








































30 SIUJ  •  Volume 1, Number 1  •  October 2020 SIUJ.ORG

MOLECULAR BIOMARKERS IN UROLOGIC ONCOLOGY: ICUD-WUOF CONSULTATION

Key Words Competing Interests Article Information

Biomarkers, non-invasive, serum, urine, 
prediction

None declared. Received on July 1, 2020 
Accepted on August 16, 2020

Soc Int Urol J. 2020;1(1):30–38

The Clinical Applications of Serum and Urinary 
Biomarkers in Prostate Cancer
Renu S. Eapen,1 Peter E. Lonergan,2 Dominic Bagguley,3 Sean Ong,3 Ben Condon,3  
Nathan Lawrentschuk,1,3,4,5 Maxwell V. Meng2

1 Department of Genitourinary Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia, 2 Department of Urology, Helen Diller Family Comprehensive Cancer 
Center, University of California, San Francisco, United States, 3 EJ Whitten Prostate Cancer Research Centre at Epworth, Melbourne, Australia, 4 Department of Surgery, 
University of Melbourne, Australia, 5 Department of Urology, Royal Melbourne Hospital, Australia

Abstract

At every stage of the prostate cancer journey from screening and diagnosis to management of advanced disease, 
patients and clinicians face dilemmas and decisions that can impact long-term outcomes. Although traditional risk 
stratification in prostate cancer is based on serum prostate specific antigen, clinical stage and Gleason score, in recent 
years, biomarkers have been developed that may be useful in several clinical scenarios. Biomarkers that can accurately 
predict an individual patient’s risk, prognosis, and response to specific treatments could lead to improvements in 
decision-making and clinical care. Although there is evidence to support the use of biomarkers to guide management 
decisions, the optimal scenario in which to use them, how to interpret the results, and how to incorporate those results 
into clinical decision-making can be confusing. Nevertheless, in the era of personalized and precision medicine, it is 
important for clinicians to be aware of what tests are available, what clinical questions they seek to answer, and what 
limitations they have. This review focuses on the serum and urine biomarkers for the management of prostate cancer 
that have been under intense investigation in recent years.

Introduction

Prostate cancer (PCa) is a heterogenous disease with a highly variable clinical course and behavior. Traditional risk 
stratification of PCa has been based on standard clinical parameters such as prostate specific antigen, clinical stage, 
and biopsy Gleason scores. Following the widespread use of PSA testing, the pendulum swung towards overdiagnosis 
of clinically insignificant PCa and the subsequent overtreatment with its associated morbidity [1]. Traditional models 
and nomograms, although allowing risk stratification of patients to a certain degree, do not allow accurate prediction 
of outcomes for an individual patient with PCa, leading to potential undertreatment of high-risk disease [2,3]. 
Because of these limitations, leading to discordant care, many areas of uro-oncology have recognized the need for 
the development of reliable biomarkers to aid decision-making in various challenging clinical contexts. Finding 
the “ideal” biomarker that can accurately predict a patient’s individual risk and improve on existing, validated risk 
stratification tools has become an area of intense research interest in the last decade.

Biomarkers can be classified according to the source (eg, serum, urine, or tissue) (Table 1) or the clinical decision 
juncture at which they are used (Figure 1). In this 2-part summary, we review commercially available blood, urine 
and tissue-based biomarkers and summarize the currently available data on their use in a variety of clinical scenarios.

The first section will focus on the serum and urinary PCa biomarkers. Blood and urine sources have the advantage of 
being non-invasive, easily attainable, and convenient for patients and physicians. The subsequent article will focus on 
tissue-based biomarkers [4].

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31SIUJ.ORG SIUJ  •  Volume 1, Number 1  •  October 2020

The Clinical Applications of Serum and Urinary Biomarkers in Prostate Cancer

Serum Biomarkers
Prostate Specific Antigen
Measurement of serum PSA is the most widely used test 
to aid in the detection of early prostate cancer, despite 
its well-known limitations, including high false-positive 
rates, poor specificity for prostate cancer, which lead to 
over diagnosis.

