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Using the free-to-total prostate-specific antigen ratio to detect prostate cancer in men with nonspecific elevations of prostate-specific antigen levels

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Abstract

BACKGROUND: Prostate-specific antigen (PSA) levels between 4.0 to 10.0 ng/ml have poor specificity in prostate cancer screening, leading to unnecessary biopsies.

OBJECTIVE: To determine whether the free-to-total PSA ratio (F/T PSA) improved the diagnostic accuracy of these nonspecific PSA levels.

MEASUREMENTS AND MAIN RESULTS: Medline was searched from 1986 to 1997. Additional studies were identified from article bibliographies and by searching urology journals. Two investigators independently identified English-language studies providing F/T PSA ratio test-operating characteristics data on ≧10 cancer patients with PSA values between 2.0 and 10.0 ng/ml. Twenty-one of 90 retrieved studies met selection criteria. Two investigators independently extracted data on methodology and diagnostic performance. Investigator-selected cut points for the optimal F/T PSA ratio had a median likelihood ratio of 1.76 (interquartile range, 1.40 to 2.11) for a positive test and 0.27 (0.20 to 0.40) for a negative test. Assuming a 25% pretest probability of cancer, the posttest probabilities were 37% following a positive test and 8% following a negative test. The summary receiver operating characteristic curve showed that maintaining test sensitivity above 90% was associated with false positive rates of 60% to 90%. Methodologic problems limited the validity and generalizability of the literature.

CONCLUSIONS: A negative test reduced the posttest probability of cancer to approximately 10%. However, patients may find that this probability is not low enough to avoid undergoing prostate biopsy. The optimal F/T PSA ratio cut point and precise estimates for test specificity still need to be determined.

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Authors and Affiliations

  1. the Medicine Service, Albuquerque Department of Veterans Affairs Medical Center, USA

    Richard M. Hoffman MD, MPH & David L. Clanon MD

  2. University of New Mexico School of Medicine, Albuquerque, NM

    Richard M. Hoffman MD, MPH

  3. Department of Medicine, The University of Vermont, Burlington, Vt

    Benjamin Littenberg MD

  4. the Department of Medical Education and Research, Good Samaritan Regional Medical Center, Phoenix, Ariz

    Joseph J. Frank PhD & John C. Peirce MD, MA, MS

  5. the Laboratory Sciences of Arizona, Phoenix, Ariz

    Joseph J. Frank PhD

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  1. Richard M. Hoffman MD, MPH
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  2. David L. Clanon MD
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Correspondence to Richard M. Hoffman MD, MPH.

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This work was supported by the VA Medical Center, Albuquerque, NM.

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Hoffman, R.M., Clanon, D.L., Littenberg, B. et al. Using the free-to-total prostate-specific antigen ratio to detect prostate cancer in men with nonspecific elevations of prostate-specific antigen levels. J GEN INTERN MED 15, 739–748 (2000). https://doi.org/10.1046/j.1525-1497.2000.90907.x

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