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Kawada T, Shim SR, Quhal F, Rajwa P, Pradere B, Yanagisawa T, Bekku K, Laukhtina E, von Deimling M, Teoh JYC, Karakiewicz PI, Araki M, Shariat SF. Diagnostic Accuracy of Liquid Biomarkers for Clinically Significant Prostate Cancer Detection: A Systematic Review and Diagnostic Meta-analysis of Multiple Thresholds. Eur Urol Oncol 2024; 7:649-662. [PMID: 37981495 DOI: 10.1016/j.euo.2023.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/21/2023] [Accepted: 10/31/2023] [Indexed: 11/21/2023]
Abstract
CONTEXT Many liquid biomarkers have entered clinical practice with the praise to improve the detection of clinically significant prostate cancer (csPCa), helping avoid unnecessary prostate biopsies. OBJECTIVE We aimed to assess the diagnostic accuracy of multianalyte biomarkers for csPCa detection using multiple thresholds. EVIDENCE ACQUISITION A comprehensive literature search was done through PubMed, Web of Science, and Scopus in March 2023 for prospective and retrospective studies reporting the diagnostic performance of liquid biomarkers for detecting csPCa. The outcomes of interest were the diagnostic performance of liquid biomarkers for csPCa detection and identification of optimal thresholds for each biomarker. EVIDENCE SYNTHESIS Overall, 49 studies were eligible for this meta-analysis. Using each representative threshold based on the Youden Index, the pooled sensitivity and specificity for detecting csPCa were 0.85 and 0.37 for prostate cancer gene 3 (PCA3), 0.85 and 0.52 for prostate health index (PHI), 0.87 and 0.58 for four kallikrein (4K), 0.82 and 0.56 for SelectMDx, 0.85 and 0.54 for ExoDx, and 0.82 and 0.59 for mi prostate score (MPS), respectively. The diagnostic odds ratio was highest for 4K (8.84), followed by MPS (7.0) and PHI (6.28). According to the meta-analysis incorporating multiple thresholds, the corresponding sensitivity was 0.77 for 4K, 0.69 for PHI, and 0.63 for PCA3; specificity was 0.72 for PHI, 0.70 for 4K, and 0.69 for PCA3. CONCLUSIONS Regarding the detection of csPCa, 4K had the highest diagnostic performance among the commercial liquid biomarkers. Based on the optimal thresholds calculated by the present meta-analysis, 4K had the highest sensitivity and PHI had the highest specificity for detecting csPCa. Nevertheless, clinical decision-making requires combination strategies between liquid and imaging biomarkers. PATIENT SUMMARY Novel biomarkers for prostate cancer detection were useful for more accurate diagnosis of clinically significant prostate cancer to avoid unnecessary biopsies.
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Affiliation(s)
- Tatsushi Kawada
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Sung Ryul Shim
- Department of Biomedical Informatics, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Fahad Quhal
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Pawel Rajwa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Silesia, Zabrze, Poland
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology UROSUD, La Croix Du Sud Hospital, Quint Fonsegrives, France
| | - Takafumi Yanagisawa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kensuke Bekku
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Markus von Deimling
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy Yuen-Chun Teoh
- S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, Canada
| | - Motoo Araki
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, Canada; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Hourani Center for Applied Scientific Research, AI-Ahliyya Amman University, Amman, Jordan; Research Center for Evidence-Based Medicine, Iranian EBM Center: A Joanna Briggs Institute Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran.
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2
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Olson P, Wagner J. Established and emerging liquid biomarkers for prostate cancer detection: A review. Urol Oncol 2024:S1078-1439(24)00486-1. [PMID: 38871601 DOI: 10.1016/j.urolonc.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/03/2024] [Accepted: 05/18/2024] [Indexed: 06/15/2024]
Abstract
Prostate cancer remains one of the most frequently diagnosed cancers among men in the world today. Since its introduction in 1987 and FDA approval in 1994, prostate specific antigen (PSA) has reduced prostate cancer specific mortality considerably. However, the positive and negative predictive value of PSA is less than ideal and can lead to the over-detection of clinically insignificant prostate cancer. In the search for better screening measures to identify this cohort, liquid biomarkers for prostate cancer have emerged. In this review we will explore the commonly used urine and blood based prostate cancer liquid biomarkers. We detail the mechanism of each test and the validation studies that underscore their efficacy. Additionally, we will examine each test's effect on shared decision making as well as their cost efficacy in clinical practice.
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Affiliation(s)
- Philip Olson
- Division of Urology, University of Connecticut Health Center, Farmington, CT.
| | - Joseph Wagner
- Urology Division, Hartford Healthcare Medical Group, Hartford Hospital, Hartford, CT
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3
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Denijs FB, van Harten MJ, Meenderink JJL, Leenen RCA, Remmers S, Venderbos LDF, van den Bergh RCN, Beyer K, Roobol MJ. Risk calculators for the detection of prostate cancer: a systematic review. Prostate Cancer Prostatic Dis 2024:10.1038/s41391-024-00852-w. [PMID: 38830997 DOI: 10.1038/s41391-024-00852-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/17/2024] [Accepted: 05/23/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Prostate cancer (PCa) (early) detection poses significant challenges, including unnecessary testing and the risk of potential overdiagnosis. The European Association of Urology therefore suggests an individual risk-adapted approach, incorporating risk calculators (RCs) into the PCa detection pathway. In the context of 'The PRostate Cancer Awareness and Initiative for Screening in the European Union' (PRAISE-U) project ( https://uroweb.org/praise-u ), we aim to provide an overview of the currently available clinical RCs applicable in an early PCa detection algorithm. METHODS We performed a systematic review to identify RCs predicting detection of clinically significant PCa at biopsy. A search was performed in the databases Medline ALL, Embase, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar for publications between January 2010 and July 2023. We retrieved relevant literature by using the terms "prostate cancer", "screening/diagnosis" and "predictive model". Inclusion criteria included systematic reviews, meta-analyses, and clinical trials. Exclusion criteria applied to studies involving pre-targeted high-risk populations, diagnosed PCa patients, or a sample sizes under 50 men. RESULTS We identified 6474 articles, of which 140 were included after screening abstracts and full texts. In total, we identified 96 unique RCs. Among these, 45 underwent external validation, with 28 validated in multiple cohorts. Of the externally validated RCs, 17 are based on clinical factors, 19 incorporate clinical factors along with MRI details, 4 were based on blood biomarkers alone or in combination with clinical factors, and 5 included urinary biomarkers. The median AUC of externally validated RCs ranged from 0.63 to 0.93. CONCLUSIONS This systematic review offers an extensive analysis of currently available RCs, their variable utilization, and performance within validation cohorts. RCs have consistently demonstrated their capacity to mitigate the limitations associated with early detection and have been integrated into modern practice and screening trials. Nevertheless, the lack of external validation data raises concerns about numerous RCs, and it is crucial to factor in this omission when evaluating whether a specific RC is applicable to one's target population.
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Affiliation(s)
- Frederique B Denijs
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Meike J van Harten
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jonas J L Meenderink
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Renée C A Leenen
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sebastiaan Remmers
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lionne D F Venderbos
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roderick C N van den Bergh
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Katharina Beyer
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Monique J Roobol
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Liu Y, Hatano K, Nonomura N. Liquid Biomarkers in Prostate Cancer Diagnosis: Current Status and Emerging Prospects. World J Mens Health 2024; 42:42.e45. [PMID: 38772530 DOI: 10.5534/wjmh.230386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/12/2024] [Accepted: 01/22/2024] [Indexed: 05/23/2024] Open
Abstract
Prostate cancer (PCa) is a major health concern that necessitates appropriate diagnostic approaches for timely intervention. This review critically evaluates the role of liquid biopsy techniques, focusing on blood- and urine-based biomarkers, in overcoming the limitations of conventional diagnostic methods. The 4Kscore test and Prostate Health Index have demonstrated efficacy in distinguishing PCa from benign conditions. Urinary biomarker tests such as PCa antigen 3, MyProstateScore, SelectMDx, and ExoDx Prostate IntelliScore test have revolutionized risk stratification and minimized unnecessary biopsies. Emerging biomarkers, including non-coding RNAs, circulating tumor DNA, and prostate-specific antigen (PSA) glycosylation, offer valuable insights into PCa biology, enabling personalized treatment strategies. Advancements in non-invasive liquid biomarkers for PCa diagnosis may facilitate the stratification of patients and avoid unnecessary biopsies, particularly when PSA is in the gray area of 4 to 10 ng/mL.
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Affiliation(s)
- Yutong Liu
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Koji Hatano
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Norio Nonomura
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan
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5
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Brinkley GJ, Fang AM, Rais-Bahrami S. Integration of magnetic resonance imaging into prostate cancer nomograms. Ther Adv Urol 2022; 14:17562872221096386. [PMID: 35586139 PMCID: PMC9109484 DOI: 10.1177/17562872221096386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/05/2022] [Indexed: 11/16/2022] Open
Abstract
The decision whether to undergo prostate biopsy must be carefully weighed. Nomograms have widely been utilized as risk calculators to improve the identification of prostate cancer by weighing several clinical factors. The recent inclusion of multiparametric magnetic resonance imaging (mpMRI) findings into nomograms has drastically improved their nomogram's accuracy at identifying clinically significant prostate cancer. Several novel nomograms have incorporated mpMRI to aid in the decision-making process in proceeding with a prostate biopsy in patients who are biopsy-naïve, have a prior negative biopsy, or are on active surveillance. Furthermore, novel nomograms have incorporated mpMRI to aid in treatment planning of definitive therapy. This literature review highlights how the inclusion of mpMRI into prostate cancer nomograms has improved upon their performance, potentially reduce unnecessary procedures, and enhance the individual risk assessment by improving confidence in clinical decision-making by both patients and their care providers.
