Riv Ital Med Lab (2012) 8:231–238
DOI 10.1007/s13631-012-0067-7
A RT I C O L O O R I G I N A L E
Prostate-specific antigen (PSA) isoform p2PSA in prostate cancer
screening: systematic review of current evidence and further
perspectives
L’isoforma p2PSA dell’antigene prostatico specifico (PSA) nello screening del cancro
prostatico: review sistematica sui dati attualmente disponibili e sulle nuove prospettive
Giuseppe Lippi · Rosalia Aloe · Camilla Mattiuzzi
Ricevuto: 17 agosto 2012 / Accettato: 5 settembre 2012 / Pubblicato online: 2 dicembre 2012
© Springer-Verlag Italia 2012
Summary Background. There is now evidence that the
advantages of screening for prostate cancer based only
on prostate specific antigen (PSA) are probably offset by
the health and economic disadvantages arising from
over-diagnosis and over-treatment. Among novel and
promising biomarkers, attention has recently been
focused on the PSA isoform p2PSA, alone or in combina-
tion with free PSA (as %p2PSA), and in combination with
total and free PSA as the prostate health index (phi).
Methods. We performed an electronic search for original
articles published in English, French, Spanish and Italian
reporting studies that assessed the diagnostic perform-
ance of %p2PSA for prostate cancer screening in direct
comparison with PSA, using the keywords “Prostate
G. Lippi, R. Aloe
Unità Operativa Diagnostica Ematochimica, Dipartimento di
Patologia e Medicina di Laboratorio, Azienda Ospedaliero-
Universitaria di Parma, Italy
C. Mattiuzzi
Servizio Governance Clinica, Ospedale di Trento, Trento, Italy
G. Lippi (쾷)
Unità Operativa Diagnostica Ematochimica, Dipartimento di
Patologia e Medicina di Laboratorio, Azienda Ospedaliero-
Universitaria di Parma, Via Gramsci, 14, 43126 - Parma, Italy
Tel.: +39-0521-703050
E-mail: glippi@ao.pr.it
Cancer”, and “Measurement” or “Screening”, and
“proPSA” or “p2PSA” or “[-2]proPSA”. Titles,
abstracts and full texts were carefully read, and articles
not matching the inclusion criteria were excluded.
Heterogeneity was evaluated by the I-squared test. The
pooled estimates of accuracy and the resulting area
under the receiver operator characteristic curve (AUC)
were calculated using a random effect model.
Results. On the basis of the electronic search, 11 articles
and 12 studies, including a total of 5,139 subjects (2,338
with prostate cancer) and with modest heterogeneity (I-
squared, 66%) were selected. The %p2PSA pooled esti-
mates were always greater than those of PSA, and so was
the cumulative pooled AUC (0.687 versus 0.538;
p<0.001). The diagnostic odds ratio was more than dou-
ble for %p2PSA than for total PSA (4.0 versus 1.7). With
a sensitivity of 0.95, routine p2PSA testing may result in
up to 10% fewer unnecessary biopsies than the use of
PSA for screening. The AUC of phi was slightly but not
significantly better than that of %p2PSA (0.736 versus
0.717; p=0.21).
Conclusions. These findings provide a rationale for plan-
ning further studies to assess whether %p2PSA testing
may generate more favourable outcomes in terms of mor-
tality and quality of life. Direct comparison does not per-
mit the conclusion that the phi is globally superior to
%p2PSA for detecting prostate cancer.
Key words Prostate cancer · Screening · Prostate-specific
antigen · p2PSA · Prostate health index
123
232
Riassunto Premesse. È stato dimostrato che i benefici
dello screening del cancro prostatatico con l’antigene
prostatico specifico (PSA) sono probabilmente superati
da svantaggi clinici ed economici, soprattutto relativi a
un eccesso di diagnosi e interventi terapeutici. Tra i vari
biomarcatori, l’isoforma p2PSA del PSA ha focalizzato
molta attenzione negli ultimi anni, sia usata da sola,
oppure come %p2PSA in combinazione con PSA libero,
o come Prostate Health Index (phi), in combinazione con
il PSA totale e libero.
Metodi. Abbiamo eseguito una ricerca elettronica per
articoli originali pubblicati in inglese, francese, spagnolo
e italiano, che hanno studiato le prestazioni diagnostiche
di %p2PSA per lo screening del tumore della prostata in
confronto diretto con PSA, utilizzando le parole chiave
“Prostate Cancer”, e “Measurement” o “Screening”, e
“proPSA” o “p2PSA” o “[-2]proPSA”. Titolo, riassunto e
testo sono stati attentamente letti e gli articoli non corri-
spondenti ai criteri d’inclusione sono stati esclusi.
