Molecular Analysis of Low Grade Prostate Cancer Using a Genomic Classifier of Metastatic Potential

Morphologic patterns observed in prostate biopsy cases with discrepant grade group and molecular risk classification

BACKGROUND

Molecular-based risk classifier tests are increasingly being utilized by urologists and radiation oncologists to guide clinical decision making. The Decipher prostate biopsy test is a 22-gene RNA biomarker assay designed to predict likelihood of high-grade disease at radical prostatectomy and risk of metastasis and mortality. The test provides a risk category of low, intermediate, or high. We investigated histologic features of biopsies in which the Grade Group (GG) and Decipher risk category (molecular risk) were discrepant.

METHODS

Our institutional urologic outcomes database was searched for men who underwent prostate biopsies with subsequent Decipher testing from 2016 to 2020. We defined discrepant GG and molecular risk as either GG1-2 with high Decipher risk category or GG ≥ 3 with low Decipher risk category. The biopsy slide on which Decipher testing was performed was re-reviewed for GG and various histologic features, including % Gleason pattern 4, types of Gleason pattern 4 and 5, other "high risk" features (e.g., complex papillary, ductal carcinoma, intraductal carcinoma [IDC]), and other unusual and often "difficult to grade" patterns (e.g., atrophic carcinoma, mucin rupture, pseudohyperplastic carcinoma, collagenous fibroplasia, foamy gland carcinoma, carcinoma with basal cell marker expression, carcinoma with prominent vacuoles, and stromal reaction). Follow-up data was also obtained from the electronic medical record.

RESULTS

Of 178 men who underwent prostate biopsies and had Decipher testing performed, 41 (23%) had discrepant GG and molecular risk. Slides were available for review for 33/41 (80%). Of these 33 patients, 23 (70%) had GG1-2 (GG1 n = 5, GG2 n = 18) with high Decipher risk, and 10 (30%) had GG ≥ 3 with low Decipher risk. Of the 5 GG1 cases, one case was considered GG2 on re-review; no other high risk features were identified but each case showed at least one of the following "difficult to grade" patterns: 3 atrophic carcinoma, 1 collagenous fibroplasia, 1 carcinoma with mucin rupture, and 1 carcinoma with basal cell marker expression. Of the 18 GG2 high Decipher risk cases, 2 showed GG3 on re-review, 5 showed large cribriform and/or other high risk features, and 10 showed a "difficult to grade" pattern. Of the 10 GG ≥ 3 low Decipher risk cases, 5 had known high risk features including 2 with large cribriform, 1 with IDC, and 1 with Gleason pattern 5.

CONCLUSIONS

In GG1-2 high Decipher risk cases, difficult to grade patterns were frequently seen in the absence of other known high risk morphologic features; whether these constitute true high risk cases requires further study. In the GG ≥ 3 low Decipher risk cases, aggressive histologic patterns such as large cribriform and IDC were observed in half (50%) of cases; therefore, the molecular classifier may not capture all high risk histologic patterns.

Does post prostatectomy decipher score predict biochemical recurrence and impact care?

PURPOSE

To examine the ability of the Decipher test to predict early biochemical recurrence after radical prostatectomy and to impact clinical decisions in advance of metastasis and death.

METHODS

We identified Decipher tests ordered after radical prostatectomy for adverse pathology in men treated for prostate cancer between 1/1/14 and 8/31/18. Biochemical recurrence was defined as prostate-specific antigen > 0.02 ng/mL. Decipher score is reported as lower risk (< 0.6) and higher risk ≥ 0.60). Kaplan-Meier analysis was used to examine the relationship between Decipher score and time to biochemical recurrence (months). Cox regression was used to analyze the relationship between Decipher score and time to biochemical recurrence while controlling for a number of clinical characteristics. Secondary analyses focused on a subset of men with prostate-specific antigen > 0.02 and < 0.20 ng/mL to determine if high-risk Decipher scores were associated with receipt of salvage treatment.