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Affiliation(s)
- Garrett J Brinkley
- Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew M Fang
- Department of Urology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Soroush Rais-Bahrami
- Department of Urology, The University of Alabama at Birmingham, Faculty Office Tower 1107, 510 20th Street South, Birmingham, AL 35294, USA
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6
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Carlsson SV, Murata K, Danila DC, Lilja H. PSA: role in screening and monitoring patients with prostate cancer. Cancer Biomark 2022. [DOI: 10.1016/b978-0-12-824302-2.00001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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7
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Chang EK, Gadzinski AJ, Nyame YA. Blood and urine biomarkers in prostate cancer: Are we ready for reflex testing in men with an elevated prostate-specific antigen? Asian J Urol 2021; 8:343-353. [PMID: 34765442 PMCID: PMC8566358 DOI: 10.1016/j.ajur.2021.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 10/28/2022] Open
Abstract
Objective There is no consensus on the role of biomarkers in determining the utility of prostate biopsy in men with elevated prostate-specific antigen (PSA). There are numerous biomarkers such as prostate health index, 4Kscore, prostate cancer antigen 3, ExoDX, SelectMDx, and Mi-Prostate Score that may be useful in this decision-making process. However, it is unclear whether any of these tests are accurate and cost-effective enough to warrant being a widespread reflex test following an elevated PSA. Our goal was to report on the clinical utility of these blood and urine biomarkers in prostate cancer screening. Methods We performed a systematic review of studies published between January 2000 and October 2020 to report the available parameters and cost-effectiveness of the aforementioned diagnostic tests. We focus on the negative predictive value, the area under the curve, and the decision curve analysis in comparing reflexive tests due to their relevance in evaluating diagnostic screening tests. Results Overall, the biomarkers are roughly equivalent in predictive accuracy. Each test has additional clinical utility to the current diagnostic standard of care, but the added benefit is not substantial to justify using the test reflexively after an elevated PSA. Conclusions Our findings suggest these biomarkers should not be used in binary fashion and should be understood in the context of pre-existing risk predictors, patient's ethnicity, cost of the test, patient life-expectancy, and patient goals. There are more recent diagnostic tools such as multi-parametric magnetic resonance imaging, polygenic single-nucleotide panels, IsoPSA, and miR Sentinel tests that are promising in the realm of prostate cancer screening and need to be investigated further to be considered a consensus reflexive test in the setting of prostate cancer screening.
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Affiliation(s)
- Edward K Chang
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA
| | - Adam J Gadzinski
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA
| | - Yaw A Nyame
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA.,Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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8
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Montoya Perez I, Merisaari H, Jambor I, Ettala O, Taimen P, Knaapila J, Kekki H, Khan FL, Syrjälä E, Steiner A, Syvänen KT, Verho J, Seppänen M, Rannikko A, Riikonen J, Mirtti T, Lamminen T, Saunavaara J, Falagario U, Martini A, Pahikkala T, Pettersson K, Boström PJ, Aronen HJ. Detection of Prostate Cancer Using Biparametric Prostate MRI, Radiomics, and Kallikreins: A Retrospective Multicenter Study of Men With a Clinical Suspicion of Prostate Cancer. J Magn Reson Imaging 2021; 55:465-477. [PMID: 34227169 DOI: 10.1002/jmri.27811] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Accurate detection of clinically significant prostate cancer (csPCa), Gleason Grade Group ≥ 2, remains a challenge. Prostate MRI radiomics and blood kallikreins have been proposed as tools to improve the performance of biparametric MRI (bpMRI). PURPOSE To develop and validate radiomics and kallikrein models for the detection of csPCa. STUDY TYPE Retrospective. POPULATION A total of 543 men with a clinical suspicion of csPCa, 411 (76%, 411/543) had kallikreins available and 360 (88%, 360/411) did not take 5-alpha-reductase inhibitors. Two data splits into training, validation (split 1: single center, n = 72; split 2: random 50% of pooled datasets from all four centers), and testing (split 1: 4 centers, n = 288; split 2: remaining 50%) were evaluated. FIELD STRENGTH/SEQUENCE A 3 T/1.5 T, TSE T2-weighted imaging, 3x SE DWI. ASSESSMENT In total, 20,363 radiomic features calculated from manually delineated whole gland (WG) and bpMRI suspicion lesion masks were evaluated in addition to clinical parameters, prostate-specific antigen, four kallikreins, MRI-based qualitative (PI-RADSv2.1/IMPROD bpMRI Likert) scores. STATISTICAL TESTS For the detection of csPCa, area under receiver operating curve (AUC) was calculated using the DeLong's method. A multivariate analysis was conducted to determine the predictive power of combining variables. The values of P-value < 0.05 were considered significant. RESULTS The highest prediction performance was achieved by IMPROD bpMRI Likert and PI-RADSv2.1 score with AUC = 0.85 and 0.85 in split 1, 0.85 and 0.83 in split 2, respectively. bpMRI WG and/or kallikreins demonstrated AUCs ranging from 0.62 to 0.73 in split 1 and from 0.68 to 0.76 in split 2. AUC of bpMRI lesion-derived radiomics model was not statistically different to IMPROD bpMRI Likert score (split 1: AUC = 0.83, P-value = 0.306; split 2: AUC = 0.83, P-value = 0.488). DATA CONCLUSION The use of radiomics and kallikreins failed to outperform PI-RADSv2.1/IMPROD bpMRI Likert and their combination did not lead to further performance gains. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Ileana Montoya Perez
- Department of Diagnostic Radiology, University of Turku, Turku, Finland.,Department of Computing, University of Turku, Turku, Finland.,Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland
| | - Harri Merisaari
- Department of Diagnostic Radiology, University of Turku, Turku, Finland.,Department of Computing, University of Turku, Turku, Finland.,Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland
| | - Ivan Jambor
- Department of Diagnostic Radiology, University of Turku, Turku, Finland.,Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Otto Ettala
- Department of Urology, University of Turku, Turku University Hospital, Turku, Finland
| | - Pekka Taimen
- Institute of Biomedicine, Department of Pathology, University of Turku, Turku University Hospital, Turku, Finland
| | - Juha Knaapila
- Department of Urology, University of Turku, Turku University Hospital, Turku, Finland
| | - Henna Kekki
- Department of Biotechnology, University of Turku, Turku, Finland
| | - Ferdhos L Khan
- Department of Biotechnology, University of Turku, Turku, Finland
| | - Elise Syrjälä
- Department of Computing, University of Turku, Turku, Finland
| | - Aida Steiner
- Department of Diagnostic Radiology, University of Turku, Turku, Finland.,Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland
| | - Kari T Syvänen
- Department of Urology, University of Turku, Turku University Hospital, Turku, Finland
| | - Janne Verho
- Department of Diagnostic Radiology, University of Turku, Turku, Finland.,Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland
| | - Marjo Seppänen
- Department of Surgery, Satakunta Central Hospital, Pori, Finland
| | - Antti Rannikko
- Department of Urology, Helsinki University, Helsinki University Hospital, Helsinki, Finland
| | - Jarno Riikonen
- Department of Urology, Tampere University Hospital, University of Tampere, Tampere, Finland
| | - Tuomas Mirtti
- Department of Pathology, University of Helsinki, Helsinki, Finland
| | - Tarja Lamminen
- Department of Urology, University of Turku, Turku University Hospital, Turku, Finland
| | - Jani Saunavaara
- Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Ugo Falagario
- Department of Urology, University of Foggia, Foggia, Italy
| | - Alberto Martini
- Department of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Tapio Pahikkala
- Department of Computing, University of Turku, Turku, Finland
| | - Kim Pettersson
- Department of Biotechnology, University of Turku, Turku, Finland
| | - Peter J Boström
- Department of Urology, University of Turku, Turku University Hospital, Turku, Finland
| | - Hannu J Aronen
- Department of Diagnostic Radiology, University of Turku, Turku, Finland.,Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland
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4Kscore diagnostic value in patients with high-grade prostate cancer using cutoff values of 7.5% to 10%: A meta-analysis. Urol Oncol 2021; 39:366.e1-366.e10. [PMID: 33685800 DOI: 10.1016/j.urolonc.2020.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/24/2020] [Accepted: 11/01/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Reported 4Kscore thresholds used to differentiate between patients with and without high-grade prostate cancer (CaP) were variable. Patients with 4Kscore results <7.5% have been proven to be at low risk of carrying high-grade CaP. This study employed a meta-analysis approach in order to assess the diagnostic accuracy of the 4Kscore as a means of detecting high-grade CaP in prostate biopsy samples using cutoff values of 7.5% to 10%. METHODS Relevant studies published as of December 2019 were identified via searching PubMed, Embase, and Cochrane Library. Data pertaining to 4Kscore diagnostic accuracy were then extracted from these studies and utilized for the calculation of pooled sensitivity , specificity , diagnostic odds ratio , and area under the curve values relating to high-grade CaP diagnosis. RESULTS In total, 9 studies incorporating 1,689 high-grade CaP patients were included in our meta-analysis. Following the exclusion of 1 outlier study, the pooled sensitivity, specificity , diagnostic odds ratio , and area under the curve values for 4Kscore diagnostic accuracy with corresponding 95% confidence intervals (CIs) were 0.90 (95%CI: 0.86-0.92), 0.44 (95%CI: 0.36-0.52), 7 (95%CI: 5-8), and 0.81 (95%CI: 0.77-0.84), respectively. CONCLUSION These findings indicate that 4Kscore can be used as a model for the diagnosis of high-grade CaP. However, we detected significant heterogeneity among studies that was not explained by subgroup or meta-regression analysis, thus lowering our confidence in these results. It is therefore essential that future large, well-designed studies be conducted so as to confirm whether the 4Kscore can be used with cutoff values of 7.5% to 10% to reliably detect high-grade CaP.
