Detection of Prostate Cancer and Predicting Progression: Current and Future Diagnostic Markers
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Vol. 10, 3943–3953, June 15, 2004 Clinical Cancer Research 3943 Review Detection of Prostate Cancer and Predicting Progression: Current and Future Diagnostic Markers James V. Tricoli,1 Mason Schoenfeldt,3 and of serum prostate-specific antigen (PSA) screening of asymp- Barbara A. Conley2 tomatic populations, prostate cancer incidence rates have in- creased dramatically, as has the number of men undergoing 1Diagnostics Research Branch, Cancer Diagnosis Program, National Cancer Institute, Rockville, Maryland; 2Aerodigestive Clinical Cancer radical prostatectomy and radiation therapy for this disease (1, Research Section, Center for Cancer Research, National Cancer 2). However, false positives for PSA continue to be a significant Institute, Bethesda, Maryland; and 3The EMMES Corporation, problem resulting in unnecessary biopsies, and the value of Rockville, Maryland broad-based PSA testing with regard to predicting surgical cures has recently come into question (3). ABSTRACT Currently, there are no markers that differentiate clinically Carcinoma of the prostate is the second leading cause of relevant from clinically benign disease. Better indicators of male cancer-related death in the United States. Better indi- prostate cancer presence and progression are needed to avoid cators of prostate cancer presence and progression are unnecessary treatment, predict disease course, and develop more needed to avoid unnecessary treatment, predict disease effective therapy. A variety of putative prostate cancer markers course, and develop more effective therapy. Numerous mo- have been described in human serum, urine, seminal fluid, and lecular markers have been described in human serum, histological specimens. These markers exhibit varying capaci- urine, seminal fluid, and histological specimens that exhibit ties to detect prostate cancer and to predict disease course. These varying capacities to detect prostate cancer and predict markers are distinct from chromosomal aberrations that have disease course. However, to date, few of these markers have been associated with prostate cancer, which will not be dealt been adequately validated for clinical use. The purpose of with here (4). this review is to examine the current status of these markers The purpose of this review is to examine the current status in prostate cancer and to assess the diagnostic potential for of markers in prostate cancer and to assess the diagnostic future markers from identified genes and molecules that potential for future markers from identified genes and molecules display loss, mutation, or alteration in expression between that display loss, mutation, or alteration in expression between tumor and normal prostate tissues. In this review we cite 91 tumor and normal prostate tissues. To date, few of these markers molecular markers that display some level of correlation have achieved widespread clinical utility. If we are to improve with prostate cancer presence, disease progression, can- on the treatment of prostate cancer in the 21st century, we must cer recurrence, prediction of response to therapy, and/or identify and develop markers that are more clinically informa- disease-free survival. We suggest criteria to consider when tive for this disease and that will allow risk-based individual- selecting a marker for further development as a clinical tool ization of therapy. and discuss five examples of markers (chromogranin A, glutathione S-transferase 1, prostate stem cell antigen, A BRIEF HISTORY OF PROSTATE prostate-specific membrane antigen, and telomerase reverse transcriptase) that fulfill some of these criteria. Finally, we CANCER DIAGNOSTICS discuss how to conduct evaluations of candidate prostate The first documented case of prostate cancer was reported cancer markers and some of the issues involved in the by Langstaff in 1817 (5). One hundred eighteen years later, in validation process. 1935, prostatic acid phosphatase (PAP) levels were identified in the ejaculate of men, thus linking this enzyme to the prostate (6). Subsequent studies showed high PAP concentrations in primary INTRODUCTION and metastatic prostate cancer tissues and in human serum, Carcinoma of the prostate is the second leading cause of making it the first candidate marker for the diagnosis of prostate male cancer-related death in the United States, and it is esti- cancer (7, 8). Reductions in serum PAP levels were found to mated that in 2003 there were approximately 220,900 new cases occur in response to antiandrogen therapy, whereas increasing and 28,900 deaths from this disease (1). Since the introduction serum levels were associated with treatment failure and relapse (9, 10). However, whereas serum PAP levels were elevated in a significant number of men with metastatic disease (8), fewer than 20% of men with localized prostate cancer exhibited ab- Received 9/10/03; revised 3/16/04; accepted 3/26/04. normal enzyme levels (11, 12). Meticulous sample collection The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked and preparation were required because both platelets and leu- advertisement in accordance with 18 U.S.C. Section 1734 solely to kocytes are contaminating sources of acid phosphatases (13) and indicate this fact. because PAP activity is rapidly lost at room temperature (14). Requests for reprints: James V. Tricoli, Diagnostics Research Branch, Development of a radioimmune assay for PAP in 1975 provided Cancer Diagnosis Program, National Cancer Institute, 6130 Executive Boulevard, Executive Plaza North, Suite 6044, Rockville, MD 20852. some improvement in test sensitivity (15), but the sensitivity Phone: (301) 496-1591; Fax: (301) 402-7819; E-mail: tricolij@mail. levels were still inadequate for detection of early-stage disease. nci.nih.gov. Therefore, it was clear that a more sensitive and robust indicator Downloaded from clincancerres.aacrjournals.org on October 1, 2021. © 2004 American Association for Cancer Research. 3944 Prostate Cancer Diagnostics of disease presence would be required to detect prostate cancer correlation with one or more of the following factors: presence in its earlier stages, when cure is more likely. of prostate cancer, disease progression, cancer recurrence, pre- PSA is a kallekrein-like serine protease that was first diction of response to therapy, or disease-free survival. Infor- described in 1971 (16). PSA is secreted from prostate epithelial mation on these markers was accumulated through literature cells and encoded by an androgen-responsive gene located on searches using PubMed and from the GeneCards database of chromosome 19q13.3–13.4 (17). The main function of PSA is to human genes, their products, and their involvement in diseases liquefy human semen through its proteolytic action (18). PSA (31). Evidence for the association of a specific marker with was initially thought to be a prostate-specific protein; however, human prostate cancer range from a single publication, as in the subsequent investigations demonstrated that PSA is secreted in case of UROC 28, to thousands of publications, as in the case of small quantities from a number of other normal male tissues and PSA. In light of the rapid pace of new marker discovery through even some female tissues (19, 20). PSA was first detected in the the use of comprehensive DNA expression analysis and pro- serum of prostate cancer patients in 1980 (19), and a normal teomics, there are no doubt candidate markers missing from this PSA serum concentration limit of 4 ng/ml for men was subse- list. However, we have made Table 1 as current as possible, and quently established (20). A serum level above 4 ng/ml was taken we hope that it will serve as a resource for the prostate cancer as an indicator of the possible presence of prostate cancer and research community. In Table 1, we present 89 proteins (the served as the trigger for further clinical evaluation. Eventually, transcripts for DD3 and PCGEM1 do not contain open reading a number of studies enrolling large numbers of men over the age frames) that have been correlated with some aspect of prostate of 50 years suggested that quantitation of serum PSA was a cancer presence or progression in one or more studies. They are useful diagnostic tool for detecting the presence of prostate listed in alphabetical order and categorized according to their cancer, particularly when combined with digital rectal exami- subcellular location: nucleus; cytoplasm; plasma membrane; nation (21–24). However, other studies have called into question cytoskeleton; mitochondria; microsomal membrane; endoplas- the sensitivity and specificity of the PSA test (25–28). One mic reticulum; lysosome; or secreted. The latest information on problem is that serum PSA levels can be elevated as a result of chromosomal location and molecular weight is included, along conditions other than prostate cancer, such as benign prostatic with the most common biochemical function of the protein and hypertrophy (BPH) and prostatitis. As a result, false positives its major cellular function. In cases in which the biochemical are a significant problem for the PSA test and can lead to and/or cellular functions of the proteins remain to be deter- unnecessary biopsies and other interventions. Of greater con- mined, the word “unknown” appears in the appropriate column. cern, 20–30% of men with prostate cancer have serum PSA Alterations for some of these markers, such as p53 and telom- levels in the normal range, resulting