More than one million prostate biopsies are performed each year in the United States alone, including many repeat biopsies for fear of cancer missed. Unnecessary repeat biopsies could be avoided with better diagnostic tests. Two independent trials have validated the performance of an epigenetic test that could provide physicians with a better tool to help eliminate unnecessary repeat prostate biopsies.
In the previously reported independent MATLOC (Methylation Analysis To Locate Occult Cancer) trial, a multiplex epigenetic assay (ConfirmMDx for Prostate Cancer) profiling the APC, GSTP1, and RASSF1 genes demonstrated a negative predictive value of 90%. GSTP1 methylation is a specific biomarker for (prostate) cancer and this gene is methylated in up to 90% of prostate cancer cases. Additionally, APC and RASSF1 are important field effect markers and increase the diagnostic sensitivity of the assay.
A second multicenter study, DOCUMENT (Detection Of Cancer Using Methylated Events in Negative Tissue), has validated the performance of the epigenetic assay used in the MATLOC trial as an independent predictor of prostate cancer risk to guide decision making for repeat biopsy. In the DOCUMENT study, patients with a negative biopsy were evaluated to identify those at low risk for harboring cancer missed through biopsy sampling error who could forego an unnecessary repeat biopsy. The validation study resulted in a negative predictive value of 88%. The study’s results were published in The Journal of Urology (2014; doi:10.1016/j.juro.2014.04.013).
“This epigenetic assay is a significant, independent predictor and has been shown to be the most valuable diagnostic aid of all evaluated risk factors in two independent trials,” commented Alan W. Partin, MD, PhD, of the James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine in Baltimore, Maryland. “Negative findings of this assay could be used to reduce concern over unsampled cancer and effectively avoid unnecessary repeat biopsies.”
A total of 350 patients were enrolled in the DOCUMENT trial from five geographically dispersed medical centers in the United States. Patients were grouped into those with two consecutive negative biopsies (controls) and those with a negative biopsy followed by a positive biopsy within 24 months. The study evaluated the initial archived, negative for cancer, prostate biopsy core tissue samples. All of the men underwent a repeat biopsy on average 1 year after the initial biopsy.
Only biopsies with a minimum of eight cores per biopsy, collected no earlier than 2007, were included in the study, while initial biopsies with atypical cells suspicious for cancer, ie, atypical small acinar proliferation by the sites’ pathologists, were excluded, since this would have triggered a repeat biopsy based on histopathology alone.
After correcting for age, prostate specific antigen (PSA), digital rectal exam, histopathologic characteristics of the first biopsy, and race, this epigenetic test proved to be the most significant, independent, and strongest predictor of patient outcome with an odds ratio of 2.69 as well as the most valuable diagnostic aid of all evaluated risk factors. The slightly decreased sensitivity of the DOCUMENT trial compared to the MATLOC trial is most likely associated with a higher PSA screening prevalence in the DOCUMENT cohort.