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Wagaskar VG, Sobotka S, Ratnani P, Young J, Lantz A, Parekh S, Falagario UG, Li L, Lewis S, Haines K, Punnen S, Wiklund P, Tewari A. A 4K score/MRI-based nomogram for predicting prostate cancer, clinically significant prostate cancer, and unfavorable prostate cancer. Cancer Rep (Hoboken) 2021; 4:e1357. [PMID: 33661541 PMCID: PMC8388161 DOI: 10.1002/cnr2.1357] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/28/2021] [Accepted: 02/08/2021] [Indexed: 12/02/2022] Open
Abstract
Background The detection of prostate cancer requires histological confirmation in biopsy core. Currently, number of unnecessary prostate biopsies are being performed in the United States. This is due to the absence of appropriate biopsy decision‐making protocol. Aim To develop and validate a 4K score/multiparametric magnetic resonance imaging (mpMRI)‐based nomogram to predict prostate cancer (PCa), clinically significant prostate cancer (csPCa), and unfavorable prostate cancer (uPCa). Methods and Results Retrospective, single‐center study evaluating a cohort of 574 men with 4K score test >7% or suspicious digital rectal examination (DRE) or Prostate Imaging Reporting and Data System (PI‐RADS) scores 3, 4, or 5 on mpMRI that underwent systematic and/or mpMRI/ultrasound fusion–targeted prostate biopsy between 2016 and 2020. External cohort included 622 men. csPCa and uPCa were defined as Gleason score ≥3 + 4 and ≥4 + 3 on biopsy, respectively. Multivariable logistic regression analysis was performed to build nomogram for predicting PCa, csPCa, and uPCa. Validation was performed by plotting the area under the curve (AUC) and comparing nomogram‐predicted probabilities with actual rates of PCa, csPCa, and uPCa probabilities in the external cohort. 4K score, a PI‐RADS ≥4, prostate volume and prior negative biopsy were significant predictors of PCa, csPCa, and uPCa. AUCs were 0.84, 0.88, and 0.86 for the prediction of PCa, csPCa, and uPCa, respectively. The predicted and actual rates of PCa, csPCa, and uPCa showed agreement across all percentage probability ranges in the validation cohort. Using the prediction model at threshold of 30, 30% of overall biopsies, 41% of benign biopsies, and 19% of diagnosed indolent PCa could be avoided, while missing 9% of csPCa. Conclusion This novel nomogram would reduce unnecessary prostate biopsies and decrease detection of clinically insignificant PCa.
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Affiliation(s)
- Vinayak G Wagaskar
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Stanislaw Sobotka
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Parita Ratnani
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - James Young
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Anna Lantz
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Sneha Parekh
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Ugo Giovanni Falagario
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Li Li
- Department of Pathology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Sara Lewis
- Department of Radiology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Kenneth Haines
- Department of Pathology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Sanoj Punnen
- Department of Urology, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Ash Tewari
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
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11
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Jin W, Fei X, Wang X, Song Y, Chen F. Detection and Prognosis of Prostate Cancer Using Blood-Based Biomarkers. Mediators Inflamm 2020; 2020:8730608. [PMID: 32454797 PMCID: PMC7218965 DOI: 10.1155/2020/8730608] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/24/2020] [Accepted: 04/27/2020] [Indexed: 12/15/2022] Open
Abstract
Prostate cancer (PCa) is second only to lung cancer as a cause of death. Clinical assessment of patients and treatment efficiency therefore depend on the disease being diagnosed as early as possible. However, due to issues regarding the use of prostate-specific antigen (PSA) for screening purposes, PCa management is among the most contentious of healthcare matters. PSA screening is problematic primarily because of diagnosis difficulties and the high rate of false-positive biopsies. Novel PCa biomarkers, such as the Prostate Health Index (PHI) and the 4Kscore, have been proposed in recent times to improve PSA prediction accuracy and have shown higher performance by preventing redundant biopsies. The 4Kscore also shows high precision in determining the risk of developing high-grade PCa, whereas elevated PHI levels suggest that the tumor is aggressive. Some evidence also supports the effectiveness of miRNAs as biomarkers for distinguishing PCa from benign prostatic hyperplasia and for assessing the aggressiveness of the disease. A number of miRNAs that possibly act as tumor inhibitors or oncogenes are impaired in PCa. These new biomarkers are comprehensively reviewed in the present study in terms of their potential use in diagnosing and treating PCa.
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Affiliation(s)
- Wei Jin
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xiang Fei
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xia Wang
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yan Song
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Fangjie Chen
- Department of Medical Genetics, School of Life Sciences, China Medical University, Shenyang, Liaoning, China
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12
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Nassir AM. A piece in prostate cancer puzzle: Future perspective of novel molecular signatures. Saudi J Biol Sci 2020; 27:1148-1154. [PMID: 32256177 PMCID: PMC7105665 DOI: 10.1016/j.sjbs.2020.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/26/2020] [Accepted: 02/01/2020] [Indexed: 12/24/2022] Open
Abstract
Prostate cancer (PCa) has a variable biological potential. It constitutes the second most common cancer amongst men worldwide and the fifth most common cancer in Saudi Arabia. Identifying men at higher risk of developing PCa, differentiating indolent from aggressive disease and predicting the likelihood of progression will improve decision-making and selection for active surveillance protocols. Biomarkers have been utilized for PCa screening and predicting cancer behavior and response to treatment. The prostate specific antigen (PSA) screening helps detect PCa in early stages, while implementing a plan for management and outcome. However, PSA screening is still controversial, due to the risks of over diagnosis and treatment, and its inability to detect a good proportion of advanced tumors. Alternatively, a new era of PCa biomarkers has emerged with higher PCa specificity than PSA and its isoforms hopefully improving screening methods, such as Prostate Health Index (PHI) score, Progensa Prostate Cancer Antigen 3 (PCA3), Mi-Prostate Score (MiPS), Prostate Stem Cell Antigen (PSCA), 4Kscore test, and Urokinase Plasminogen Activation (uPA and uPAR). Few novel biomarkers have shown promise in preliminary results. This review will display promising biomarkers including some important FDA approved ones, highlighting their clinical implication and future place in the PCa puzzle, along with addressing their current limitations.
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Affiliation(s)
- Anmar M Nassir
- Department of Surgery, Umm Al-Qura University, Makkah, Saudi Arabia.,Department of Urology, King Abdullah Medical City, Makkah, Saudi Arabia
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13
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Janes H, Brown MD, Glidden DV, Mayer KH, Buchbinder SP, McMahan VM, Schechter M, Guanira J, Casapia M. Evaluating the impact of policies recommending PrEP to subpopulations of men and transgender women who have sex with men based on demographic and behavioral risk factors. PLoS One 2019; 14:e0222183. [PMID: 31536518 PMCID: PMC6752862 DOI: 10.1371/journal.pone.0222183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 08/23/2019] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Developing guidelines to inform the use of antiretroviral pre-exposure prophylaxis (PrEP) for HIV prevention in resource-limited settings must necessarily be informed by considering the resources and infrastructure needed for PrEP delivery. We describe an approach that identifies subpopulations of cisgender men who have sex with men (MSM) and transgender women (TGW) to prioritize for the rollout of PrEP in resource-limited settings. METHODS We use data from the iPrEx study, a multi-national phase III study of PrEP for HIV prevention in MSM/TGW, to build statistical models that identify subpopulations at high risk of HIV acquisition without PrEP, and with high expected PrEP benefit. We then evaluate empirically the population impact of policies recommending PrEP to these subpopulations, and contrast these with existing policies. RESULTS A policy recommending PrEP to a high risk subpopulation of MSM/TGW reporting condomless receptive anal intercourse over the last 3 months (estimated 3.3% 1-year HIV incidence) yields an estimated 1.95% absolute reduction in 1-year HIV incidence at the population level, and 3.83% reduction over 2 years. Importantly, such a policy requires rolling PrEP out to just 59.7% of MSM/TGW in the iPrEx population. We find that this policy is identical to that which prioritizes MSM/TGW with high expected PrEP benefit. It is estimated to achieve nearly the same reduction in HIV incidence as the PrEP guideline put forth by the US Centers for Disease Control, which relies on the measurement of more behavioral risk factors and which would recommend PrEP to a larger subset of the MSM/TGW population (86% vs. 60%). CONCLUSIONS These findings may be used to focus future mathematical modelling studies of PrEP in resource-limited settings on prioritizing PrEP for high-risk subpopulations of MSM/TGW. The statistical approach we took could be employed to develop PrEP policies for other at-risk populations and resource-limited settings.
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Affiliation(s)
- Holly Janes
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Marshall D. Brown
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - David V. Glidden
- Department of Epidemiology and Biostatistics, University of California School of Medicine, San Francisco, California, United States of America
| | - Kenneth H. Mayer
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, and The Fenway Institute, Fenway Health, Boston, Massachusetts, United States of America
| | - Susan P. Buchbinder
- Bridge HIV, San Francisco Department of Public Health, San Francisco, California, United States of America
| | - Vanessa M. McMahan
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Mauro Schechter
- Projeto Praça Onze, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Juan Guanira
- Asociación Civil Impacta Salud y Educación, Lima, Peru
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14
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Assessment of men's risk thresholds to proceed with prostate biopsy for the early detection of prostate cancer. Int Urol Nephrol 2019; 51:1297-1302. [PMID: 31187423 DOI: 10.1007/s11255-019-02196-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/04/2019] [Indexed: 12/30/2022]
Abstract
PURPOSE To delineate the range of "risk thresholds" for prostate biopsy to determine how improved prostate cancer (CaP) risk prediction tools may impact shared decision-making (SDM). METHODS We conducted a cross-sectional survey study involving men 45-75 years old attending a multispecialty urology clinic. Data included demographics, personal and family prostate cancer history, and prostate biopsy history. Respondents were presented with a summary of the details, risks, and benefits of prostate biopsy, then asked to indicate the specific risk threshold (% chance) of high-grade CaP at which they would proceed with prostate biopsy. RESULTS Of a total of 103 respondents, 18 men (17%) had a personal history of CaP, and 31 (30%) had undergone prostate biopsy. The median risk threshold to proceed with prostate biopsy was 25% (interquartile range 10-50%). Risk thresholds did not vary by race, education, or employment. Personal history of CaP or prostate biopsy was significantly associated with lower mean risk thresholds (19% vs. 32% [P = 0.02] and 23% vs. 33% [P = 0.04], respectively). In the lowest versus highest risk threshold quartiles, there were significantly higher rates of CaP (36% vs. 1%, P = 0.01) and prior prostate biopsy (46% vs. 17%, P < 0.01). CONCLUSIONS Men have a wide range of risk thresholds for high-grade CaP to proceed with prostate biopsy. Men with a prior history of CaP or biopsy reported lower risk thresholds, which may reflect their greater concern for this disease. The extent to which refined risk prediction tools will improve SDM warrants further study.