L'eterogeneità è stata valutata mediante test di I-quadra-
to. Le stime cumulative delle performance e l'area sotto
la curva (AUC) mediante analisi receiver operator cha-
racteristic (ROC) sono state calcolate in base ad un
modello ad effetto casuale.
Risultati. Undici articoli e dodici studi, per un totale di
5.139 soggetti (2.338 con cancro prostatico) e con mode-
sta eterogeneità (I-quadrato: 66%) sono stati selezionati.
Le performance diagnostiche di %p2PSA sono sempre
risultate superiori a quelle del PSA, così come l’AUC
cumulativa (0,687 versus 0,538; p <0,001). La diagnostic
odds ratio è doppia per %p2PSA rispetto a PSA totale
(4,0 versus 1,7). Alla sensibilità di 0,95, l’esecuzione
routinaria del p2PSA può risparmiare fino al 10% di
biopsie non necessarie rispetto al PSA. L’AUC del phi
non è superiore ma non significativamente migliore di
quella del %p2PSA (0,736 versus 0,717; p = 0,21).
Conclusioni. Questi risultati forniscono una base raziona-
le ad ulteriori studi volti a valutare se l’uso del %p2PSA
può generare risultati più favorevoli in termini di mortali-
tà e qualità della vita. Il confronto diretto non permette
invece di concludere che phi sia globalmente superiore a
p2PSA% per lo screening del cancro della prostata.
Parole chiave Cancro della prostata · Screening ·
Prostate-specific antigen · p2PSA · Prostate health index
Introduction
Although the prevalence varies broadly worldwide,
prostate cancer is a major healthcare problem, especially
in Western countries. According to the recent statistics of
the American Cancer Society, prostate cancer is the most
123
Riv Ital Med Lab (2012) 8:231–238
prevalent malignancy in the men (28.5% of all cancers,
followed by lung, colorectal and bladder cancers), as
well as the second cause of death from malignancy in
men (9.3% of all deaths, after lung cancer and followed
by colon and pancreatic cancer) [1]. The probability of
developing a prostate cancer is the highest throughout the
lifespan of men (16.5%), being more than double that of
developing lung cancer (7.7%), and more than three
times higher than that of developing colorectal malignan-
cies (4.9%). Even more importantly, in the US one in
every three men who develop a malignancy will have a
prostate cancer between the ages of 40 and 69 years.
Althought the trend of prostate cancer has markedly
declined by nearly 30% over the past two decades for the
adoption of large screening programmes, the statistics
are substantially the same in Italy, where prostate cancer
also has the highest prevalence in men (20%, followed by
lung, colorectal and bladder malignancies), and repre-
sents the third cause of death from cancer (8%) after lung
and colon cancer [2]. It is also estimated that the preva-
lence of this disease will exhibit an exponential growth in
the next two decades in Italy, increasing by 2% in the
decade after 2020, and by 20% in the decade after 2030.
The most evident benefits of cancer screening are rep-
resented by a reduction in disease-related mortality and
rate of advanced disease, coupled with an increase in the
number of life-years gained and quality-adjusted life-
years. When one or more of these criteria are not fulfilled,
universal agreement about the availability of large-scale
or even restricted testing cannot be reached. According to
the American Cancer Society, asymptomatic men who
have at least a 10-year life expectancy should be offered
information about uncertainties, risks, and potential bene-
fits of prostate cancer screening to provide the opportuni-
ty to make an informed decision. Men at average risk
should receive this information beginning at age 50 years,
whereas those at higher risk should receive this informa-
tion before that age [3]. At variance with these recommen-
dations, the US Preventive Services Task Force recom-
mends against PSA screening in healthy men, based on
the notion that the risks would outweigh the potential ben-
efits [4]. This position is also supported by the European
Association of Urology, which has recently concluded
that current evidence is insufficient to warrant widespread
population-based screening by PSA [5].