PSA is not tumor specific as it is secreted by both 
benign and malignant prostatic tissue. Therefore, apart 
from PCa, many benign processes such as inflammation, 
benign prostatic hyperplasia (BPH), and trauma may 
lead to increased PSA values. PSA gained FDA approval 
for PCa screening in 1994 after it was shown to have 
higher sensitivity than prostatic acid phosphatase (PAP) 
in the detection of prostate cancer [5].

Historically, a serum PSA level above 4 ng/mL was 
the accepted cutoff to predict the potential presence of 
prostate cancer [6]. However, it has since been recognized 
that 20% of patients diagnosed with prostate cancer have 
a PSA lower than 4 ng/mL [7,8]. Furthermore, it has been 
reported that when using a PSA threshold of 4 ng/mL, 
the specificity in detecting PCa is only 12.8%, leading 
to high false-positive rates and unnecessary biopsies [9]. 
To enable better discrimination between PCa and BPH, 
the measurement of the ratio of free to total PSA was 
proposed as a more accurate indicator, and many studies 
have demonstrated its usefulness [10-13]. In a large 
prospective multicenter clinical trial of 773 patients with 
PSA levels between 2 and 10 ng/mL, it was shown that a 
percent free PSA (%fPSA) cutoff of 25% detected 95% of 
cancers and avoided 20% of unnecessary biopsies, with 
minimal loss in sensitivity [14]. A multivariable analysis 
showed %f PSA to be an independent predictor of 
prostate cancer (OR 3.2, 95% CI 2.5 to 4.1; P < 0.001) and 
more significant than total PSA (tPSA). Generally, the 
lower the %fPSA, the higher the risk of cancer. However, 

prostate volume has been found to have an influence 
on %f PSA. Stephan et al. reported diagnostic value of 
%f PSA in patients with prostate volume < 40cm3, but 
advised caution in using %f PSA in those with larger 
glands [15].

Other PSA metrics have also been employed to 
enhance the diagnostic and predictive capacity of PSA. 
These include PSA density (PSAD), PSA doubling 
time (PSADT), and PSA velocity (PSAV). PSA density 
is a quotient of serum PSA and prostate volume and 
may be a means of distinguishing between BPH and 
PCa [16]. A higher PSAD may not only indicate the 
presence of PCa but may also reflect the aggressiveness 
of the cancer. Studies have shown a correlation between 
higher PSAD and adverse PCa prognostic features [17]. 
A high PSAV and a shorter PSADT, especially in the 
setting of post-treatment biochemical recurrence (BCR), 
are associated with an increased risk of castration 
resistance, metastases, and cancer-specific and overall 
mortality [18].
Prostate Health Index (PHI)
Prostate Health Index (Beckman Coulter Inc., Brea, US) 
combines 3 quantitative kallikrein immunoassays—
t PSA, %f PSA, a nd [-2]proPSA (p2PSA)—v ia a 
mathematical algorithm into a single score. The PHI 
received FDA approval in 2012 and is indicated as 
an adjunct to tPSA in men aged over 50 years with 
tPSA between 4 and 10 ng/mL and non-suspicious 
digital rectal examination (DRE) findings. Numerous 
validation studies have addressed the clinical utility of 
PHI. A prospective multi-institutional trial enrolled 892 
men with no history of PCa, normal DRE, and tPSA of 
2 to 19 ng/mL, and found that within this range of PSA, 
at a sensitivity of 80% to 95%, the specificity and area 
under the curve (AUC) of PHI exceeded those of PSA 
and %fPSA [19]. Similarly, Stephan et al. evaluated 1362 
patients with tPSA of 1.6 to 8.0 ng/mL who underwent 
systematic biopsy with ≥ 10 cores, and showed that PHI 
(AUC = 0.74) outperformed %p2PSA (AUC = 0.72), 
p2PSA (AUC = 0.63), %f PSA (AUC = 0.61), and tPSA 
(AUC = 0.56) in predicting PCa [20]. Furthermore, 
these large series have demonstrated the advantage of 
PHI over %fPSA in distinguishing between high-grade 
disease (Gleason score ≥ 4 + 3) and low-grade disease or 
negative biopsies [19,20]. Catalona et al. showed that an 
increasing PHI was associated with a 4.7-fold increased 
risk of PCa and 1.6-fold increase in higher-grade disease. 
Other prospective studies have indicated the ability of 
PHI to detect aggressive (Gleason score ≥ 7) cancer with 
higher specificity than tPSA and %fPSA in biopsy naïve 
men, reducing the need for unnecessary biopsies [21].