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15
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Hoey C, Liu SK. Circulating blood miRNAs for prostate cancer risk stratification: miRroring the underlying tumor biology with liquid biopsies. Res Rep Urol 2019; 11:29-42. [PMID: 30881943 PMCID: PMC6398395 DOI: 10.2147/rru.s165625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Current risk stratification methods for prostate cancer – although they have seen marked improvements over the past decades – are far from perfect. Despite the significant utility of prostate-specific antigen as a biomarker to monitor for disease recurrence, it cannot predict which tumors will recur or recommend the best treatment for patients. Similarly, although biopsies are imperative for diagnosis and staging, they are saddled with limitations and risks. We must move toward a noninvasive biomarker that has predictive and prognostic efficacy. We therefore review the current literature on circulating miRNA biomarkers, apply their use to two significant clinical problems (ie, how limitations of prostate biopsies can impact diagnosis and treatment management, and the need to tailor treatment for a clinically heterogeneous disease), and evaluate how circulating miRNAs have inherent properties that make them ideal liquid biomarkers. We also outline current gaps in knowledge that must be addressed before they can be implemented into routine clinical practice. With further research on their function and validation of their biomarker utility in large prospective cohorts, circulating miRNAs will likely prove to be the liquid biopsies of tomorrow.
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Affiliation(s)
- Christianne Hoey
- Biological Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada, .,Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada,
| | - Stanley K Liu
- Biological Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada, .,Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada, .,Department of Radiation Oncology, University of Toronto, Toronto, ON M5S 3E2, Canada,
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16
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Verbeek JF, Bangma CH, Kweldam CF, van der Kwast TH, Kümmerlin IP, van Leenders GJ, Roobol MJ. Reducing unnecessary biopsies while detecting clinically significant prostate cancer including cribriform growth with the ERSPC Rotterdam risk calculator and 4Kscore. Urol Oncol 2019; 37:138-144. [DOI: 10.1016/j.urolonc.2018.11.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/15/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
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17
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Lamy PJ, Allory Y, Gauchez AS, Asselain B, Beuzeboc P, de Cremoux P, Fontugne J, Georges A, Hennequin C, Lehmann-Che J, Massard C, Millet I, Murez T, Schlageter MH, Rouvière O, Kassab-Chahmi D, Rozet F, Descotes JL, Rébillard X. Prognostic Biomarkers Used for Localised Prostate Cancer Management: A Systematic Review. Eur Urol Focus 2018; 4:790-803. [DOI: 10.1016/j.euf.2017.02.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 02/08/2017] [Accepted: 02/24/2017] [Indexed: 11/28/2022]
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18
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Punnen S, Freedland SJ, Polascik TJ, Loeb S, Risk MC, Savage S, Mathur SC, Uchio E, Dong Y, Silberstein JL. A Multi-Institutional Prospective Trial Confirms Noninvasive Blood Test Maintains Predictive Value in African American Men. J Urol 2018; 199:1459-1463. [DOI: 10.1016/j.juro.2017.11.113] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Sanoj Punnen
- Department of Urology, University of Miami and Miami Veterans Affairs Medical Center, Miami, Florida
| | - Stephen J. Freedland
- Cedars-Sinai Medical Center, Los Angeles, California
- Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Thomas J. Polascik
- Durham Veterans Affairs Medical Center, Durham, North Carolina
- Duke Cancer Institute, Durham, North Carolina
| | - Stacy Loeb
- Department of Urology and Population Health, New York University and Manhattan Veterans Affairs Medical Center, New York, New York
| | - Michael C. Risk
- Department of Urology, University of Minnesota and Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - Stephen Savage
- Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
| | - Sharad C. Mathur
- Pathology and Laboratory Medicine Service, Kansas City Veterans Affairs Medical Center, Kansas City, Missouri
| | - Edward Uchio
- Department of Urology, University of California-Irvine, Irvine, California
- Veterans Affairs Long Beach Health System, Long Beach, California
| | - Yan Dong
- OPKO Diagnostics, Woburn, Massachusetts
| | - Jonathan L. Silberstein
- Tulane University School of Medicine and Southeast Louisiana Veterans Health Care Center, New Orleans, Louisiana
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19
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Abstract
Prostate cancer is the most common non-cutaneous cancer among men in the United States. In the last decade there has been a rapid expansion in the field of biomarker assays for diagnosis, prognosis, and treatment prediction in prostate cancer. The evidence base for these assays is rapidly evolving. With several commercial assays available at each stage of the disease, deciding which genomic assays are appropriate for which patients can be nuanced for physicians. In an effort to help guide these decisions in clinical practice, we aim to give an update on the current status of the biomarker field of prostate cancer.
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Affiliation(s)
- Zachary Kornberg
- Department of Radiation Oncology, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Matthew R Cooperberg
- Department of Urology, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Felix Y Feng
- Department of Radiation Oncology, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
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20
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Sjoberg DD, Vickers AJ, Assel M, Dahlin A, Poon BY, Ulmert D, Lilja H. Twenty-year Risk of Prostate Cancer Death by Midlife Prostate-specific Antigen and a Panel of Four Kallikrein Markers in a Large Population-based Cohort of Healthy Men. Eur Urol 2018. [PMID: 29519548 DOI: 10.1016/j.eururo.2018.02.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Prostate-specific antigen (PSA) screening reduces prostate cancer deaths but leads to harm from overdiagnosis and overtreatment. OBJECTIVE To determine the long-term risk of prostate cancer mortality using kallikrein blood markers measured at baseline in a large population of healthy men to identify men with low risk for prostate cancer death. DESIGN, SETTING, PARTICIPANTS Study based on the Malmö Diet and Cancer cohort enrolling 11 506 unscreened men aged 45-73 yr during 1991-1996, providing cryopreserved blood at enrollment and followed without PSA screening to December 31, 2014. We measured four kallikrein markers in the blood of 1223 prostate cancer cases and 3028 controls. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Prostate cancer death (n=317) by PSA and a prespecified statistical model based on the levels of four kallikrein markers. RESULTS AND LIMITATIONS Baseline PSA predicted prostate cancer death with a concordance index of 0.86. In men with elevated PSA (≥2.0ng/ml), predictive accuracy was enhanced by the four-kallikrein panel compared with PSA (0.80 vs 0.73; improvement 0.07; 95% confidence interval 0.04, 0.10). Nearly half of men aged 60+ yr with elevated PSA had a four-kallikrein panel score of <7.5%, translating into 1.7% risk of prostate cancer death at 15 yr-a similar estimate to that of a man with a PSA of 1.6ng/ml. Men with a four-kallikrein panel score of ≥7.5% had a 13% risk of prostate cancer death at 15 yr. CONCLUSIONS A prespecified statistical model based on four kallikrein markers (commercially available as the 4Kscore) reclassified many men with modestly elevated PSA, to have a low long-term risk of prostate cancer death. Men with elevated PSA but low scores from the four-kallikrein panel can be monitored rather than being subject to biopsy. PATIENT SUMMARY Men with elevated prostate-specific antigen (PSA) are often referred for prostate biopsy. However, men with elevated PSA but low scores from the four-kallikrein panel can be monitored rather than being subject to biopsy.
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Affiliation(s)
- Daniel D Sjoberg
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew J Vickers
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa Assel
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anders Dahlin
- Department of Clinical Microbiology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Bing Ying Poon
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Ulmert
- Molecular Pharmacology Program, Sloan Kettering Institute, New York, NY, USA; Division of Urological Research, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Hans Lilja
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Department of Translational Medicine, Lund University, Malmö, Sweden.
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21
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Rodriguez JF, Eggener SE. Prostate Cancer and the Evolving Role of Biomarkers in Screening and Diagnosis. Radiol Clin North Am 2018; 56:187-196. [DOI: 10.1016/j.rcl.2017.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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22
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23
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Abstract
Diagnostic biomarkers derived from blood, urine, or prostate tissue provide additional information beyond clinical calculators to determine the risk of detecting high-grade prostate cancer. Once diagnosed, multiple markers leverage prostate cancer biopsy tissue to prognosticate clinical outcomes, including adverse pathology at radical prostatectomy, disease recurrence, and prostate cancer mortality; however the clinical utility of some outcomes to patient decision making is unclear. Markers using tissue from radical prostatectomy specimens provide additional information about the risk of biochemical recurrence, development of metastatic disease, and subsequent mortality beyond existing multivariable clinical calculators (the use of a marker to simply sub-stratify risk groups such as the NCCN groups is of minimal value). No biomarkers currently available for prostate cancer have been prospectively validated to be predict an improved clinical outcome for a specific therapy based on the test result; however, further research and development of these tests may produce a truly predictive biomarker for prostate cancer treatment.
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Affiliation(s)
- Adam J Gadzinski
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Matthew R Cooperberg
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA.