The leading problems, remarkably emphasized in
most national and international guidelines, are represent-
ed by potential over-diagnosis and over-treatment [6, 7],
since PSA is characterized by poor specificity and does
not allow high-grade, more aggressive cancers to be dis-
tinguished from indolent and slow-growing cancers. Very
recent evidence has also confirmed that radical prostatec-
tomy did not significantly reduce all-cause or prostate
Riv Ital Med Lab (2012) 8:231–238 233

cancer mortality during the early era of PSA testing in the for original articles reporting clinical trials published in
US [8], and the hypothetical benefits of PSA screening English, French, Spanish and Italian, with a sample size
were also considerably attenuated by psychological impli- greater than 50, that had investigated the diagnostic per-
cations and significant loss of quality-adjusted life-years formance of %p2PSA for screening of prostate cancer in
after diagnosis by PSA screening [9]. To avoid the inher- direct comparison with PSA. The trials also had to
ent caveats of a screening strategy based on PSA only, include patients with biopsy-detected prostate cancer,
several different approaches have been attempted, includ- and the number of true-positive, false-positive, false-
ing PSA density, PSA transition zone density, complexed negative and true-negative test results had to be reported
PSA, free PSA (fPSA) to total PSA ratio, PSA velocity, directly, or their calculation possible from sensitivity,
and age-specific PSA reference ranges [10, 11]. Besides specificity or area under the receiver operator character-
the impressive but virtually impractical canine olfactory istic (ROC) curve (AUC) in combination with prevalence
detection [12], novel diagnostics tests and algorithms are and sample size (Fig. 1).
also emerging, including PSA mRNA, sarcosine, The following key words were entered: “Prostate
kallikrein-related peptidase 2, kallikrein 11, early prostate Cancer”, and “Measurement” or “Screening”, and
cancer antigen, prostate cancer antigen 3, hepsin, prostate “proPSA” or “p2PSA” or “[-2]proPSA”. The title and
stem cell antigen and alpha-methylacyl-CoA racemase, abstract of all retrieved articles were carefully read, and
but each of these carries drawbacks and limitations [11]. those not matching the inclusion criteria were excluded.
The PSA that enters the bloodstream is rapidly bound The bibliographic references of the reminder articles
by protease inhibitors, whereas a minor fraction (“inac- were carefully read to identify other pertinent investiga-
tive” or fPSA) is directly inactivated in the prostate tis- tions. All articles were systematically reviewed for qual-
sue by internal cleavages that prevent formation of com- ity by two authors (G.L. and C.M.), according to the
plexes with protease inhibitors or other proteins. This Quality Assessment of Diagnostic Accuracy Studies
fPSA has a heterogeneous biochemical structure, which (QUADAS) checklist criteria [14]. Potential divergences
comprises the propeptide (pPSA), an internally cleaved were resolved by a third opinion (R.A.). Heterogeneity
form that is conventionally known as benign PSA, and an was evaluated using I-squared test, with thresholds of
intact, denatured species that is similar to the native pro- 25%, 50% and 75%, which designate low, moderate and
tein except for alterations in structure or conformation
that render the molecule enzymatically inactive. Several
molecular domains are then included under the term
pPSA (i.e. [-7]pPSA), which thereby includes the [-5], [-
4] and [-2]pPSA molecular isoforms [11]. Among these,
[-2]pPSA – also referred to as p2PSA – represents a sub-
stantial percentage of fPSA in patients with prostate can-
cer and diagnostically relevant PSA levels (i.e. about
10 ng/mL), so has been the major focus as a reliable and
specific biomarker of prostate cancer alone, in combina-
tion with fPSA as %p2PSA (i.e. [(p2PSA pg/mL)/(fPSA
ng/mL × 1,000)]/100), and in combination with total and
fPSA as the prostate health index (phi) (i.e.
[p2PSA/fPSA × √PSA]). Since the diagnostic accuracies
of %p2PSA and phi have been reported to be nearly iden-
tical, and largely offset that of p2PSA [13], we performed
a systematic review of the current scientific literature
assessing %p2PSA in the screening of prostate cancer, in
order to establish whether the new parameter displays
better diagnostic performance helping to reduce the num-
ber of unnecessary biopsies.

Methods

We carried out an electronic search on PubMed,

Thomson and Google Scholar, with no date restriction, Fig. 1 Summary of electronic search results

123
234
high heterogeneity [15]. The pooled estimates and 95%
confidence intervals (95% CI) of sensitivity, specificity,
negative predictive value (NPV) and positive predictive
value (PPV) were calculated using a random effect
model, as required for the I-squared values of >50%.
Cumulative AUCs with 95% CI weighted for sample size
were obtained according to the method described by
Higgins et al. [15]. Statistical analysis was performed
with MedCalc Version 12.3.0 (MedCalc Software,
Mariakerke, Belgium).
Results
The results of the electronic search using the criteria
detailed above are shown in Figure 1. A total of 131 arti-
cles remained after elimination of replicates among the
scientific databases, and of these studies, 112 citations
were immediately excluded after reading the title and/or
abstract because they did not contain original data, were
posters or abstracts with questionable peer-review pro-
cessing, were in a language other than English, Spanish,
French or Italian, or did not use p2PSA for screening of
prostate cancer. After careful reading of the references of
the remaining 19 articles, two additional pertinent cita-
tions were included. The accurate reading of the full text
according to the QUADAS scale criteria led to exclusion
of 9 articles for reporting repeated data, assessing iso-
forms other than p2PSA, not containing data about PSA
or containing insufficient data for calculation of pooled
accuracy. Inter-rater reliability was good (k = 0.78, 95%
CI 0.58 to 0.99, p<0.001).