RESULTS

A total of 203 cases were analyzed: 37.9% and 62.1% had lower and higher risk Decipher scores respectively, and 56.2% had a biochemical recurrence. Median (inter-quartile range) follow-up was 20 (13.5, 25.3) months. Decipher score was significantly associated with time to biochemical recurrence (p = 0.027) while in the secondary analyses, high-risk Decipher scores (≥ 0.60) were associated with salvage treatment (p = 0.018). Stage category and Decipher score were significant predictors of time from elevated PSA to salvage treatment in the secondary analyses.

CONCLUSION

While it might not contribute statistically, Decipher score can be clinically useful in helping patients reach treatment decisions.

Prostate Cancer, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology

The NCCN Guidelines for Prostate Cancer include recommendations regarding diagnosis, risk stratification and workup, treatment options for localized disease, and management of recurrent and advanced disease for clinicians who treat patients with prostate cancer. The portions of the guidelines included herein focus on the roles of germline and somatic genetic testing, risk stratification with nomograms and tumor multigene molecular testing, androgen deprivation therapy, secondary hormonal therapy, chemotherapy, and immunotherapy in patients with prostate cancer.

Identification of candidate miRNAs in early-onset and late-onset prostate cancer by network analysis

The incidence of patients under 55 years old diagnosed with Prostate Cancer (EO-PCa) has increased during recent years. The molecular biology of PCa cancer in this group of patients remains unclear. Here, we applied weighted gene coexpression network analysis of the expression of miRNAs from 24 EO-PCa patients (38–45 years) and 25 late-onset PCa patients (LO-PCa, 71–74 years) to identify key miRNAs in EO-PCa patients. In total, 69 differentially expressed miRNAs were identified. Specifically, 26 and 14 miRNAs were exclusively deregulated in young and elderly patients, respectively, and 29 miRNAs were shared. We identified 20 hub miRNAs for the network built for EO-PCa. Six of these hub miRNAs exhibited prognostic significance in relapse‐free or overall survival. Additionally, two of the hub miRNAs were coexpressed with mRNAs of genes previously identified as deregulated in EO-PCa and in the most aggressive forms of PCa in African-American patients compared with Caucasian patients. These genes are involved in activation of immune response pathways, increased rates of metastasis and poor prognosis in PCa patients. In conclusion, our analysis identified miRNAs that are potentially important in the molecular pathology of EO-PCa. These genes may serve as biomarkers in EO-PCa and as possible therapeutic targets.

Prostate cancer: more effective use of underutilized postoperative radiation therapy

Introduction: Adverse pathological features at radical prostatectomy such as extracapsular extension, seminal-vesicle involvement, positive surgical margins and/or lymph node invasion define a particular subgroup of patients that might benefit from additional treatment after surgery, in particular radiation therapy.Areas covered: Post-prostatectomy radiation is intended as adjuvant, early-salvage or salvage depending on the timing and PSA levels at the treatment. After providing the most used definitions, the high-level evidence supporting adjuvant radiation is reviewed together with the limitations affecting its utilization. In recent years early-salvage radiation was hypothesized to be a non-inferior alternative based on good-quality retrospective data. Recently, preliminary results of ongoing trials provide additional evidence. In light of the need to identify patients that will truly benefit from adjuvant radiation, clinically based and molecular tools available for this purpose are reviewed.Expert opinion: In order to tailor treatment for the patient after radical prostatectomy, there is a need for a tool that could both improve the oncological outcomes and be cost-effective. To date, genomic testing provides the most promising results that will be reasonably improved in the coming years.

Questioning the Status Quo: Should Gleason Grade Group 1 Prostate Cancer be Considered a "Negative Core" in Pre-Radical Prostatectomy Risk Nomograms? An International Multicenter Analysis

OBJECTIVE

To assess the impact of excluding Gleason Grade Group 1 (GG1) prostate cancer (CaP) cores from current pre-radical prostatectomy (RP) nomograms.