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24
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Assel M, Sjöblom L, Murtola TJ, Talala K, Kujala P, Stenman UH, Taari K, Auvinen A, Vickers A, Visakorpi T, Tammela TL, Lilja H. A Four-kallikrein Panel and β-Microseminoprotein in Predicting High-grade Prostate Cancer on Biopsy: An Independent Replication from the Finnish Section of the European Randomized Study of Screening for Prostate Cancer. Eur Urol Focus 2017; 5:561-567. [PMID: 29137895 DOI: 10.1016/j.euf.2017.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 11/05/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND A panel of four kallikrein markers (total, free, and intact prostate-specific antigen [PSA] and human kallikrein-related peptidase 2 [hK2]) improves predictive accuracy for Gleason score ≥7 (high-grade) prostate cancer among men biopsied for elevated PSA. A four-kallikrein panel model was originally developed and validated by the Dutch center of the European Randomized Study of Screening for Prostate Cancer (ERSPC). The kallikrein panel is now commercially available as 4Kscore™. OBJECTIVE To assess whether these findings could be replicated among participants in the Finnish section of ERSPC (FinRSPC) and whether β-microseminoprotein (MSP), a candidate prostate cancer biomarker, adds predictive value. DESIGN, SETTING, AND PARTICIPANTS Among 4861 biopsied screening-positive participants in the first three screening rounds of FinRSPC, a case-control subset was selected that included 1632 biopsy-positive cases matched by age at biopsy to biopsy-negative controls. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The predictive accuracy of prespecified prediction models was compared with biopsy outcomes. RESULTS AND LIMITATIONS Among men with PSA of 4.0-25ng/ml, 1111 had prostate cancer, 318 of whom had high-grade disease. Total PSA and age predicted high-grade cancer with an area under the curve of 0.648 (95% confidence interval [CI] 0.614-0.681) and the four-kallikrein panel increased discrimination to 0.746 (95% CI 0.717-0.774). Adding MSP to the four-kallikrein panel led to a significant (Wald test; p=0.015) but small increase (0.003) in discrimination. Limitations include a risk of verification bias among men with PSA of 3.0-3.99ng/ml and the absence of digital rectal examination results. CONCLUSIONS These findings provide additional evidence that kallikrein markers can be used to inform biopsy decision-making. Further studies are needed to define the role of MSP. PATIENT SUMMARY Four kallikrein markers and β-microseminoprotein in blood improve discrimination of high-grade prostate cancer at biopsy in men with elevated prostate-specific antigen.
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Affiliation(s)
- Melissa Assel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Liisa Sjöblom
- Prostate Cancer Research Center, Institute of Biosciences and Medical Technology, University of Tampere, Tampere, Finland; Fimlab Laboratories, Tampere University Hospital, Tampere, Finland
| | - Teemu J Murtola
- Prostate Cancer Research Center, School of Health Sciences, University of Tampere, Tampere, Finland; Department of Urology, Tampere University Hospital, Tampere, Finland
| | | | - Paula Kujala
- Fimlab Laboratories, Tampere University Hospital, Tampere, Finland; Department of Pathology, Tampere University Hospital, Tampere, Finland
| | - Ulf-Håkan Stenman
- Department of Clinical Chemistry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kimmo Taari
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anssi Auvinen
- Prostate Cancer Research Center, School of Health Sciences, University of Tampere, Tampere, Finland
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tapio Visakorpi
- Prostate Cancer Research Center, Institute of Biosciences and Medical Technology, University of Tampere, Tampere, Finland; Fimlab Laboratories, Tampere University Hospital, Tampere, Finland
| | - Teuvo L Tammela
- Prostate Cancer Research Center, School of Health Sciences, University of Tampere, Tampere, Finland; Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Hans Lilja
- Prostate Cancer Research Center, Institute of Biosciences and Medical Technology, University of Tampere, Tampere, Finland; Departments of Laboratory Medicine, Surgery, and Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Department of Translational Medicine, Lund University, Malmö, Sweden.
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25
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Rendon RA, Mason RJ, Marzouk K, Finelli A, Saad F, So A, Violette P, Breau RH. Recommandations de l'Association des urologues du Canada sur le dépistage et le diagnostic précoce du cancer de la prostate. Can Urol Assoc J 2017; 11:298-309. [PMID: 29381452 DOI: 10.5489/cuaj.4888] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Ricardo A Rendon
- Département d'urologie, Université Dalhousie, Halifax, N.-É., Canada
| | - Ross J Mason
- Département d'urologie, Clinique Mayo, Rochester, Minn., États-Unis
| | - Karim Marzouk
- Division d'urologie, Centre de cancérologie Memorial Sloan Kettering, New York, NY, États-Unis
| | - Antonio Finelli
- Division d'urologie, Université de Toronto, Toronto, Ont., Canada
| | - Fred Saad
- Département de chirurgie (urologie), Université de Montréal, Montréal, Qc, Canada
| | - Alan So
- Département des sciences urologiques, Université de la Colombie-Britannique, Vancouver, C.-B., Canada
| | - Phillipe Violette
- Département de chirurgie, Université Western, London, Ont., Canada.,Départements de chirurgie et de méthodologie de recherche en santé, Données et répercussions, Université McMaster, Hamilton, Ont., Canada
| | - Rodney H Breau
- Division d'urologie, Université d'Ottawa, Ottawa, Ont., Canada
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26
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Zappala SM, Dong Y. Re: Russo GI, Regis F, Castelli T, et al. A Systematic Review and Meta-analysis of the Diagnostic Accuracy of Prostate Health Index and 4-kallikrein Panel Score in Predicting Overall and High-grade Prostate Cancer. Clin Genitourin Cancer 2017; 15:429-39. Clin Genitourin Cancer 2017; 16:S1558-7673(17)30240-9. [PMID: 29074283 DOI: 10.1016/j.clgc.2017.07.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 07/31/2017] [Indexed: 10/19/2022]
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27
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A Systematic Review and Meta-analysis of the Diagnostic Accuracy of Prostate Health Index and 4-Kallikrein Panel Score in Predicting Overall and High-grade Prostate Cancer. Clin Genitourin Cancer 2017; 15:429-439.e1. [DOI: 10.1016/j.clgc.2016.12.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 12/14/2016] [Accepted: 12/22/2016] [Indexed: 01/01/2023]
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28
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Zappala SM, Dong Y, Linder V, Reeve M, Sjoberg DD, Mathur V, Roberts R, Okrongly D, Newmark J, Sant G, Steiner M. The 4Kscore blood test accurately identifies men with aggressive prostate cancer prior to prostate biopsy with or without DRE information. Int J Clin Pract 2017; 71. [PMID: 28497893 DOI: 10.1111/ijcp.12943] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 02/26/2017] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The 4Kscore Test is a prebiopsy blood test that incorporates four prostate protein biomarkers along with patient clinical information to determine a man's risk for high-grade, aggressive (Gleason ≥7) prostate cancer. However, some men likely to benefit from the test may be seen in primary care settings where the digital rectal examination (DRE) information is not always obtained. In this study, we assessed the clinical validity of the 4Kscore Test when the DRE information was not included in the algorithm. METHODS The Prospective 4Kscore Validation Study enrolled 1012 men scheduled for prostate biopsy across 26 urology practices in the United States. The 4Kscore was calculated for each patient with and without DRE information. The primary outcome was Gleason ≥7 prostate cancer on prostate biopsy. The contribution of DRE to the predictive accuracy of the test was evaluated by area under the receiver operating curve (AUC-ROC), risk calibration and clinical consequences. RESULTS High-grade, aggressive prostate cancer was found in 231 (23%) of the 1012 patients. Both versions of the 4Kscore Test, with and without DRE, showed excellent discrimination (AUC=0.821 with DRE and AUC=0.818 without DRE input) and excellent calibration. No clinically significant difference was found between the two versions of the 4Kscore. CONCLUSIONS The 4Kscore Test algorithm, whether DRE findings are available or not, performs well in predicting a man's risk of high-grade, aggressive prostate cancer. Patients who are suspected of having aggressive prostate cancer can safely have their risk better defined by 4Kscore even if a DRE has not been performed recently.
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Affiliation(s)
| | - Yan Dong
- OPKO Diagnostics, Woburn, MA, USA
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Punnen S, Nahar B, Prakash NS, Sjoberg DD, Zappala SM, Parekh DJ. The 4Kscore Predicts the Grade and Stage of Prostate Cancer in the Radical Prostatectomy Specimen: Results from a Multi-institutional Prospective Trial. Eur Urol Focus 2017; 3:94-99. [DOI: 10.1016/j.euf.2015.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 11/25/2015] [Accepted: 12/11/2015] [Indexed: 01/22/2023]
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McMahon GC, Brown GA, Mueller TJ. Utilization of individualized prostate cancer and genomic biomarkers for the practicing urologist. Rev Urol 2017; 19:97-105. [PMID: 28959146 PMCID: PMC5610359 DOI: 10.3909/riu0730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Prostate cancer encompasses a complex heterogeneous disease spectrum. Physicians and patients are faced with the ambiguity of who should be screened, biopsied, rebiopsied, treated, or provided with adjuvant therapy. Personalized outcomes and treatments are especially important given the varied nature of the disease, plethora of treatment options, risks of morbidity, and quality of life. Today's practicing urologist has a multitude of tests from which to choose, creating the difficult task of appropriate use. This review focuses on two blood-, one urine-, and five genomic-based tests, which, when used in the appropriate clinical setting, can facilitate the patient-physician decision-making process.
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Affiliation(s)
- Gregory C McMahon
- Department of Urology, Rowan University School of Osteopathic MedicineStratford, NJ
| | - Gordon A Brown
- Department of Urology, Rowan University School of Osteopathic MedicineStratford, NJ
- Delaware Valley Urology, LLC,Voorhees, NJ
| | - Thomas J Mueller
- Department of Urology, Rowan University School of Osteopathic MedicineStratford, NJ
- Delaware Valley Urology, LLC,Voorhees, NJ
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Alford AV, Brito JM, Yadav KK, Yadav SS, Tewari AK, Renzulli J. The Use of Biomarkers in Prostate Cancer Screening and Treatment. Rev Urol 2017; 19:221-234. [PMID: 29472826 PMCID: PMC5811879 DOI: 10.3909/riu0772] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Prostate cancer screening and diagnosis has been guided by prostate-specific antigen levels for the past 25 years, but with the most recent US Preventive Services Task Force screening recommendations, as well as concerns regarding overdiagnosis and overtreatment, a new wave of prostate cancer biomarkers has recently emerged. These assays allow the testing of urine, serum, or prostate tissue for molecular signs of prostate cancer, and provide information regarding both diagnosis and prognosis. In this review, we discuss 12 commercially available biomarker assays approved for the diagnosis and treatment of prostate cancer. The results of clinical validation studies and clinical decision-making studies are presented. This information is designed to assist urologists in making clinical decisions with respect to ordering and interpreting these tests for different patients. There are numerous fluid and biopsy-based genomic tests available for prostate cancer patients that provide the physician and patient with different information about risk of future disease and treatment outcomes. It is important that providers be able to recommend the appropriate test for each individual patient; this decision is based on tissue availability and prognostic information desired. Future studies will continue to emphasize the important role of genomic biomarkers in making individualized treatment decisions for prostate cancer patients.