Overall, 11 articles (mean quality score 11.6) were
finally selected, all containing complete information for
calculation of pooled accuracy, although in 5 of them the
95% CI of the AUC was unavailable from the published
data [16–26]. The level of sensitivity was made uniform at
0.95 in all studies to achieve greater homogeneity. One arti-
cle contained data from two independent centres and was
therefor analysed as two different investigations. The 12
studies included a total of 5,139 subjects (2,338 with biop-
sy-detected prostate cancer), with modest heterogeneity (I-
squared 66%, p<0.01). In 9 studies p2PSA had been meas-
ured with an automated immunochemistry platform
(Beckman Coulter Access), whereas in the remaining stud-
ies p2PSA was assessed with a manual ELISA. The
%p2PSA cut-off value was specified in 9 studies, with a
pooled value of 1.76 (95% CI 1.46 to 2.05) and high het-
erogeneity (I-squared 94%, p<0.001), which is at least par-
tially explained by the well-known problem of PSA stan-
dardization with Hybritech and WHO calibration [27].
The diagnostic performance of the 12 studies as well
as the pooled data are shown in Table 1. Although caution
123
Riv Ital Med Lab (2012) 8:231–238
should be used in interpreting the predictive values since
these were obtained in a sample population with a
remarkably high prevalence of prostate cancer (i.e. 45%)
due to the typical design of the clinical studies included in
the meta-analysis, the pooled estimates of PSA at 0.95
sensitivity were 0.08 (95% CI 0.07 to 0.09) for specifici-
ty, 0.66 (95% CI 0.60 to 0.71) for NPV and 0.46 (95% CI
0.45 to 0.48) for PPV. The corresponding pooled esti-
mates of %p2PSA were 0.17 (95% CI 0.16 to 0.19,
p<0.001 versus total PSA) for specificity, 0.81 (95% CI
0.77 to 0.84, p<0.001 versus total PSA) for NPV and 0.49
(95% CI 0.48 to 0.50, p=0.001 versus total PSA) for PPV.
The pooled AUC of %p2PSA (0.687, 95% CI 0.638 to
0.736) was also significantly greater than that of total
PSA (0.538, 95% CI 0.513 to 0.564, p<0.001). The posi-
tive likelihood ratio was higher for %p2PSA (1.15, 95%
CI 1.13 to 1.17) than for total PSA (1.03, 95% CI 1.02 to
1.05), whereas the negative likelihood ratio was lower
for %p2PSA (0.29, 95% CI 0.24 to 0.35) than for total
PSA (0.62, 95% CI 0.50 to 0.77). Even more interesting-
ly, the diagnostic odds ratio of %p2PSA was more than
double that of total PSA (4.0 versus 1.7).
Considering the number of false-positive results
obtained with both biomarkers (2,576 for total PSA and
2,316 for %p2PSA, respectively), routine %p2PSA
assessment may therefore result in up to 10% fewer
unnecessary biopsies using a diagnostic threshold to
maintain 0.95 sensitivity. The diagnostic accuracy of
%p2PSA and phi for the five studies in which both AUCs
were available is shown in Figure 2. Although the AUC
of phi (0.736, 95% CI 0.713 to 0.760) was slightly better
than that of %p2PSA (0.717, 95% CI 0.689 to 0.745), the
difference was not statistically significant (p=0.21).
Discussion
Prostate cancer has the highest prevalence among male
adult cancers in Western countries, and is currently
included among the three leading causes of death for
malignancies in men. Several lines of evidence indicate
that the benefits of a widespread screening policy based
only on PSA are probably offset by health and economic
disadvantages [8, 9]. It is also noteworthy that more than
1,000 men would need to be invited for PSA screening
and 37 cancers would need to be detected to prevent one
death from prostate cancer at 11 years of follow-up [28].
These concerning figures indicate the need for additional
research with the aim of identifying novel screening
strategies based on more efficient biomarkers than total
PSA. Among these, the assessment of %p2PSA carries
several advantages, which were partially confirmed in
this meta-analysis.