The utility of PHI in detecting clinically significant 
prostate cancer (csPCa) was evaluated by Tosoian and 
colleagues, who reported that the median PHI density 

Abbreviations 

%fPSA percent free PSA
BPH benign prostatic hyperplasia
csPCa clinically significant prostate cancer
DRE digital rectal examination
EPI ExoDx Prostate Intelliscore
HOXC6 homeobox C6
PAP prostatic acid phosphatase
PCa prostate cancer
PSAD PSA density
PSADT PSA doubling time
PSAV PSA velocity
SOC standard of care
tPSA total PSA

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(based on prostate volume) was higher for those with 
csPCa (1.21) than for those with clinically insignificant 
PCa (0.70) and negative biopsies (0.53) with P < 0.001. 
Using a threshold of 0.43, PHI density was 97.9% 
sensitive and 38% specific for csPCa and 100% sensitive 
for Gleason ≥7 disease [22]. The authors concluded that 
discriminative ability of PHI density (AUC = 0.84) 
for csPCa was higher than PHI, PSA, PSAD, %f PSA, 
and prostate volume (AUC 0.52 to 0.79). Up to 38% of 
biopsies could be avoided while missing only 2% of 

csPCa [22]. Another advantage of PHI over %fPSA is the 
lack of influence of patient age and prostate volume [19].

A recent study has evaluated the impact of PHI on 
clinical decision-making. In an observational study of 
500 men, White et al. found that those who received a 
PHI test had a significantly lower biopsy rate compared 
to the control group (36.4% versus 60.3%; P < 0.001). The 
PHI test purportedly impacted physicians’ management 
plans, including the decision to defer biopsies when 

TABLE 1.

Commercially available biomarkers that are FDA and Clinical Laboratory Improvements  
Amendments (CLIA) approved

Biomarker Molecular markers tested

Serum

Prostate Specific Antigen (PSA)* PSA

Prostate Health Index (PHI)*  
Beckman Coulter Inc, United States

tPSA, %fPSA, p2PSA

4K score 
OPKO Lab, United States

tPSA, fPSA, intact PSA, hK2

Urine

Progensa Prostate Cancer Antigen 3 (PCA3)* 
Hologic, United States

PCA3

ExoDX Prostate (Intelliscore) 
Exosome Diagnostics Inc, United States

PCA3, ERG

Michigan Prostate Score (MiPS), United States TMPRSS2-ERG mRNA, PCA3

Select MDX 
MDx Health, United States

HOXC6, DLX1

Tissue

Confirm MDx 
MDxHealth, United States

DNA methylation (GSTP1, APC, RASSF1, ACTB)

Oncotype Dx 
Genomic Health, United States

RNA (17 gene expression)

Promark 
Metamark Genetics, United States

8 Proteins

Prolaris* 
Myriad Genetics, United States

RNA (46 gene expression)

Decipher 
Genome Dx Biosciences, United States

RNA (22 gene expression)

* FDA-approved biomarkers

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33SIUJ.ORG SIUJ  •  Volume 1, Number 1  •  October 2020

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PHI score was low and to perform biopsies when the 
PHI score was intermediate or high [23]. Similarly, the 
prospective comparative analysis of 345 men by Tosoian 
et al. demonstrated that PHI testing reduced the rate of 
biopsy procedures whilst the detection of higher-grade 
cancers remained unchanged [24].