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Affiliation(s)
- Ashley V Alford
- 1Department of Urology, Columbia University Medical Center, New York Presbyterian Hospital New York, NY
| | - Joseph M Brito
- Department of Urology, Brown University, Rhode Island Hospital Providence, RI
| | - Kamlesh K Yadav
- Department of Urology, Icahn School of Medicine at Mount Sinai New York, NY
| | - Shalini S Yadav
- Department of Urology, Icahn School of Medicine at Mount Sinai New York, NY
| | - Ashutosh K Tewari
- Department of Urology, Icahn School of Medicine at Mount Sinai New York, NY
| | - Joseph Renzulli
- Department of Urology, Brown University, Rhode Island Hospital Providence, RI
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Zappala SM, Scardino PT, Okrongly D, Linder V, Dong Y. Clinical performance of the 4Kscore Test to predict high-grade prostate cancer at biopsy: A meta-analysis of us and European clinical validation study results. Rev Urol 2017; 19:149-155. [PMID: 29302237 PMCID: PMC5737341 DOI: 10.3909/riu0776] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The 4Kscore® Test (OPKO Diagnostics, Woburn, MA) is a blood test utilized prior to a prostate biopsy to determine a patient's risk of high-grade prostate cancer (PCa) should the biopsy be performed, thus providing critical information in the clinical management of men with a suspicious prostate-specific antigen value or digital rectal examination result. Multiple US and European clinical studies confirmed that a prebiopsy 4Kscore Test has a high degree of discrimination for a subsequent discovery of high-grade (Gleason score ≥7) PCa. The aim of this study was to evaluate the predictive accuracy of the 4Kscore Test to discriminate between patients with and without high-grade PCa based on published clinical validation studies. A systematic review and meta-analysis of the eligible 4Kscore Test clinical validation studies was conducted. The pooled area under the curve (AUC) of the 4Kscore Test as reported from all the studies, and the heterogeneity among these studies were analyzed and repeated for subgroups of the studies. Twelve clinical validation studies were included in the meta-analysis, comprising a total of 11,134 patients. The pooled AUC to discriminate for high-grade PCa for all 12 studies was 0.81 (fixed effects 95% CI, 0.80-0.83). Restricting the analysis to the six publications that used the contemporary 4Kscore Test algorithm led to very similar results (AUC 0.81; 95% CI, 0.79-0.83). Heterogeneity was high among all of the 12 studies, as well as among the six publications that used the contemporary 4Kscore Test (Cochrane's Q test, p = 0.001 for both); however, in both cases, after exclusion of a single outlying study with a much lower AUC, heterogeneity was no longer significant (p = 0.08 and p = 0.21). The pooled estimate of 4Kscore Test discrimination (AUC) for high-grade PCa is >0.80, and is consistent across multiple US and European clinical validation studies.
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Affiliation(s)
| | - Peter T Scardino
- Memorial Sloan Kettering Cancer CenterNew York, NY
- Weill Cornell Medical CollegeNew York, NY
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Abstract
A new generation of prostate cancer (PCa) biomarkers has emerged, including diagnostic serum and urine markers aimed at refining the identification high-grade tumors and tissue-based gene expression assays offering prognostic and predictive clinical information. Such tests seek to improve treatment-related decisions at multiple decision points, including initial diagnosis and following initial primary therapy. In this review, we aim to contextualize the body of evidence surrounding these emerging tests, with attention on studies addressing clinical utility.
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Jakobsen NA, Hamdy FC, Bryant RJ. Novel biomarkers for the detection of prostate cancer. JOURNAL OF CLINICAL UROLOGY 2016; 9:3-10. [PMID: 28344810 PMCID: PMC5356177 DOI: 10.1177/2051415816656121] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 05/04/2016] [Indexed: 01/19/2023]
Abstract
Prostate-specific antigen (PSA) is widely used as a biomarker in the detection of prostate cancer and for decision making regarding treatment options, response to therapy, and clinical follow-up. Despite its widespread use, it is well recognised that PSA has suboptimal performance as a screening tool due to poor specificity, resulting in high negative biopsy rates and potential ‘over-diagnosis’ and ‘over-treatment’ of clinically insignificant cancers. In particular, PSA does not reliably distinguish either cancer from benign prostatic conditions, or ‘clinically significant’ from ‘indolent cancers’, and it is inaccurate in predicting disease burden and response to treatment. There is an urgent demand for novel biomarkers to address these clinical needs. This article provides an update on the novel candidate biomarkers in development, which have shown potential for improving the detection of clinically significant cases of this malignancy.
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Filella X, Foj L. Prostate Cancer Detection and Prognosis: From Prostate Specific Antigen (PSA) to Exosomal Biomarkers. Int J Mol Sci 2016; 17:ijms17111784. [PMID: 27792187 PMCID: PMC5133785 DOI: 10.3390/ijms17111784] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/04/2016] [Accepted: 10/14/2016] [Indexed: 12/22/2022] Open
Abstract
Prostate specific antigen (PSA) remains the most used biomarker in the management of early prostate cancer (PCa), in spite of the problems related to false positive results and overdiagnosis. New biomarkers have been proposed in recent years with the aim of increasing specificity and distinguishing aggressive from non-aggressive PCa. The emerging role of the prostate health index and the 4Kscore is reviewed in this article. Both are blood-based tests related to the aggressiveness of the tumor, which provide the risk of suffering PCa and avoiding negative biopsies. Furthermore, the use of urine has emerged as a non-invasive way to identify new biomarkers in recent years, including the PCA3 and TMPRSS2:ERG fusion gene. Available results about the PCA3 score showed its usefulness to decide the repetition of biopsy in patients with a previous negative result, although its relationship with the aggressiveness of the tumor is controversial. More recently, aberrant microRNA expression in PCa has been reported by different authors. Preliminary results suggest the utility of circulating and urinary microRNAs in the detection and prognosis of PCa. Although several of these new biomarkers have been recommended by different guidelines, large prospective and comparative studies are necessary to establish their value in PCa detection and prognosis.
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Affiliation(s)
- Xavier Filella
- Department of Biochemistry and Molecular Genetics (CDB), Hospital Clínic, IDIBAPS, C/Villarroel, 170, 08036 Barcelona, Catalonia, Spain.
| | - Laura Foj
- Department of Biochemistry and Molecular Genetics (CDB), Hospital Clínic, IDIBAPS, C/Villarroel, 170, 08036 Barcelona, Catalonia, Spain.
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Penson DF, Resnick MJ. Let's Not Throw the Baby out With the Bathwater in Prostate Cancer Screening. J Clin Oncol 2016; 34:3489-3491. [PMID: 27432920 DOI: 10.1200/jco.2016.68.7194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- David F Penson
- Vanderbilt University; and the VA Tennessee Valley Geriatric Research, Education, and Clinical Center, Nashville, TN
| | - Matthew J Resnick
- Vanderbilt University; and the VA Tennessee Valley Geriatric Research, Education, and Clinical Center, Nashville, TN
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Properties of the 4-Kallikrein Panel Outside the Diagnostic Gray Zone: Meta-Analysis of Patients with Positive Digital Rectal Examination or Prostate Specific Antigen 10 ng/ml and Above. J Urol 2016; 197:607-613. [PMID: 27693450 DOI: 10.1016/j.juro.2016.09.086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2016] [Indexed: 11/22/2022]
Abstract
PURPOSE The 4-kallikrein panel, commercially available as the 4Kscore™, is a reflex test for prostate cancer early detection that has been extensively validated in multiple international cohorts. It has been suggested that use of such reflex tests be limited to those with prostate specific antigen less than 10 ng/ml and negative digital rectal examination. We aimed to determine the value of the panel in men outside this "diagnostic gray zone." MATERIALS AND METHODS We performed an individual patient data meta-analysis using data from prior studies on the 4-kallikrein panel. We calculated the properties of the panel for predicting high grade (Gleason 7+) cancer in a subgroup of men with either positive digital rectal examination or prostate specific antigen 10 to 25 ng/ml. RESULTS A total 2,891 men from 8 cohorts were included. An important proportion of patients, including 32% in the United States validation study, had prostate specific antigen 10 to 25 ng/ml or a positive digital rectal examination. For men with prostate specific antigen 10 to 25 ng/ml the fixed-effects estimate for the discrimination of the kallikrein model was 0.84 vs 0.69 for the base model (difference 0.128, 95% CI 0.098-0.159). In the positive digital rectal examination group discrimination was 0.82 vs 0.72 (difference 0.092, 95% CI 0.069-0.115). Decision analysis showed a clinical net benefit for use of the panel in this subgroup with a reduction in biopsy rates of about 20% and only a small number of high grade cancers missed, or fewer than 3% of those not biopsied. CONCLUSIONS The use of the kallikrein panel in men with a positive digital rectal examination or prostate specific antigen 10 to 25 ng/ml is justified.
