA (Hazards Ratio: 4.23, 95% CI: 3.62-6.46, P<0.001).

CONCLUSIONS

This study firstly shows that EPCA might be used as a highly sensitive and specific serum biomarker to predict IPCa presence and to help reduce the unnecessary biopsies taken before TURP in patients with BPH.