Another potential application of the PHI score 
is the integration into a multivariable model with  
mu lt i-pa ra met r ic mag net ic resona nce i mag i ng 
(mpMRI). Gnanapragasam et al. found that adding 
PHI to mpMRI improved the prediction of overall and 
csPCa (AUC 0.71 and 0.75) compared with mpMRI or 
PSA alone (AUC 0.64 and 0.69) [24]. In determining 
whether to re-biopsy men with a negative mpMRI, PHI 
performed better than PSA and PSAD in identifying 
csPCa. With a PHI threshold of > 35, 42% of men 
avoided biopsy while missing only one of 21 significant 
cancers [25].
4K Score
The 4K score (OPKO Health, Miami, US) comprises 
a panel of 4 kallikrein (4K) markers including tPSA, 
%f PSA, intact PSA, and human kallikrein 2 (hK2) 
and combines clinical variables (age, DRE findings, 
and previous biopsy status) into a model to predict 
the likelihood of having csPCa (Gleason score ≥ 7) 
on prostate biopsy. It may have value in reducing 
unnecessary prostate biopsies [25]. The merit of the 4K 
score in the pre-biopsy setting has been extensively 
evaluated, particularly in Europe and the US [26–34].

Vickers et al. reported on 2914 men in the European 
Randomized Study of Screening for Prostate Cancer 
(ERSPC) who underwent prostate biopsy for PSA 
≥ 3ng/mL, in which PCa was diagnosed in 28% of 
men [30]. Incorporating the 4K score with PSA and 
age significantly improved predictive accuracy with 
(AUC 0.78 versus 0.70) and without (AUC 0.76 versus 
0.64) DRE results (P < 0.001). For every 1000 men, the 
addition of the 4K score would reduce the number of 
unnecessary biopsies by 513, albeit with the tradeoff 
that 12% of csPCa would be missed [30]. A smaller 
series of 262 men showed similar results, with the 4K 
score having greater diagnostic accuracy than “base” 
clinical models incorporating PSA, age, and DRE 
findings only, with AUC increases from 0.63 to 0.78 
in PCa prediction and 0.77 to 0.87 for prediction of  
high-grade PCa [27]. Parek h et a l. prospectively 
evaluated the diagnostic performance of the 4K score in 
1012 men undergoing biopsy without restrictions on the 
indication for biopsy. Clinically significant PCa (Gleason 
≥ 7) was found in 23% of patients in this cohort [31].  
The 4K score outperformed the PCPT Risk Calculator 
2.0 (AUC 0.82 versus 0.74; P < 0.001) in detecting csPCa 
and would have reduced the number of unnecessary 
biopsies by 58%. In a large representative cohort study 
of 40379 men from Sweden, Stattin et al. studied the 
4K score for its ability to predict the risk of distant 
metastases [32]. Using a risk stratification approach 
to prostate biopsy using PSA and 4K score, they found 
that in patients with PSA ≥ 3 ng/mL, the risk of distant 
metastases at 5, 10, 15, and 20 years would be greater for 
the high-risk group with 4K ≥ 7.5% (2.4%, 5.6%, 9.9%, 
and 16.4%) than for the low-risk group with 4K < 7.5% 
(0%, 0.2%, 1%, and 1.8%) [32].

In men with previously negative prostate biopsy but 
persistently elevated PSA, 4K score was found to have 
superior predictive capacity for high-grade cancers while 
minimizing unnecessary biopsies [32]. The 4K score 
showed higher discriminatory accuracy than PSA and 
DRE alone (AUC 0.68 versus 0.58, P < 0.001) in detecting 
PCa on repeat biopsy. For the prediction of high-grade 
(Gleason ≥ 7) PCa, the 4K score outperformed clinical 
factors alone (AUC 0.87 versus 0.76. P = 0.003). Using 
a 4K risk threshold of 15%, 712 repeat biopsies could 
potentially be avoided for every 1000 men, with only 3 of 
the 53 missed cancer diagnoses having a Gleason score 
≥ 7 [32].

A comparison of 4K score and PHI in a populated-
based cohort study of 531 men with PSA 3 to 15 ng/mL 
showed their predictive values to be similar in predicting 
any PCa (AUC 0.69 for 4K, AUC 0.70 for PHI), as well 
as high-grade PCa (AUC = 71.8 for 4K, AUC = 71.1 for 
PHI) [33]. Compared with a base model of age and PSA, 

Screening /
Pre-1st Biopsy

PSA
4K score

PHI
PCA3

Select MDx
MiPS
ExoDx

Previous Negative Biopsy / 
Pre-2nd Biopsy

4K score
PHI

PCA3

FIGURE 1.

