PSA-related markers in the detection of prostate cancer and high-grade disease in the contemporary era with extended biopsy

ObjectiveTo determine the relationship of total PSA (tPSA), percent free PSA (%fPSA), and complexed PSA (cPSA) with prostate cancer detection and the diagnosis of poorly-differentiated cancers in the contemporary era.MethodsWe retrospectively reviewed the clinical and pathological records of 292 men who met the following inclusion criteria: (1) tPSA 2.5 to 10 ng/ml; (2) initial biopsy only; (3) extended biopsy scheme (≥10 peripheral zone cores); (4) no previous prostate surgeries. The ability of PSA-related markers to detect cancer was determined by area under the receiver operating characteristics curve analysis (AUC-ROC). Various clinically relevant %fPSA cutoffs and cPSA ranges were analyzed to determine the association with poorly-differentiated cancers.ResultsCancer was detected in 126 (43%) men, with mean Gleason score of 7. The cancer detection rates for various cutoffs of tPSA, cPSA and %fPSA were very similar. On ROC analysis for cancer diagnosis, the AUCs for tPSA, %fPSA, and cPSA were 0.53, 0.54, and 0.52, respectively. Men with %fPSA <15 were more likely to have poorly-differentiated cancer than those with %fPSA ≥15 (66% vs. 41%, P < 0.005). Similarly, cPSA ranges (2–4, 4.1–6, and >6) were associated with the detection of poorly-differentiated cancers (37%, 57%, and 80% P < 0.003).ConclusionsWith the use of extended prostate sampling in the contemporary screening population, the addition of cPSA and %fPSA does not enhance the diagnostic performance of tPSA. However, the significant association between cPSA and poorly-differentiated cancers suggests that this may be a more useful initial test for prostate cancer screening.