Riv Ital Med Lab (2012) 8:231–238 235

Table 1 Studies in which the diagnostic performance of PSA and isoform p2PSA in prostate cancer screening was assessed

Patient selection criteria Study population Diagnostic performance

Reference
PSA range (ng/mL) Diagnostic standard
PSA p2proPSA
Patients Controls
AUC Sensitivity Specificity Method AUC Sensitivity Specificity

[16] 2–10 Biopsy-detected 456 635 0.52 0.95 0.07 Manual 0.64 0.95 0.14
prostate cancer ELISA
[17] 4–10 Biopsy-detected 142 238 0.57 0.95 0.08 Manual 0.64 0.95 0.12
prostate cancer ELISA
[18] 4–10 Biopsy-detected 221 315 0.51 0.95 0.10 Manual 0.63 0.95 0.19
prostate cancer ELISA
[19] 2–10 Biopsy-detected 50 39 0.52 0.95 0.06 Beckman
prostate cancer Coulter 0.73 0.95 0.31
Access
[20] 2–10 Biopsy-detected 264 211 0.56 0.95 0.11 Beckman
prostate cancer Coulter 0.78 0.95 0.18
Access
[21] 2–10 Biopsy-detected 226 179 0.58 0.95 0.10 Beckman
prostate cancer Coulter 0.72 0.95 0.20
Access
[21] 2–10 Biopsy-detected 174 177 0.53 0.95 0.08 Beckman
prostate cancer Coulter 0.70 0.95 0.22
Access
[22] 2–10 Biopsy-detected 195 234 0.58 0.95 0.12 Beckman
prostate cancer Coulter 0.70 0.95 0.16
Access
[23] 2.5–10 Biopsy-detected 26 37 0.50 0.95 0.10 Beckman
prostate cancer Coulter 0.76 0.95 0.42
Access
[24] 2–10 Biopsy-detected 107 161 0.53 0.95 0.08 Beckman
prostate cancer Coulter 0.76 0.95 0.32
Access
[25] 2–10 Biopsy-detected 430 462 0.52 0.95 0.07 Beckman
prostate cancer Coulter 0.70 0.95 0.16
Access
[26] 2–20 Biopsy-detected 47 113 0.51 0.95 0.01 Beckman
prostate cancer Coulter 0.68 0.95 0.10
Access

Catalona et al. have previously concluded that p2PSA
has the highest cancer specificity in the PSA range 4–10
ng/mL, which would allow 31% of unnecessary biopsies
to be avoided, while detecting 97% of cancers with a
pathology Gleason score of 7 or greater, as well as 94%
of extracapsular tumours [18]. The results of our study
including a broader range of PSA values (i.e. mostly
within the range 2–10 ng/mL) do not completely support
this optimistic conclusion, since the cut-off at the optimal
sensitivity required for a screening test (i.e. 0.95) was
still associated with a high number of false-positive
results, so that the overall reduction in unnecessary biop-
sies according to the pooled literature data would be only
approximately 10%. It is, however, undeniable that this
novel biomarker shows a higher total accuracy than total
PSA, with a markedly higher NPV (0.81 versus 0.66).
Additional information can be gathered from other
articles excluded for various reasons from our analysis.
A study by Naya et al., who did not provide data on the
diagnostic accuracy of total PSA, showed an AUC of
0.644 (95% CI, 0.444–0.945) for %p2PSA [29]. In a
study by Liang et al., who also did not provide data on
total PSA, the AUC of %p2PSA and phi in patients with
PSA in the range 2–10  ng/mL were 0.57 and 0.59,
respectively [30]. Sensitivity and specificity were also
similar, with slightly better sensitivities for phi at speci-
ficity values over 0.90 (i.e. 0.27 versus 0.19). In a study
by Isharwal et al., which was excluded because data on
accuracy were completely lacking, the odds ratio for
predicting unfavourable biopsy conversion at annual
surveillance biopsy examination was identical between
%p2PSA (2.65, 95% CI 1.36–5.16) and phi (2.65, 95%
CI 1.39–5.07) [31]. In a study reported as an abstract,
Blanchet et al. found that the diagnostic accuracies of
%[-2]proPSA and phi in men with a total PSA between
1.8 and 8.0  ng/mL were identical (both AUCs, 0.72),

123
236
Fig. 2 Diagnostic performance of PSA isoform p2PSA in combination with free PSA (%p2PSA, 쏆), or as a component of the prostate health
Index (phi, 앳) in the screening of prostate cancer, according to the area under the receiver operating characteristic (ROC) curve (AUC) and 95%
CI of five individual studies and the cumulative AUC, pooled and weighted for the sample size of the studies
and significantly greater than the accuracies of total
PSA (AUC, 0.53) and %fPSA (AUC, 0.58) [32]. Nearly
identical results were reported in other material pub-
lished by the same team of authors [33–36]. Finally,
Ferro et al. also reported that %p2PSA (AUC, 0.73) and
phi (AUC, 0.77) showed better discriminatory perform-
ance than fPSA and p2PSA [37]. At the optimal cut-off
value (i.e. 1.7 ng/mL), %p2PSA exhibited greater speci-
ficity (0.85 versus 0.61) but lower sensitivity (0.49 ver-
sus 0.85) than phi.
