Free/total PSA ratio improves differentiation of benign and malignant disease of the prostate: Critical analysis of two different test populations

Objectives. To evaluate the ability of free PSA (fPSA), total PSA (tPSA), and the free/total PSA (f/t PSA) ratio to differentiate between benign prostate disease (benign prostatic hyperplasia [BPH] and no evidence of malignancy [NEM]) and prostate cancer (CAP) using two different testing populations, and to compare predictive probabilities for the two test populations. Methods. One test population consisted of sera from 531 men with clinically well-defined and biopsy-confirmed BPH (n = 255) or CaP (n = 276), with tPSA values ranging from 2 to 20 ng/mL. All of these serum samples were retrospective and obtained from patients evaluated in academic settings before any treatment. A second test population consisted of a prospective analysis of sera obtained from 4870 men, collected by urologists throughout the United States and processed at a single pathology laboratory. All these patients had a systematic biopsy evaluated and diagnosed at the same pathology laboratory, with the diagnosis categorized as either NEM (n = 2961) or CaP (n = 1909). No additional information on concurrent disease or pre- or current treatment status was known for this test population. For both populations, two tPSA reflex range groups, 2 to 10 and 2 to 20 ng/mL, were evaluated. Results. Both test populations benefited from the application of either fPSA alone or the f/t PSA ratio to differentiate benign from malignant disease (t test P value less than 0.001). The receiver operating characteristic (ROC) curve for the f/t PSA ratio had an area under the curve (AUC) of 72% for n = 531 versus 63% for n = 4870, irrespective of the tPSA reflex range. Average fPSA values demonstrated a linear correlation to a range of tPSA concentrations for both test populations. Predictive probabilities (adjusted for established cancer prevalence rates in the academic population [n = 531]) calculated using f/t PSA ratios also demonstrated their value in contrasting the performance characteristics in the two test populations. Conclusions. The fPSA and f/t PSA ratio improved the differentiation of benign disease and CaP in two different patient samples. The f/t PSA ratio demonstrated an increased sensitivity and specificity when applied to differentiate clinically well-defined BPH and CaP (n = 531). The differences in the results between the two test samples are probably attributable to the variability of the patient's disease and treatment status in the larger, less refined, community-based population. The use of predictive probabilities provides the opportunity to provide patient- specific cancer probabilities instead of using population-based specific single cutoffs.