METHODS

Multi-institutional retrospective chart review was performed on all RP patients with prostate biopsy between 2008 and 2018. Patients were individually assessed using the Memorial Sloan Kettering Cancer Center (MSKCC) and Briganti nomograms using the following iterations: (1) Original [ORIG] - all available core data and (2) Selective [SEL] - GG1 cores considered negative. Nomogram outcomes - lymph node invasion (LNI), extracapsular extension (ECE), organ-confined disease (OCD), seminal vesicle invasion (SVI), were compared across iterations and stratified based on biopsy GG. Clinically significant impact on management (CSIM) was defined as change in LNI risk above or below 2% or 5% (Δ2/Δ5). Nomogram outcomes were validated with RP pathology.

RESULTS

7718 men met inclusion criteria. In men with GG2 who also had GG1 cores, SEL better predicted LNI (MSKCC - ORIG 4.97% vs SEL 3.50%; Briganti - ORIG 4.81% vs SEL 2.49%, RP outcome 2.46%), OCD (MSKCC - ORIG 40.91% vs SEL 48.44%, RP outcome: 68.46%) and ECE (MSKCC - ORIG 57.87% vs SEL 50.38%, RP outcome: 30.41%), but not SVI (MSKCC - ORIG 5.42% vs SEL 3.34%, RP outcome: 5.62%). This was also consistent in patients with GG3-5 disease. The greatest CSIM was on GG1-2 CaP; Δ2 and Δ5 in GG1 patients was 26.3%-31.0% and 1.5%-5.2%, respectively, and Δ2 and Δ5 in GG2 patients was 3.4%-22.2% and 12.3%-13.6%, respectively.

CONCLUSION

Excluding GG1 CaP cores from pre-RP nomograms better predicts final RP pathologic outcomes. More importantly, this may better reflect extent of true cancer burden.

Decipher identifies men with otherwise clinically favorable-intermediate risk disease who may not be good candidates for active surveillance

BACKGROUND

We aimed to validate Decipher to predict adverse pathology (AP) at radical prostatectomy (RP) in men with National Comprehensive Cancer Network (NCCN) favorable-intermediate risk (F-IR) prostate cancer (PCa), and to better select F-IR candidates for active surveillance (AS).

METHODS

In all, 647 patients diagnosed with NCCN very low/low risk (VL/LR) or F-IR prostate cancer were identified from a multi-institutional PCa biopsy database; all underwent RP with complete postoperative clinicopathological information and Decipher genomic risk scores. The performance of all risk assessment tools was evaluated using logistic regression model for the endpoint of AP, defined as grade group 3-5, pT3b or higher, or lymph node invasion.

RESULTS

The median age was 61 years (interquartile range 56-66) for 220 patients with NCCN F-IR disease, 53% classified as low-risk by Cancer of the Prostate Risk Assessment (CAPRA 0-2) and 47% as intermediate-risk (CAPRA 3-5). Decipher classified 79%, 13% and 8% of men as low-, intermediate- and high-risk with 13%, 10%, and 41% rate of AP, respectively. Decipher was an independent predictor of AP with an odds ratio of 1.34 per 0.1 unit increased (p value = 0.002) and remained significant when adjusting by CAPRA. Notably, F-IR with Decipher low or intermediate score did not associate with significantly higher odds of AP compared to VL/LR.

CONCLUSIONS

NCCN risk groups, including F-IR, are highly heterogeneous and should be replaced with multivariable risk-stratification. In particular, incorporating Decipher may be useful for safely expanding the use of AS in this patient population.

Correlation between MRI phenotypes and a genomic classifier of prostate cancer: preliminary findings

OBJECTIVES

We sought to evaluate the correlation between MRI phenotypes of prostate cancer as defined by PI-RADS v2 and the Decipher Genomic Classifier (used to estimate the risk of early metastases).

METHODS

This single-center, retrospective study included 72 nonconsecutive men with prostate cancer who underwent MRI before radical prostatectomy performed between April 2014 and August 2017 and whose MRI registered lesions were microdissected from radical prostatectomy specimens and then profiled using Decipher (89 lesions; 23 MRI invisible [PI-RADS v2 scores ≤ 2] and 66 MRI visible [PI-RADS v2 scores ≥ 3]). Linear regression analysis was used to assess clinicopathologic and MRI predictors of Decipher results; correlation coefficients (r) were used to quantify these associations. AUC was used to determine whether PI-RADS v2 could accurately distinguish between low-risk (Decipher score < 0.45) and intermediate-/high-risk (Decipher score ≥ 0.45) lesions.