Although most of the available studies on p2PSA
were retrospective in nature and more prone to selection
bias due to the inclusion of populations stratified accord-
ing to PSA values, our findings provide a rationale for
larger validation studies to establish whether %p2PSA
testing may generate more favourable results in terms of
detection of more aggressive cancers, mortality and qual-
ity of life, and thereby replace other strategies in routine
practice. This is supported by a preliminary analysis car-
ried out in the US assessing the cost-effectiveness of
early prostate cancer detection with p2PSA and phi com-
pared with the PSA test alone, which concluded that the
introduction of p2PSA and/or phi would lead to an
expected gain of 0.08 quality-adjusted life-years [38].
Our results also show that direct comparison of phi and
%p2PSA produced only a marginal and not statistically
significant improvement in accuracy, which does not per-
mit the conclusion that one approach is globally superior
to the other for detecting prostate cancer at this time.
123
Riv Ital Med Lab (2012) 8:231–238
It is noteworthy, however, that the replacement of PSA
with p2PSA may carry some economic and technical draw-
backs. First, the current cost of p2PSA is 10 to 20 orders of
magnitude greater than that of PSA. The much larger
expenditure attributable to systematic screening with
p2PSA should be weighed against the economic gain from
avoiding a substantial number of unnecessary biopsies,
physician’s office visits and laboratory tests as a result of
the better specificity of p2PSA. Interestingly, Nichol et al.
recently evaluated the budgetary impact of introducing
p2PSA and phi for detecting prostate cancer, and found that
the addition of p2PSA to total PSA and %fPSA increased
the total laboratory expenditure by nearly US $51,524 at a
PSA cut-off of 2 ng/mL, but still they found a remarkable
overall healthcare saving of $356,647 [39]. The preanalyt-
ical requirements for p2PSA are more stringent than those
for PSA. For proper assessment, blood samples should be
centrifuged or refrigerated immediately upon collection in
a serum gel tube – preferably within 3 to 5 hours – to pre-
vent negative bias in the measurement of total and fPSA
[40, 41], the latter necessary for the calculation of %2PSA
and both included in the phi formula. The serum should
then be stored at room temperature or refrigerated for less
than 48 hours or frozen if delayed analysis is planned [41].
Since speculative diagnostic use of p2PSA and other
PSA isoforms has a history of only 10 years, their biolo-
gy is still incompletely appreciated. It is unclear, for
example, whether the presence of other pathological con-
ditions such as chronic renal disease [42] or coronary
Riv Ital Med Lab (2012) 8:231–238
artery disease [43] affect risk prediction of prostate can-
cer, since the metabolism of p2PSA in blood may be sig-
nificantly impaired in patients suffering from these disor-
ders. With regard to the analytical features, the commer-
cial test is based on a sandwich immunoassay using a
p2PSA monoclonal antibody conjugated to paramagnetic
beads coupled with an anti-PSA monoclonal antibody
conjugated to alkaline phosphatase. The assay is calibrat-
ed against recombinant p2PSA and exhibits excellent
analytical performance, with extended linearity
(0.5–5,000 pg/mL), low limit of detection (0.69 pg/mL)
and acceptable imprecision (i.e. <20%) at 3.23  pg/mL.
The total imprecision is lower than 7%, and therefore
globally comparable to that of other contemporary
immunoassays [44].