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Loeb S, Lilja H, Vickers A. Beyond prostate-specific antigen: utilizing novel strategies to screen men for prostate cancer. Curr Opin Urol 2016; 26:459-65. [PMID: 27262138 PMCID: PMC5035435 DOI: 10.1097/mou.0000000000000316] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to review blood and urine tests that are currently available and under investigation for a role in prostate cancer screening and detection. RECENT FINDINGS Compared with total prostate-specific antigen (PSA) alone, its combination with percentage free-to-total PSA contributes greater specificity for prostate cancer, and is a component of two newer blood tests called the 4kScore and Prostate Health Index. All three tests improve the prediction of high-grade disease and are commercially available options to aid in initial or repeat prostate biopsy decisions. PCA3 is a urinary marker that is currently available for repeat prostate biopsy decisions. Although PCA3 alone has inferior prediction of clinically significant disease and requires collection of urine after digital rectal examination, it may be combined with other clinical variables or other urine markers like TMPRSS2:ERG to improve performance. Little data are available to support a role for single nucleotide polymorphisms or other investigational markers in early detection. SUMMARY Several commercially available blood and urine tests have been shown to improve specificity of PSA for high-grade prostate cancer. Use of such tests would decrease unnecessary biopsy and overdiagnosis of indolent disease. Biopsy of men with moderately elevated PSA without use of such a reflex test should be discouraged.
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Affiliation(s)
- Stacy Loeb
- Departments of Urology and Population Health, New York University, New York, USA
| | - Hans Lilja
- Departments of Laboratory Medicine, Surgery, Medicine, Memorial Sloan Kettering Cancer Center, New York, USA and Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom, and Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
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McDonald ML, Parsons JK. 4-Kallikrein Test and Kallikrein Markers in Prostate Cancer Screening. Urol Clin North Am 2016; 43:39-46. [DOI: 10.1016/j.ucl.2015.08.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Ferro M, Buonerba C, Terracciano D, Lucarelli G, Cosimato V, Bottero D, Deliu VM, Ditonno P, Perdonà S, Autorino R, Coman I, De Placido S, Di Lorenzo G, De Cobelli O. Biomarkers in localized prostate cancer. Future Oncol 2016; 12:399-411. [PMID: 26768791 DOI: 10.2217/fon.15.318] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Biomarkers can improve prostate cancer diagnosis and treatment. Accuracy of prostate-specific antigen (PSA) for early diagnosis of prostate cancer is not satisfactory, as it is an organ- but not cancer-specific biomarker, and it can be improved by using models that incorporate PSA along with other test results, such as prostate cancer antigen 3, the molecular forms of PSA (proPSA, benign PSA and intact PSA), as well as kallikreins. Recent reports suggest that new tools may be provided by metabolomic studies as shown by preliminary data on sarcosine. Additional molecular biomarkers have been identified by the use of genomics, proteomics and metabolomics. We review the most relevant biomarkers for early diagnosis and management of localized prostate cancer.
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Affiliation(s)
- Matteo Ferro
- Division of Urology, European Institute of Oncology, Milan, Italy
| | - Carlo Buonerba
- Medical Oncology, Department of Clinical Medicine & Surgery, University 'Federico II', Naples, Italy
| | - Daniela Terracciano
- Department of Translational Medical Sciences, University 'Federico II', Naples, Italy
| | - Giuseppe Lucarelli
- Department of Emergency & Organ Transplantation - Urology, Andrology & Kidney Transplantation Unit, University of Bari, Bari, Italy
| | - Vincenzo Cosimato
- Department of Translational Medical Sciences, University 'Federico II', Naples, Italy
| | - Danilo Bottero
- Division of Urology, European Institute of Oncology, Milan, Italy
| | - Victor M Deliu
- Division of Urology, European Institute of Oncology, Milan, Italy
| | - Pasquale Ditonno
- Department of Emergency & Organ Transplantation - Urology, Andrology & Kidney Transplantation Unit, University of Bari, Bari, Italy
| | - Sisto Perdonà
- Department of Urology, National Cancer Institute of Naples, Naples, Italy
| | - Riccardo Autorino
- Urology Institute, University Hospitals Case Medical Center, Cleveland, OH 44106, USA
| | - Ioman Coman
- Department of Urology 'Iuliu Hatieganu', University of Medicine & Pharmacy, 400012 Cluj-Napoca, Romania
| | - Sabino De Placido
- Medical Oncology, Department of Clinical Medicine & Surgery, University 'Federico II', Naples, Italy
| | - Giuseppe Di Lorenzo
- Medical Oncology, Department of Clinical Medicine & Surgery, University 'Federico II', Naples, Italy
| | - Ottavio De Cobelli
- Division of Urology, European Institute of Oncology, Milan, Italy.,Department of Urology 'Iuliu Hatieganu', University of Medicine & Pharmacy, 400012 Cluj-Napoca, Romania
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Biomarkers for prostate cancer: present challenges and future opportunities. Future Sci OA 2015; 2:FSO72. [PMID: 28031932 PMCID: PMC5137959 DOI: 10.4155/fso.15.72] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 08/10/2015] [Indexed: 01/30/2023] Open
Abstract
Prostate cancer (PCa) has variable biological potential with multiple treatment options. A more personalized approach, therefore, is needed to better define men at higher risk of developing PCa, discriminate indolent from aggressive disease and improve risk stratification after treatment by predicting the likelihood of progression. This may improve clinical decision-making regarding management, improve selection for active surveillance protocols and minimize morbidity from treatment. Discovery of new biomarkers associated with prostate carcinogenesis present an opportunity to provide patients with novel genetic signatures to better understand their risk of developing PCa and help forecast their clinical course. In this review, we examine the current literature evaluating biomarkers in PCa. We also address current limitations and present several ideas for future studies.
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Nordström T, Vickers A, Assel M, Lilja H, Grönberg H, Eklund M. Comparison Between the Four-kallikrein Panel and Prostate Health Index for Predicting Prostate Cancer. Eur Urol 2015; 68:139-46. [PMID: 25151013 PMCID: PMC4503229 DOI: 10.1016/j.eururo.2014.08.010] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 08/04/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The four-kallikrein panel and the Prostate Health Index (PHI) have been shown to improve prediction of prostate cancer (PCa) compared with prostate-specific antigen (PSA). No comparison of the four-kallikrein panel and PHI has been presented. OBJECTIVE To compare the four-kallikrein panel and PHI for predicting PCa in an independent cohort. DESIGN, SETTING, AND PARTICIPANTS Participants were from a population-based cohort of PSA-tested men in Stockholm County. We included 531 men with PSA levels between 3 and 15 ng/ml undergoing first-time prostate biopsy during 2010-2012. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Models were fitted to case status. We computed calibration curves, the area under the receiver-operating characteristics curve (AUC), decision curves, and percentage of saved biopsies. RESULTS AND LIMITATIONS The four-kallikrein panel showed AUCs of 69.0 when predicting any-grade PCa and 71.8 when predicting high-grade cancer (Gleason score ≥7). Similar values were found for PHI: 70.4 and 71.1, respectively. Both models had higher AUCs than a base model with PSA value and age (p<0.0001 for both); differences between models were not significant. Sensitivity analyses including men with any PSA level or a previous biopsy did not materially affect our findings. Using 10% predicted risk of high-grade PCa by the four-kallikrein panel or PHI of 39 as cut-off for biopsy saved 29% of performed biopsies at a cost of delayed diagnosis for 10% of the men with high-grade cancers. Both models showed limited net benefit in decision analysis. The main study limitation was lack of digital rectal examination data and biopsy decision being based on PSA information. CONCLUSIONS The four-kallikrein panel and PHI similarly improved discrimination when predicting PCa and high-grade PCa. Both are simple blood tests that can reduce the number of unnecessary biopsies compared with screening with total PSA, representing an important new option to reduce harm. PATIENT SUMMARY Prostate-specific antigen screening is controversial due to limitations of the test. We found that two blood tests, the Prostate Health Index and the four-kallikrein panel, performed similarly and could both aid in decision making among Swedish men undergoing a prostate biopsy.
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Affiliation(s)
- Tobias Nordström
- Department of Clinical Sciences, Danderyd's Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Melissa Assel
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Hans Lilja
- Departments of Laboratory Medicine, Surgery (Urology), and Medicine (Genitourinary Oncology), Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Department of Laboratory Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Henrik Grönberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Eklund
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, University of California at San Francisco, San Francisco, CA, USA
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Braun K, Sjoberg DD, Vickers AJ, Lilja H, Bjartell AS. A Four-kallikrein Panel Predicts High-grade Cancer on Biopsy: Independent Validation in a Community Cohort. Eur Urol 2015; 69:505-11. [PMID: 25979570 DOI: 10.1016/j.eururo.2015.04.028] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 04/18/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND A statistical model based on four kallikrein markers (total prostate-specific antigen [tPSA], free PSA [fPSA], intact PSA, and human kallikrein-related peptidase 2) in blood can predict risk of Gleason score ≥7 (high-grade) cancer at prostate biopsy. OBJECTIVE To determine the value of this model in predicting high-grade cancer at biopsy in a community-based setting in which referral criteria included percentage of fPSA to tPSA (%fPSA). DESIGN, SETTING, AND PARTICIPANTS We evaluated the model, with or without adding blood levels of microseminoprotein-β (MSMB) in a cohort of 749 men referred for prostate biopsy due to elevated PSA (≥3 ng/ml), low %fPSA (<20%), or suspicious digital rectal examination at Skåne University Hospital, Malmö, Sweden. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The kallikrein markers, with or without MSMB levels, measured in cryopreserved anticoagulated blood were combined with age in a published statistical model (Prostate Testing for Cancer and Treatment [ProtecT]) to predict high-grade cancer at biopsy. Predictive accuracy was compared with a base model. RESULTS AND LIMITATIONS The %fPSA was low (median: 17; interquartile range: 13-22) in this cohort because this marker was used as a referral criterion. The ProtecT model improved discrimination over age and PSA for high-grade cancer (0.777 vs 0.720; p=0.002). At one illustrative cut point, use of the panel would reduce the number of biopsies by 236 per 1000 and detect 195 of 208 (94%) but delay diagnosis of 13 of 208 high-grade cancers. MSMB levels in blood did not improve the accuracy of the panel (p=0.2). CONCLUSIONS The kallikrein model is predictive of high-grade cancer if criteria for biopsy referral also include %fPSA, and it can reduce unnecessary biopsies without missing an undue number of tumors. PATIENT SUMMARY We evaluated a published model to predict biopsy outcome in men biopsied due to low percentage of free to total prostate-specific antigen. The model helps reduce unnecessary biopsies without missing an undue number of high-grade cancers.