RESULTS

MRI-visible lesions had higher Decipher scores than MRI-invisible lesions (mean difference 0.22; 95% CI 0.13, 0.32; p < 0.0001); most MRI-invisible lesions (82.6%) were low risk. PI-RADS v2 had moderate correlation with Decipher (r = 0.54) and had higher accuracy (AUC 0.863) than prostate cancer grade groups (AUC 0.780) in peripheral zone lesions (95% CI for difference 0.01, 0.15; p = 0.018).

CONCLUSIONS

MRI phenotypes of prostate cancer are positively correlated with Decipher risk groups. Although PI-RADS v2 can accurately distinguish between lesions classified by Decipher as low or intermediate/high risk, some lesions classified as intermediate/high risk by Decipher are invisible on MRI.

KEY POINTS

• MRI phenotypes of prostate cancer as defined by PI-RADS v2 positively correlated with a genomic classifier that estimates the risk of early metastases. • Most but not all MRI-invisible lesions had a low risk for early metastases according to the genomic classifier. • MRI could be used in conjunction with genomic assays to identify lesions that may carry biological potential for early metastases.

Clinically Localized Prostate Cancer: ASCO Clinical Practice Guideline Endorsement of an American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology Guideline

Purpose

In April 2017, the American Urological Association, American Society for Radiation Oncology, and Society of Urologic Oncology released a joint evidence-based practice guideline on clinically localized prostate cancer. The American Society of Clinical Oncology (ASCO) has a policy and set of procedures for endorsing clinical practice guidelines that have been developed by other professional organizations.

Methods

The Clinically Localized Prostate Cancer guideline was reviewed for developmental rigor by methodologists. An ASCO Expert Panel then reviewed the content and the recommendations.

Results

The ASCO Expert Panel determined that the recommendations from the Clinically Localized Prostate Cancer guideline were clear, thorough, and based upon the most relevant scientific evidence. ASCO endorsed the Clinically Localized Prostate Cancer guideline except for two recommendations on cryosurgery. The two recommendations covering cryosurgery were not endorsed because the panel found that there is insufficient evidence to support the use of cryotherapy in this setting.

Recommendations

The ASCO Expert Panel endorsed all but two of the original guideline recommendations as written and offered a series of discussion points to guide practice.

Clinical Utility of Gene Expression Classifiers in Men With Newly Diagnosed Prostate Cancer

PURPOSE

Tissue-based gene expression classifiers (GECs) may assist with management decisions in patients with newly diagnosed prostate cancer. We sought to assess the current use of GEC tests and determine how the test results are associated with primary disease management.

METHODS

In this observational study, patients diagnosed with localized prostate cancer were tracked through the Michigan Urological Surgery Improvement Collaborative registry. The utilization and results of three GECs (Decipher Prostate Biopsy, Oncotype DX Prostate, and Prolaris) were prospectively collected. Practice patterns, predictors of GEC use, and effect of GEC results on disease management were investigated.

RESULTS

Of 3,966 newly diagnosed patients, 747 (18.8%) underwent GEC testing. The rate of GEC use in individual practices ranged from 0% to 93%, and patients undergoing GEC testing were more likely to have a lower prostate-specific antigen level, lower Gleason score, lower clinical T stage, and fewer positive cores (all P < .05). Among patients with clinical favorable risk of cancer, the rate of active surveillance (AS) differed significantly among patients with a GEC result above the threshold (46.2%), those with a GEC result below the threshold (75.9%), and those who did not undergo GEC (57.9%; P < .001 for comparison of the three groups). This results in an estimate that, for every nine men with favorable risk of cancer who undergo GEC testing, one additional patient may have their disease initially managed with AS. On multivariable analysis, patients with favorable-risk prostate cancer who were classified as GEC low risk were more likely to be managed on AS than those without testing (odds ratio, 1.84; P = .006).