Serum and urinary biomarkers according to their clinical 
applications

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both 4K and PHI had higher AUC (P < 0.001). Using 
high-grade PCa risk thresholds of 10% for 4K and 39 
for PHI, 29% of biopsies could potentially be avoided 
with the caveat that 10% of high-grade cancers could be 
missed [33].

Although there is little evidence to support their 
use in primary screening, both PHI and 4K scores are 
mentioned by the European Association of Urology 
(EAU), American Association of Urology (AUA), and 
National Comprehensive Cancer Network (NCCN) 
as potential markers that may be used to risk stratify 
patients in the early detection of PCa. Their benefits 
of predicting risk of high-grade PCa and reducing 
unnecessary biopsies in men with PSA from 2 to 10 ng/
mL is recognized, as is their superiority over %fPSA [35].

Urinary Biomarkers
Progensa prostate cancer antigen 3 (PCA3)
PCA3 (Hologic, Marlborough, US) is a non-coding 
large chain RNA that is highly overexpressed in the 
majority of malignant prostate tissue compared with 
benign prostate tissue [36,37]. The Progensa PCA3 gene 
assay measures PCA3 mRNA concentrations in the first 
void urine collected after DRE [38]. In 2012, the FDA 
approved the use of PCA3 to facilitate the decision-
making process to re-biopsy men with a previous 
negative biopsy. Multiple studies have evaluated the 
clinical utility of PCA3 in the early detection of PCa 
and as a prognostic marker in the active surveillance of 
patients with low-risk PCa [39–41].

A key European multicenter prospective study by 
Haese et al. correlated PCA3 scores of 463 men with 
previous negative prostate biopsies to the repeat biopsy 
outcomes, with a higher PCA3 score associated with a 
greater probability of a positive repeat biopsy [39]. Men 
who had a PCA3 score ≥ 35 had a 39% chance of having 
a positive biopsy compared with 22% in men with a 
PCA3 score < 35 (P < 0.001). The mean PCA3 score 
was significantly higher in men with a positive biopsy 
than in those with a negative biopsy (63.8 versus 35.5;  
P < 0.001). Furthermore, a PCA3 threshold of 35 
provided greater diagnostic accuracy than a comparable 
%fPSA cutoff of 25%. PCA3 was found to be independent 
of tPSA, prostate volume, and patient age [39].

In a retrospective analysis of 13 men, Wu et al. 
reported that use of a PCA3 score threshold of 25 
yielded sensitivity and specificity of 0.67 and 0.64, 
respectively [42]. Although PCA3 was found to be 
independently associated with PCa (AUC 0.64) in 
multivariable analyses, the highest diagnostic accuracy 
was derived from a model comprising PCA3, PSAD, 
PSA, DRE, and TRUS findings (AUC 0.82) [42].

A prospective validation trial by Wei et al. included 
859 PSA-screened patients undergoing initial biopsy and 
repeat biopsy after prior negative biopsy [41]. The authors 
demonstrated a positive predictive value (PPV) of 80% 
for PCA3 > 60 at initial biopsy and a negative predictive 
value (NPV) of 88% for PCA3 < 20 at repeat biopsy. 
Their findings supported the use of PCA3 in reducing 
unnecessary biopsies in men with a prior negative 
biopsy and concluded that for initial biopsy, a PCA3 
> 60 significantly increases the probability of cancer 
detection [41].

In another European prospective multicenter study 
of 516 men, de la Taille et al. observed that the mean 
PCA3 score was higher in those men with a positive 
versus negative biopsy (69.6 versus 31.0; P < 0.001) and 
higher in men with csPCa. PCA3 scores > 35 had the 
highest diagnostic accuracy with sensitivity of 64% and 
specificity of 76%. PCA3 score was independent of age, 
total PSA and prostate volume and outperformed total 
PSA, PSAD, and %fPSA [43].