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Affiliation(s)
- Katharina Braun
- Department of Urology, University Hospital Ruhr-University Bochum, Marien Hospital Herne, Herne, Germany
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hans Lilja
- Departments of Laboratory Medicine, Medicine (Genitourinary Oncology), and Surgery (Urology), Memorial Sloan Kettering Cancer Center, New York, NY, USA; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Department of Translational Medicine, Lund University, Malmö, Sweden.
| | - Anders S Bjartell
- Department of Translational Medicine, Lund University, Malmö, Sweden
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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: 125] [Impact Index Per Article: 13.9] [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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Alberts AR, Schoots IG, Roobol MJ. Prostate-specific antigen-based prostate cancer screening: Past and future. Int J Urol 2015; 22:524-32. [PMID: 25847604 DOI: 10.1111/iju.12750] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/29/2015] [Accepted: 02/01/2015] [Indexed: 12/21/2022]
Abstract
Prostate-specific antigen-based prostate cancer screening remains a controversial topic. Up to now, there is worldwide consensus on the statement that the harms of population-based screening, mainly as a result of overdiagnosis (the detection of clinically insignificant tumors that would have never caused any symptoms), outweigh the benefits. However, worldwide opportunistic screening takes place on a wide scale. The European Randomized Study of Screening for Prostate Cancer showed a reduction in prostate cancer mortality through prostate-specific antigen based-screening. These population-based data need to be individualized in order to avoid screening in those who cannot benefit and start screening in those who will. For now, lacking a more optimal screening approach, screening should only be started after the process of shared decision-making. The focus of future research is the reduction of unnecessary testing and overdiagnosis by further research to better biomarkers and the value of the multiparametric magnetic resonance imaging, potentially combined in already existing prostate-specific antigen-based multivariate risk prediction models.
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Affiliation(s)
- Arnout R Alberts
- Department of Urology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ivo G Schoots
- Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Murphy L, Prencipe M, Gallagher WM, Watson RW. Commercialized biomarkers: new horizons in prostate cancer diagnostics. Expert Rev Mol Diagn 2015; 15:491-503. [DOI: 10.1586/14737159.2015.1011622] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Punnen S, Pavan N, Parekh DJ. Finding the Wolf in Sheep's Clothing: The 4Kscore Is a Novel Blood Test That Can Accurately Identify the Risk of Aggressive Prostate Cancer. Rev Urol 2015; 17:3-13. [PMID: 26028995 PMCID: PMC4444768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Better biomarkers that can discriminate between aggressive and indolent phenotypes of prostate cancer are urgently needed. In the first 20 years of the prostate-specific antigen (PSA) era, screening for prostate cancer has successfully reduced prostate cancer mortality, but has led to significant problems with overdiagnosis and overtreatment. As a result, many men are subjected to unnecessary prostate biopsies and overtreatment of indolent cancer in order to save one man from dying of prostate cancer. A novel blood test known as the 4Kscore® Test (OPKO Lab, Nashville, TN) incorporates a panel of four kallikrein protein biomarkers (total PSA, free PSA, intact PSA, and human kallikrein-related peptidase 2) and other clinical information in an algorithm that provides a percent risk for a high-grade (Gleason score ≥ 7) cancer on biopsy. In 10 peer-reviewed publications, the four kallikrein biomarkers and algorithm of the 4Kscore Test have been shown to improve the prediction not only of biopsy histopathology, but also surgical pathology and occurrence of aggressive, metastatic disease. Recently, a blinded prospective trial of the 4Kscore Test was conducted across the United States among 1012 men. The 4Kscore Test replicated previous European results showing accuracy in predicting biopsy outcome of Gleason score ≥ 7. In a recent case-control study nested within a population-based cohort from Västerbotten, Sweden, the four kallikrein biomarkers of the 4Kscore Test also predicted the risk for aggressive prostate cancer that metastasized within 20 years after the test was administered. These results indicate that men with an abnormal PSA or digital rectal examination result, and for whom an initial or repeat prostate biopsy is being considered, would benefit from a reflex 4Kscore Test to add important information to the clinical decision-making process. A high-risk 4Kscore Test result may be used to select men with a high probability of aggressive prostate cancer who would benefit from a biopsy of the prostate to prevent an adverse and potentially lethal outcome from prostate cancer. Men with a low 4Kscore Test result may safely defer biopsy.
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Affiliation(s)
- Sanoj Punnen
- Department of Urology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Nicola Pavan
- Department of Urology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Dipen J Parekh
- Department of Urology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
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Konety B, Zappala SM, Parekh DJ, Osterhout D, Schock J, Chudler RM, Oldford GM, Kernen KM, Hafron J. The 4Kscore® Test Reduces Prostate Biopsy Rates in Community and Academic Urology Practices. Rev Urol 2015; 17:231-240. [PMID: 26839521 PMCID: PMC4735670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
There is significant concern regarding prostate cancer screening because of the potential for overdiagnosis and overtreatment of men who are discovered to have abnormal prostate specific antigen (PSA) levels and/or digital rectal examination (DRE) results. The 4Kscore® Test (OPKO Diagnostics, LLC) is a blood test that utilizes four kallikrein levels plus clinical information in an algorithm to calculate an individual's percentage risk (< 1% to > 95%) for aggressive prostate cancer (Gleason score ≥ 7) on prostate biopsy. The 4Kscore Test, as a follow-up test after abnormal PSA and/or DRE test results, has been shown to improve the specificity for predicting the risk of aggressive prostate cancer and reduce unnecessary prostate biopsies. A clinical utility study was conducted to assess the influence of the 4Kscore Test on the decision to perform prostate biopsies in men referred to urologists for abnormal PSA and/or DRE results. The study population included 611 patients seen by 35 academic and community urologists in the United States. Urologists ordered the 4Kscore Test as part of their assessment of men referred for abnormal PSA and/or DRE test results. Results for the patients were stratified into low risk (< 7.5%), intermediate risk (7.5%-19.9%), and high risk (≥ 20%) for aggressive prostate cancer. The 4Kscore Test results influenced biopsy decisions in 88.7% of the men. Performing the 4Kscore Test resulted in a 64.6% reduction in prostate biopsies in patients; the actual percentage of cases not proceeding to biopsy were 94.0%, 52.9%, and 19.0% for men who had low-, intermediate-, and high-risk 4Kscore Test results, respectively. A higher 4Kscore Test was associated with greater likelihood of having a prostate biopsy (P < 0.001). Among the 171 patients who had a biopsy, the 4Kscore risk category is strongly associated with biopsy pathology. The 4Kscore Test, as a follow-up test for an abnormal PSA and/or DRE results, significantly influenced the physician and patient shared decision in clinical practice, which led to a reduction in prostate biopsies while increasing the probability of detecting aggressive cancer.
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Affiliation(s)
| | - Stephen M Zappala
- Department of Urology, Tufts University School of Medicine, Boston, MA
| | - Dipen J Parekh
- Department of Urology, University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | | | | | - Jason Hafron
- Michigan Institute of Urology, St. Clair Shores, MI
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Parekh DJ, Punnen S, Sjoberg DD, Asroff SW, Bailen JL, Cochran JS, Concepcion R, David RD, Deck KB, Dumbadze I, Gambla M, Grable MS, Henderson RJ, Karsh L, Krisch EB, Langford TD, Lin DW, McGee SM, Munoz JJ, Pieczonka CM, Rieger-Christ K, Saltzstein DR, Scott JW, Shore ND, Sieber PR, Waldmann TM, Wolk FN, Zappala SM. A multi-institutional prospective trial in the USA confirms that the 4Kscore accurately identifies men with high-grade prostate cancer. Eur Urol 2014; 68:464-70. [PMID: 25454615 DOI: 10.1016/j.eururo.2014.10.021] [Citation(s) in RCA: 276] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/13/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND The 4Kscore combines measurement of four kallikreins in blood with clinical information as a measure of the probability of significant (Gleason ≥7) prostate cancer (PCa) before prostate biopsy. OBJECTIVE To perform the first prospective evaluation of the 4Kscore in predicting Gleason ≥7 PCa in the USA. DESIGN, SETTING, AND PARTICIPANTS Prospective enrollment of 1012 men scheduled for prostate biopsy, regardless of prostate-specific antigen level or clinical findings, was conducted at 26 US urology centers between October 2013 and April 2014. INTERVENTION The 4Kscore. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was Gleason ≥7 PCa on prostate biopsy. The area under the receiver operating characteristic curve, risk calibration, and decision curve analysis (DCA) were determined, along with comparisons of probability cutoffs for reducing the number of biopsies and their impact on delaying diagnosis. RESULTS AND LIMITATIONS Gleason ≥7 PCa was found in 231 (23%) of the 1012 patients. The 4Kscore showed excellent calibration and demonstrated higher discrimination (AUC 0.82) and net benefit compared to a modified Prostate Cancer Prevention Trial Risk Calculator 2.0 model and standard of care (biopsy for all men) according to DCA. A possible reduction of 30-58% in the number biopsies was identified with delayed diagnosis in only 1.3-4.7% of Gleason ≥7 PCa cases, depending on the threshold used for biopsy. Pathological assessment was performed according to the standard of care at each site without centralized review. CONCLUSION The 4Kscore showed excellent diagnostic performance in detecting significant PCa. It is a useful tool in selecting men who have significant disease and are most likely to benefit from a prostate biopsy from men with no cancer or indolent cancer. PATIENT SUMMARY The 4Kscore provides each patient with an accurate and personalized measure of the risk of Gleason ≥7 cancer to aid in decision-making regarding the need for prostate biopsy.
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Affiliation(s)
- Dipen J Parekh
- Department of Urology, University of Miami Miller School of Medicine and Sylvestor Comprehensive Cancer Center, Miami, FL, USA.
| | - Sanoj Punnen
- Department of Urology, University of Miami Miller School of Medicine and Sylvestor Comprehensive Cancer Center, Miami, FL, USA
| | - Daniel D Sjoberg
- Department of Urology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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