CONCLUSION

There is large variability in practice-level use and GEC tests ordered in patients with newly diagnosed, localized prostate cancer. In patients with clinical favorable risk of cancer, GEC testing significantly increased the use of AS. Additional follow-up will help determine whether incorporation of GEC testing into initial patient care favorably affects clinical outcomes.

Molecular network-based identification of competing endogenous RNAs and mRNA signatures that predict survival in prostate cancer

Background

The aim of the study is described the regulatory mechanisms and prognostic values of differentially expressed RNAs in prostate cancer and construct an mRNA signature that predicts survival.

Methods

The RNA profiles of 499 prostate cancer tissues and 52 non-prostate cancer tissues from TCGA were analyzed. The differential expression of RNAs was examined using the edgeR package. Survival was analyzed by Kaplan–Meier method. microRNA (miRNA), messenger RNA (mRNA), and long non-coding RNA (lncRNA) networks from the miRcode database were constructed, based on the differentially expressed RNAs between non-prostate and prostate cancer tissues.

Results

A total of 773 lncRNAs, 1417 mRNAs, and 58 miRNAs were differentially expressed between non-prostate and prostate cancer samples. The newly constructed ceRNA network comprised 63 prostate cancer-specific lncRNAs, 13 miRNAs, and 18 mRNAs. Three of 63 differentially expressed lncRNAs and 1 of 18 differentially expressed mRNAs were significantly associated with overall survival in prostate cancer (P value < 0.05). After the univariate and multivariate Cox regression analyses, 4 mRNAs (HOXB5, GPC2, PGA5, and AMBN) were screened and used to establish a predictive model for the overall survival of patients. Our ROC curve analysis revealed that the 4-mRNA signature performed well.

Conclusion

These ceRNAs may play a critical role in the progression and metastasis of prostate cancer and are thus candidate therapeutic targets and potential prognostic biomarkers. A novel model that incorporated these candidates was established and might provide more powerful prognostic information in predicting survival in prostate cancer.

PTEN status assessment in the Johns Hopkins active surveillance cohort

BACKGROUND

Up to half of men with Gleason score 6 (GS6) prostate cancers initially managed with active surveillance (AS) will eventually require definitive therapy, usually due to tumor grade reclassification during follow-up. We examined the association between PTEN status on biopsy and subsequent clinicopathologic outcomes in men with GS6 cancers who enrolled in AS.

METHODS

We performed a case-control study of men enrolled in the Johns Hopkins AS cohort with diagnostic biopsy tissue available for immunohistochemical (IHC) staining. IHC was performed for PTEN using genetically validated protocols for all patients. Cases included men who underwent grade reclassification to GS ≥ 3 + 4 = 7 on biopsy within 2 years of follow-up (i.e., early reclassification) or reclassification to GS ≥ 4 + 3 = 7 on biopsy or radical prostatectomy during follow-up (i.e., extreme reclassification). Control patients were diagnosed with GS6 cancer and monitored on AS for at least 8 years without undergoing biopsy reclassification.

RESULTS

Among 67 cases with adequate tissue, 31 men underwent early reclassification and 36 men underwent extreme reclassification. Cases were compared to 65 control patients with adequate tissue for assessment. On initial prostate biopsy, cases were older (median age 67 vs. 65, p = 0.024) and were less likely to meet very-low-risk criteria (64 vs 79%, p = 0.042) as compared to controls. Although not statistically significant, PTEN loss was observed in only 1 (1.5%) of 65 controls as compared to 6 (9%) of 67 cases (p = 0.062).

CONCLUSIONS

PTEN loss was rare among men with GS6 prostate cancer enrolled in AS at Johns Hopkins. Despite this, PTEN loss was more frequent among men who underwent early or extreme reclassification to higher-grade cancer as compared to controls. Additional studies in larger low-risk cohorts may better elucidate a potential role for PTEN in selecting patients for AS.

Association Between Early Confirmatory Testing and the Adoption of Active Surveillance for Men With Favorable-risk Prostate Cancer

OBJECTIVE

To examine the relationship between the use and results of early confirmatory testing and persistence on active surveillance (AS).