Conflict of interest None
References
1. Siegel R, Naishadham D, Jemal A (2012) Cancer statistics, 2012.
CA Cancer J Clin 62:10–29
2. Centro Nazionale di Epidemiologia, Sorveglianza e Promozione
della Salute. I numeri del cancro in Italia 2011. http://www.epi-
centro.iss.it/temi/tumori/italiaEpid.asp. Accessed 27 October
2012
3. Brooks DD, Wolf A, Smith RA et al (2010) Prostate cancer scree-
ning 2010: updated recommendations from the American Cancer
Society. J Natl Med Assoc 102:423–429
4. Chou R, Croswell JM, Dana T et al (2011) Screening for prosta-
te cancer: a review of the evidence for the U.S. Preventive
Services Task Force. Ann Intern Med 155:762–771
5. Heidenreich A, Bellmunt J, Bolla M et al (2011) EAU guidelines
on prostate cancer. Part 1: screening, diagnosis, and treatment of
clinically localised disease. Eur Urol 59:61–71
6. Sciarra A, Cattarino S, Gentilucci A et al (2011) Update on scree-
ning in prostate cancer based on recent clinical trials. Rev Recent
Clin Trials 6:7–15
7. Carlsson S, Vickers AJ, Roobol M et al (2012) Prostate cancer
screening: facts, statistics, and interpretation in response to the
US Preventive Services Task Force Review. J Clin Oncol
30:2581–2584
8. Wilt TJ, Brawer MK, Jones KM et al (2012) Prostate Cancer
Intervention versus Observation Trial (PIVOT) Study Group
Radical prostatectomy versus observation for localized prostate
cancer. N Engl J Med 367:203–213
9. Heijnsdijk EA, Wever EM, Auvinen A et al (2012) Quality-of-life
effects of prostate-specific antigen screening. N Engl J Med
367:595–605
10. Greene KL, Albertsen PC, Babaian RJ et al (2009) Prostate spe-
cific antigen best practice statement: 2009 update. J Urol
182:2232–2241
11. Lippi G, Montagnana M, Guidi GC, Plebani M (2009) Prostate-
specific antigen-based screening for prostate cancer in the third
millennium: useful or hype? Ann Med 41:480–489
12. Lippi G (2011) Re: Jean-Nicolas Cornu, Géraldine Cancel-
Tassin, Valérie Ondet et al. Olfactory detection of prostate cancer
by dogs sniffing urine: a step forward in early diagnosis. Eur Urol
2011;59:197-201. Eur Urol 60:e29
13. Zhang MZ, Lu YP (2012) From pro-prostate specific antigen, [-
237
2]pro-prostate specific antigen to Beckman Coulter phi: the evo-
lution of new biomarkers for early detection of prostatic carcino-
ma. Chin Med J (Engl) 125:1643–1649
14. Whiting P, Rutjes AW, Reitsma JB et al (2003) The development
of QUADAS: a tool for the quality assessment of studies of dia-
gnostic accuracy included in systematic reviews. BMC Med Res
Methodol 3:25
15. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003)
Measuring inconsistency in meta-analyses. BMJ 327:557–560
16. Catalona WJ, Bartsch G, Rittenhouse HG et al (2003) Serum pro
prostate specific antigen improves cancer detection compared to
free and complexed prostate specific antigen in men with prosta-
te specific antigen 2 to 4 ng/ml. J Urol 170(6 Pt 1):2181–2185
17. Mikolajczyk SD, Catalona WJ, Evans CL et al (2004) Proenzyme
forms of prostate-specific antigen in serum improve the detection
of prostate cancer. Clin Chem 50:1017–1025
18. Catalona WJ, Bartsch G, Rittenhouse HG et al (2004) Serum pro-
prostate specific antigen preferentially detects aggressive prosta-
te cancers in men with 2 to 4 ng/ml prostate specific antigen. J
Urol 171(6 Pt 1):2239–2244
19. Sokoll LJ, Wang Y, Feng Z et al (2008) [-2]proenzyme prostate
specific antigen for prostate cancer detection: a National Cancer
Institute Early Detection Research Network validation study. J
Urol 180:539–543
20. Stephan C, Kahrs AM, Cammann H et al (2009) A [-2]proPSA-
based artificial neural network significantly improves differentia-
tion between prostate cancer and benign prostatic diseases.
Prostate 69:198–207
21. Jansen FH, van Schaik RH, Kurstjens J et al (2010) Prostate-spe-
cific antigen (PSA) isoform p2PSA in combination with total
PSA and free PSA improves diagnostic accuracy in prostate can-
cer detection. Eur Urol 57:921–927
22. Sokoll LJ, Sanda MG, Feng Z et al (2010) A prospective, multi-
center, National Cancer Institute Early Detection Research
Network study of [-2]proPSA: improving prostate cancer detec-
tion and correlating with cancer aggressiveness. Cancer
Epidemiol Biomarkers Prev 19:1193–1200
23. Le BV, Griffin CR, Loeb S et al (2010) [-2]Proenzyme prostate
specific antigen is more accurate than total and free prostate spe-
cific antigen in differentiating prostate cancer from benign disea-
se in a prospective prostate cancer screening study. J Urol
183:1355–1359
24. Guazzoni G, Nava L, Lazzeri M et al (2011) Prostate-specific
antigen (PSA) isoform p2PSA significantly improves the predic-
tion of prostate cancer at initial extended prostate biopsies in
patients with total PSA between 2.0 and 10 ng/ml: results of a
prospective study in a clinical setting. Eur Urol 60:214–222
25. Catalona WJ, Partin AW, Sanda MG et al (2011) A multicenter
study of [-2]pro-prostate specific antigen combined with prostate
specific antigen and free prostate specific antigen for prostate
cancer detection in the 2.0 to 10.0 ng/ml prostate specific antigen
range. J Urol 185:1650–1655
26. Perdonà S, Bruzzese D, Ferro M et al (2012) Prostate health index
(phi) and prostate cancer antigen 3 (PCA3) significantly improve
diagnostic accuracy in patients undergoing prostate biopsy.