The ability of PCA3 to predict tumor volume and 
select low-risk patients for active surveillance was 
prospectively evaluated by Ploussard et al. who reported 
that PCA3 scores strongly correlated with tumor 
volume [44]. A PCA3 score > 25 was associated with a 
3-fold increase in risk of csPCa. On multivariate analysis, 
a PCA3 score > 25 was a predictive factor for tumor 
volume > 0.5cm3 (OR 5.4; P = 0.01) and for significant 
cancer (OR 12.7, P = 0.003), suggesting its use as a tool 
in selecting better candidates for active surveillance [44]. 
Nakanishi et al. also found a significant association 
between PCA3 and tumor volume, with PCA3 being 
particularly useful in identifying low tumor volume < 
0.5 mL (AUC 0.757) [45].

As PCA3 is the only urinary biomarker with FDA 
approval, the various guidelines do mention its use to 
risk stratify patients after a previous negative biopsy and 
to determine the need for a repeat biopsy. However, it is 
not recommended as a primary screening tool, and no 
threshold for the PCA3 score has been defined to guide 
decision-making.
ExoDx prostate intelliscore (EPI)
The ExoDx Prostate Intelliscore (Exosome diagnostics, 
Waltham, US) is a newer, novel urine exosome gene 
expression assay used to predict the risk of PCa on 
biopsy. Exosomes are 1 of 2 types of microvesicles found 
in prostate secretions [46]. Exosomes may be secreted 
by both normal and malignant tissues, but elevated 
exosome secretions have been found in malignant 
biof luids such as the urine of patients with PCa. 
Exosomes contain a portion of the parent cell cytoplasm 
containing proteins and RNA that closely resemble the 

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cell of origin [47]. Exosomes lack ribosomal RNA but are 
rich in mRNA, which acts as a unique genetic footprint 
of specific tumor cells and may give information about 
the specific tumor genotype that underlies the varying 
phenotypes that are seen in a heterogenous disease like 
PCa. Exosomes isolated from post DRE urine contain 
PCA3 and ERG (erythroblastosis virus E26 oncogene 
homologues) [47]. The EPI test has the advantage of not 
requiring a pre-collection DRE, making it non-invasive 
and more convenient. The test uses an algorithm 
independent of clinical variables to provide a risk score, 
with 15.6 being the threshold discriminating between 
high-grade and low-grade PCa [48].

McKiernan et al. compared the performance of EPI 
with biopsy outcomes in men with PSA ranging from 
2 to 20 ng/mL, then went on to validate the prognostic 
score [49]. They found that incorporating EPI into the 
standard of care (SOC) improved the discrimination 
of high-grade disease from low-grade or benign 
disease. Validation in 519 patients showed the superior 
performance of EPI plus SOC (AUC 0.73) over SOC 
alone (AUC 0.63) in predicting high-grade disease  
(P < 0.001). Using an EPI cutoff score of 15.6, the authors 
concluded that 27% of biopsies could have been avoided, 
missing 5% of high-risk cancers [49].

A recent prospective randomized study by Tutrone et 
al. examined the clinical utility and the impact of EPI 
score on decision-making in men presenting for initial 
prostate biopsy with PSA 2 to 10 ng/mL [48]. A total of 
1094 patients and 72 urologists were involved in the 
study. Sixty-eight percent of urologists were influenced 
by the EPI score in their decision to recommend or 
defer a biopsy, the main reason for noncompliance with 
EPI results being a rising PSA. Eighty-seven percent of 
patients with a positive EPI score were recommended 
to proceed to biopsy, leading to the detection of 30% 
more high-grade PCa than in the control arm. On the 
other hand, 63% of patients with a negative EPI score 
were recommended to defer prostate biopsy, and the 
authors estimated that 49% fewer high-grade cancers 
were missed because of biopsy deferral compared with 
SOC [48].

The latest NCCN guidelines do mention EPI as a 
potential investigative marker, but it is not currently 
incorporated into mainstream practice.
Mi prostate score (MiPS)
The MiPS assay was developed at the University of 
Michigan Rogel Cancer Centre. It is a urine multiplex 
analysis that combines PSA with 2 PCa specif ic 
biomarkers: PCA3 and an RNA marker that is found 
only when TMPRSS2 and ERG abnormally fuse. ERG is 
an ET transcription factor that is overexpressed in 57% 
of prostate cancers [50]. In more than 90% of cases that 

overexpressed ERG, there was found to be fusion with 
TMPRSS2. TMPRSS2-ERG (T2-ERG) fusion is thought 
be a strong indicator of PCa.