METHODS

We identified all men in the Michigan Urological Surgery Improvement Collaborative registry diagnosed with favorable-risk prostate cancer from June 2016 to June 2017. We next examined trends in the use of early confirmatory test(s), defined as repeat biopsy, prostate magnetic resonance imaging, or molecular classifiers obtained within 6 months of the initial cancer diagnosis, in patients with favorable-risk prostate cancer. We then compared the proportion of men remaining on AS 6 months after diagnosis according to reassuring vs nonreassuring results, also stratifying by age and Gleason score.

RESULTS

Among 2529 patients, 32.7% underwent early confirmatory testing within 6 months of diagnosis. Its use increased from 25.4% in the second quarter of 2016 to 34.9% in the second quarter of 2017 (P = .025). Molecular classifiers were most frequently used (55%), followed by magnetic resonance imaging (34%) and repeat biopsy (11%). Sixty-four percent (n = 523) had a reassuring result. Rates of AS were higher for patients with early reassuring results; 82% remained on AS (n = 427) compared to 52% (n = 157) of those with nonreassuring results and 51% (n = 873) with no early confirmatory testing (P <.001).

CONCLUSION

Rates of AS are higher among men with early reassuring results, supporting the clinical utility of these tests. Nonetheless, high rates of AS among patients with nonreassuring results underscore the complexity of shared decision-making in this setting.

Imaging for the selection and monitoring of men on active surveillance for prostate cancer

Traditional prostate imaging is fairly limited, and only a few imaging modalities have been used for this purpose. Until today, grey scale ultrasound was the most widely used method for the characterization of the prostatic gland, however its limitations for prostate cancer (PCa) detection are well known and hence ultrasound is primarily used to localize the prostate and facilitate template prostate biopsies. In the past decade, multiparametric magnetic resonance imaging (mpMRI) of the prostate has emerged as a promising tool for the detection of PCa. Evidence has shown the value of mpMRI in the active surveillance (AS) population, given its ability to detect more aggressive disease, with data building up and supporting its use for the selection of patients suitable for surveillance. Additionally, mpMRI targeted biopsies have shown an improved detection rate of aggressive PCa when compared to regular transrectal ultrasound (TRUS) guided biopsies. Current data supports the use of mpMRI in patients considered for AS for reclassification purposes; with a negative mpMRI indicating a decreased risk of reclassification. However, a percentage of patients with negative imaging or low suspicion lesions can experience reclassification, highlighting the importance of repeat confirmatory biopsy regardless of mpMRI findings. At present, no robust data is available to recommend the substitution of regular biopsies with mpMRI in the follow-up of patients on AS and efforts are being made to determine the role of integrating genomic markers with imaging with the objective of minimizing the need of biopsies during the follow up period.

Markers of clinical utility in the differential diagnosis and prognosis of prostate cancer

Molecular diagnostics is a rapidly evolving area of surgical pathology, that is gradually beginning to transform our diagnostical procedures for a variety of tumors. Next to molecular prognostication that has begun to complement our histological diagnosis in breast cancer, additional testing to detect targets and to predict therapy response has become common practice in breast and lung cancer. Prostate cancer is a bit slower in this respect, as it is still largely diagnosed and classified on morphological grounds. Our diagnostic immunohistochemical armamentarium of basal cell markers and positive markers of malignancy now allows to clarify the majority of lesions, if applied to the appropriate morphological context (and step sections). Prognostic immunohistochemistry remains a problematic and erratic yet tempting research field that provides information on tumor relevance of proteins, but little hard data to integrate into our diagnostic workflow. Main reasons are various issues of standardization that hamper the reproducibility of cut-off values to delineate risk categories. Molecular testing of DNA-methylation or transcript profiling may be much better standardized and this review discusses a couple of commercially available tests: The ConfirmDX test measures DNA-methylation to estimate the likelihood of cancer detection on a repeat biopsy and may help to reduce unnecessary biopsies. The tests Prolaris, OncotypeDX Prostate, and Decipher all are transcript tests that have shown to provide prognostic data independent of clinico-pathological parameters and that may aid in therapy planning. However, further validation and more comparative studies will be needed to clarify the many open questions concerning sampling bias and tumor heterogeneity.