Prostate. doi: 10.1002/pros.22561. [Epub ahead of print]
27. Stenner E, Micheli W, Bussani A et al (2008) Comparison of
Hybritech and WHO standardization applied to access Hybritech
total PSA assay on UniCel®. RIMeL/IJLaM 4:43–46
28. Schröder FH, Hugosson J, Roobol MJ et al (2012) ERSPC
Investigators Prostate-cancer mortality at 11 years of follow-up.
N Engl J Med 366:981–990
29. Naya Y, Fritsche HA, Bhadkamkar VA et al (2005) Evaluation of
precursor prostate-specific antigen isoform ratios in the detection
of prostate cancer. Urol Oncol 2005;23:16–21
30. Liang Y, Ankerst DP, Ketchum NS et al (2001) Prospective eva-
123
238
luation of operating characteristics of prostate cancer detection
biomarkers. J Urol 185:104–110
31. Isharwal S, Makarov DV, Sokoll LJ et al (2011) ProPSA and dia-
gnostic biopsy tissue DNA content combination improves accu-
racy to predict need for prostate cancer treatment among men
enrolled in an active surveillance program. Urology 77:
763.e1–e6
32. Blanchet JS, Houlgatte A, Durand X et al (2010) The [-2]proPSA
and the Prostate Health Index (phi) improve the detection of pro-
state cancer for patients with total PSA between 1.8 and 8.0
ng/mL. J Mens Health 7:345
33. Blanchet JS, Durand X, Houlgatte A et al (2010) The Beckman
Coulter prostate health index (phi) increases the specificity of
detection of prostate cancer and reduces the number of negative
biopsies. J Mens Health 7:346
34. Blanchet JS, Vincendeau S, Durand X et al (2010) Detection of
aggressive prostate cancer using [-2]proPSA and the prostate
health index. J Mens Health 7:346
35. Vincendeau S, Ramirez J, Durand X et al (2010) The Beckman
Coulter prostate health index (phi) improves diagnostic accuracy
in prostate cancer detection. Eur Urol Suppl 9:309
36. Houlgatte A, Vincendeau S, Desfemmes F et al (2012) Use of [-
2] pro PSA and phi index for early detection of prostate cancer: a
prospective of 452 patients. Prog Urol 22:279–283
37. Ferro M, Bruzzese D, Perdonà S et al (2012) Predicting prostate
biopsy outcome: prostate health index (phi) and prostate cancer
123
Riv Ital Med Lab (2012) 8:231–238
antigen 3 (PCA3) are useful biomarkers. Clin Chim Acta
413:1274–1278
38. Nichol MB, Wu J, Huang J et al (2012) Cost-effectiveness of
Prostate Health Index for prostate cancer detection. BJU Int
110:353–362
39. Nichol MB, Wu J, An JJ et al (2011) Budget impact analysis of a
new prostate cancer risk index for prostate cancer detection.
Prostate Cancer Prostatic Dis 14:253–261
40. Ceriotti F, Postillo M, Fasoli L, Dorigatti F (2011) Pre-analytical
phase of [-2]proPSA measurement and Prostate Health Index cal-
culation. Biochim Clin 35:373–376
41. Semjonow A, Köpke T, Eltze E et al (2010) Pre-analytical in-vitro
stability of [-2]proPSA in blood and serum. Clin Biochem
43:926–928
42. Tadtayev S, McNicholas TA, Boustead GB (2012) Re: Giorgio
Guazzoni, Massimo Lazzeri, Luciano Nava et al. Preoperative
prostate-specific antigen isoform p2PSA and its derivatives,
%p2PSA and Prostate Health Index, predict pathologic outcomes
in patients undergoing radical prostatectomy for prostate cancer.
Eur Urol 2012;61:455-66. Eur Urol 62:e14–e15
43. Lippi G, Aloe R, Cervellin G (2011) p2PSA but not total and free
PSA increases after myocardial infarction: results of a prelimi-
nary investigation. Int J Cardiol 153:119
44. Sokoll LJ, Chan DW, Klee GG et al (2012) Multi-center analyti-
cal performance evaluation of the Access Hybritech® p2PSA
immunoassay. Clin Chim Acta 413:1279–1283