Redesigned proficiency testing materials improve survey outcomes for prostate-specific antigen. A College of American Pathologists Ligand Assay Survey tool

A practical guide to validation and verification of analytical methods in the clinical laboratory

Although the measures to improve quality in the clinical laboratory have been enormous in the past years, not least of all due to the introduction of the ISO standards 15189 and 17025, the handling of validation and verification of method performance often still differs widely from laboratory to laboratory. Much of what is published on the topic contains complex statistics and is difficult to implement in routine laboratories. The result is, that this point is often neglected or implemented incorrectly, which in turn can lead to false conclusions about method performances, potentially compromising patient safety or contributing to incorrect diagnoses. As it has long become a standard requirement for accredited laboratories to evaluate and document the analytical performance of all methods not only prior to their first implementation, but also during ongoing operation, there is a need for clear, standardized and practical guidelines on the subject. This review summarizes the current literature on the topic, focusing on the requirements for method validations, or as the case may be, verifications and describes when to validate, when to verify and which statistical tests are appropriate for each. Proper interpretation of statistical test results and acceptance criteria for each procedure are alluded to. Specific topics, which are addressed, are precision and bias verification of quantitative, qualitative and semi-quantitative procedures, method comparisons with Bland-Altman Plots, Passing-Bablok regression analysis, 2×2 contingency tables and bubble charts, linearity studies, analytical sensitivity and specificity, performing carry-over studies and establishing and confirming reference ranges.

Suitability of quality control materials for prostate-specific antigen (PSA) measurement: inter-method variability of common tumor marker control materials

BACKGROUND

Quality control materials with minimal inter-assay differences and clinically relevant proportions of different molecular forms of the analyte are needed to optimize intra- and inter-laboratory accuracy and precision.

METHODS

We assessed if clinically relevant total prostate-specific antigen (tPSA) levels were present in seven commercially available Multi Constituent Tumor Marker Controls (MC-TMC). Further, we determined the concentration of free PSA (fPSA) and calculated the percentage of free PSA (%fPSA) in all materials. Finally, we determined variability of TMC materials across several commonly used PSA platforms.

RESULTS

All MC-TMC materials contained at least one concentration of tPSA in normal and pathologic range. Control materials varied in the amount of fPSA and %fPSA, with most controls consisting of fPSA only and only one MC-TMC containing medically relevant levels of around 35% fPSA. Only a minority of MC-TMC materials showed minimal variability across four PSA methods while the majority of PSA controls showed wide inter-method differences.

CONCLUSIONS

Use of many commercially available controls for PSA could lead to biased PSA measurements because they contain medically irrelevant proportions of fPSA and show significant variation among different PSA assay platforms.

Sauver JL, Klee GG, Girman CJ, Lieber MM. Sixteen-year longitudinal changes in serum prostate-specific antigen levels: the olmsted county study

OBJECTIVE

To determine the distribution of longitudinal changes in serum prostate-specific antigen (PSA) levels from a population-based sample of men.

PATIENTS AND METHODS

In this prospective cohort study, a random sample of Olmsted County, Minnesota, men aged 40 to 79 years in 1990 were followed up biennially from January 1, 1990, through August 29, 2007. Serum PSA levels were determined at each examination, and men were censored for follow-up with a diagnosis of prostate cancer or treatment for benign prostatic hyperplasia. The empirical distributions of annual percent change and annual absolute change in serum PSA level were calculated and tabulated, including the median and 75th and 95th percentiles.

RESULTS

For men with PSA measurements 2 years apart, the median annual percent change in serum PSA level was 4.83% and the 95th percentile was about 49.76%. The variability in estimated annual change decreased with increasing time between assessments, with a 95th percentile of 21.82% after 8 or more years between assessments. Although the median absolute change per year increased with increasing age, the median percent change per year was fairly consistent across age groups.

CONCLUSION

These data demonstrate that, with shorter intervals between assessments, greater variability should be expected. These distributions should prove helpful to patients and clinicians in interpreting changes in serum PSA levels observed in typical clinical practices.

Early Detection of Cancer: Immunoassays for Plasma Tumor Markers

BACKGROUND: Plasma tumor biomarkers are widely used clinically for monitoring response to therapy and detecting cancer recurrence. However, only a limited number of them have been effectively used for the early detection of cancer. OBJECTIVE: To review plasma tumor markers used clinically for the early detection of cancer and to provide expert opinion about future directions. METHODS: Literature review, as well as our expert opinion, of plasma tumor markers that have been widely accepted for the early detection of cancer. RESULTS: In the United States, only prostate specific antigen (PSA), cancer antigen 125 (CA125), and alpha-fetoprotein (AFP) have been clinically used for the early detection of prostate, ovarian, and liver cancers, respectively. Both analytical and clinical issues related to the use of these three markers were discussed. CONCLUSION: Few plasma tumor markers have been used effectively for the early detection of cancer, mainly due to their limited sensitivity and/or specificity. Multiple approaches have been developed to improve the clinical performance of tumor markers for the early detection of cancer. Metrological traceability and antibody specificity are important issues to ensure comparability of immunoassays for the measurement of plasma tumor markers.

Mass Spectrometric Identification of Proteotypic Peptides from Clinically Used Tumor Markers

Introduction

With the rapid development of mass spectrometry-based technologies such as multiple reaction monitoring and heavy-isotope-labeled-peptide standards, quantitative analysis of biomarker proteins using mass spectrometry is rapidly progressing toward detection of target proteins/peptides from clinical samples. Proteotypic peptides are a few peptides that are repeatedly and consistently identified from a protein in a mixture and are used for quantitative analysis of the protein in a complex biological sample by mass spectrometry.

Materials and Methods

Using mass spectrometry, we identified peptide sequences and provided a list of tryptic peptides and glycopeptides as proteotypic peptides from five clinically used tumor markers, including prostate-specific antigen, carcinoembryonic antigen, Her-2, human chorionic gonadotropin, and CA125.

Conclusion

These proteotypic peptides have potential for targeted detection as well as heavy-isotope-peptide standards for quantitative analysis of marker proteins in clinical specimens using a highly specific, sensitive, and high-throughout mass spectrometry-based analysis method.

Specimen materials, target values and commutability for external quality assessment (proficiency testing) schemes

BACKGROUND

The objective of external quality assessment is to evaluate clinical acceptability of laboratory results. It is desirable to evaluate intermethod harmonization and traceability to a reference system.

METHODS

Conventional matrix-modified processed materials are used in most programs, because they can be produced in large quantities, can have multiple abnormal analytes in the same vial and have excellent stability. The principal limitation of these materials is non-commutability which makes them unsuitable for traceability or harmonization evaluation. Peer group evaluation is used which allows an individual laboratory to confirm appropriate use of a measurement technology and a manufacturer to monitor uniformity in their calibration transfer process. Authentic clinical specimen pools provide commutability but are limited by the quantity available and number of analytes at pathologic levels in the same vial. Hybrid approaches have used authentic clinical specimen pools in conjunction with non-commutable processed materials to determine method-specific matrix-corrected target values which have enabled evaluation of traceability to reference methods.

CONCLUSIONS

Conventional processed materials are limited by non-commutability. Pooled clinical specimens are limited by availability. When used together, external quality assessment can evaluate traceability to reference systems and harmonization between test procedures.