Performance of a Prostate Cancer Genomic Classifier in Predicting Metastasis in Men with Prostate-specific Antigen Persistence Postprostatectomy

BACKGROUND

Prostate cancer patients who have a detectable prostate-specific antigen (PSA) postprostatectomy may harbor pre-existing metastatic disease. To our knowledge, none of the commercially available genomic biomarkers have been investigated in such men.

OBJECTIVE

To evaluate if a 22-gene genomic classifier can independently predict development of metastasis in men with PSA persistence postoperatively.

DESIGN, SETTING, AND PARTICIPANTS

A multi-institutional study of 477 men who underwent radical prostatectomy (RP) between 1990 and 2015 from three academic centers. Patients were categorized as detectable PSA (n=150) or undetectable (n=327) based on post-RP PSA nadir ≥0.1 ng/ml.

OUTCOME MEASUREMENTS AND STATISITICAL ANALYSIS

Cumulative incidence curves for metastasis were constructed using Fine-Gray competing risks analysis. Penalized Cox univariable and multivariable (MVA) proportional hazards models were performed to evaluate the association of the genomic classifier with metastasis.

RESULTS AND LIMITATIONS

The median follow-up for censored patients was 57 mo. The median time from RP to first postoperative PSA was 1.4 mo. Detectable PSA patients were more likely to have higher adverse pathologic features compared with undetectable PSA patients. On MVA, only genomic high-risk (hazard ratio [HR]: 5.95, 95% confidence interval [CI]: 2.02-19.41, p=0.001), detectable PSA (HR: 4.26, 95% CI: 1.16-21.8, p=0.03), and lymph node invasion (HR: 12.2, 95% CI: 2.46-70.7, p=0.003) remained prognostic factors for metastasis. Among detectable PSA patients, the 5-yr metastasis rate was 0.90% for genomic low/intermediate and 18% for genomic high risk (p<0.001). Genomic high risk remained independently prognostic on MVA (HR: 5.61, 95% CI: 1.48-22.7, p=0.01) among detectable PSA patients. C-index for Cancer of the Prostate Risk Assessment Postsurgical score, Gandaglia nomogram, and the genomic classifier plus either Cancer of the Prostate Risk Assessment Postsurgical score or Gandaglia were 0.69, 0.68, and 0.82 or 0.81, respectively. Sample size was a limitation.

CONCLUSIONS

Despite patients with a detectable PSA harboring significantly higher rates of aggressive clinicopathologic features, Decipher independently predicts for metastasis. Prospective validation of these findings is warranted and will be collected as part of the ongoing randomized trial NRG GU-002.

PATIENT SUMMARY

Decipher independently predicted metastasis for patients with detectable prostate-specific antigen after prostatectomy.

Genomic tests to guide prostate cancer management following diagnosis

INTRODUCTION

Prostate cancer (PCa) is a common cancer in men, but variable clinical behaviors make its management challenging. Risk stratification is a key issue in disease management. Patient-tailored strategies are strongly advocated to reduce unnecessary treatment while maximizing the oncological outcomes of patient who need active treatment in the primary, adjuvant or salvage setting. Recently, tissue-based biomarkers or genomic tests have become available to improve the clinical decision-making. Areas covered: In this review, the authors present recent evidence about these tissue-based biomarkers, discussing the application of each of them in the clinical setting, focusing on the tests aimed to provide a better risk stratification and to guide decision-making after the diagnosis of PCa (i.e. OncotypeDX^Ⓡ, Prolaris^Ⓡ, ProMark^Ⓡ, Ki-67, Decipher^Ⓡ, PTEN, PORTOS, AR-V7 and DNA repair gene mutations). Expert commentary: Even if the clinicopathologic features are still the most frequently-used predictors of disease progression, these tools can be helpful in decision-making at every stage of the PCa management. Actually, OncotypeDX^Ⓡ, Prolaris^Ⓡ and Decipher^Ⓡ are recommended in the clinical setting by guidelines at different steps of PCa management. Consequently, further studies are indispensable to better tailor the right therapy for the right patient and at the right time.

The Use of Biomarkers in Prostate Cancer Screening and Treatment

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.