In a trial of 48 patients undergoing prostate biopsy, 
Salami et al. found an association between the presence 
of T2-ERG and PCa (OR 12.02, P < 0.001) [51]. Although 
PCA3 had higher sensitivity (93%), T2-ERG had the 
highest specificity (87%) in predicting PCa. T2-ERG also 
had better discriminative ability (AUC 0.77) compared 
with PCA3 (AUC 0.65) and serum PSA (AUC 0.72). 
Combining all 3 factors into a multivariable algorithm 
improved the AUC for cancer prediction to 0.88 with 
specificity of 90% and sensitivity of 80%, better than 
any individual marker alone [51]. Laxman et al. showed 
that compared with PCA3 alone (AUC 0.662), T2-ERG 
in combination with PCA3 and a multiplex panel of 
urinary transcripts (AUC 0.758) improved the early 
detection of PCa [52].

A validation trial in 1225 patients by Tomlins et al. 
assessed the ability of the multivariable MiPS model 
incorporating PSA, PCA3 and T2-ERG in predicting 
PCa and high-grade PCa on biopsy [53]. The authors 
showed that models incorporating T2-ERG had higher 
AUC than PSA in predicting any (0.693 versus 0.585) 
and high-grade (0.729 versus 0.651) PCa. The MiPS 
model incorporating T2-ERG outperformed other 
models incorporating only PCA3 and PSA in the 
detection of PCa (P < 0.001) [53].

The MiPS is currently an investigational tool within 
NCCN guidelines and currently not routinely used in 
mainstream practice.
Select MDx
Select MDx (MDx Health, Irvine, US) is a post DRE 
urine-based gene assay risk score that aims to predict a 
patient’s risk of high-grade PCa. The algorithm measures 
the mRNA signatures of 2 genes implicated in prostate 
carcinogenesis—homeobox C6 (HOXC6) and distal-less 
homeobox 1 (DLX1)—and combines these with clinical 
factors such as age, family history, previous negative 
biopsies, and DRE. Leyten et al. initially described a 
3-gene urinary panel including HOXC6 and DLX1 that 
was shown to have additional value over serum PSA and 
PCA3 in the detection of PCa and reducing the risk of 
overtreatment [54].

Van Neste et al. developed a model incorporating 
HOXC6 and DLX1 on a cohort of 519 patients and 
subsequently validated the risk score in an independent 
cohort of 386 patients in two prospective multicenter 
studies [55]. The authors identified the mRNA signature 
risk score in combination with PSAD and previous 
negative biopsies to be the most significant factors 
with an overall AUC approaching 0.90 (95% CI 0.85 
to 0.95). Another model adding DRE as a risk factor 

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was also tested with an AUC of 0.86. When compared 
with the PCPTRC and PCA3, this model could reduce 
unnecessary biopsies by 53% with a NPV of 98% for 
Gleason ≥ 7 disease [55].

Correlating Select MDx with mpMRI results, a 
retrospective obser vational study of 172 patients 
reported a positive association between the risk score 
and the final PI-RADS grade [56]. Median Select MDx 
scores were higher in patients with a suspicious lesion 
on mpMRI than in those with a negative mpMRI  
(P < 0.01). Select MDx was also shown to have some 
value in predicting the mpMRI result with AUC of 0.83 
compared with PSA (AUC 0.66) and PCA3 (AUC 0.65).

The cost effectiveness of Select MDx compared with 
SOC was evaluated by Dijkstra et al., who concluded 

that the judicious use of Select MDx to reduce the 
overdiagnosis and overtreatment of men with PCa and 
PSA > 3ng/mL could lead to reduction in costs and gains 
in quality adjusted life years [57].

Conclusions
A myriad of serum and urinary biomarkers have 
emerged with the goal of improving decision-making 
processes in the early diagnosis of localized PCa. 
Although a few have gained FDA approval, most 
are investigational and not used routinely in clinical 
practice. Biomarkers must add value beyond existing 
multivariable models to be cost-eff icient and of 
overall benefit. Therefore, at this time, they must be 
used judiciously in the management of patients with 
suspected and known PCa.

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