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BACKGROUND: Prostate-specific antigen (PSA) testing has limited accuracy for the early detection of prostate cancer (PCa). OBJECTIVE: To assess the value added by percentage of free to total PSA (%fPSA), prostate cancer antigen 3 (PCA3), and a kallikrein panel (4k-panel) to the European Randomised Study of Screening for Prostate Cancer (ERSPC) multivariable prediction models: risk calculator (RC) 4, including transrectal ultrasound, and RC 4 plus digital rectal examination (4+DRE) for prescreened men. DESIGN, SETTING, AND PARTICIPANTS: Participants were invited for rescreening between October 2007 and February 2009 within the Dutch part of the ERSPC study. Biopsies were taken in men with a PSA level ≥3.0 ng/ml or a PCA3 score ≥10. Additional analyses of the 4k-panel were done on serum samples. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Outcome was defined as PCa detectable by sextant biopsy. Receiver operating characteristic curve and decision curve analyses were performed to compare the predictive capabilities of %fPSA, PCA3, 4k-panel, the ERSPC RCs, and their combinations in logistic regression models. RESULTS AND LIMITATIONS: PCa was detected in 119 of 708 men. The %fPSA did not perform better univariately or added to the RCs compared with the RCs alone. In 202 men with an elevated PSA, the 4k-panel discriminated better than PCA3 when modelled univariately (area under the curve [AUC]: 0.78 vs. 0.62; p=0.01). The multivariable models with PCA3 or the 4k-panel were equivalent (AUC: 0.80 for RC 4+DRE). In the total population, PCA3 discriminated better than the 4k-panel (univariate AUC: 0.63 vs. 0.56; p=0.05). There was no statistically significant difference between the multivariable model with PCA3 (AUC: 0.73) versus the model with the 4k-panel (AUC: 0.71; p=0.18). The multivariable model with PCA3 performed better than the reference model (0.73 vs. 0.70; p=0.02). Decision curves confirmed these patterns, although numbers were small. CONCLUSIONS: Both PCA3 and, to a lesser extent, a 4k-panel have added value to the DRE-based ERSPC RC in detecting PCa in prescreened men. PATIENT SUMMARY: We studied the added value of novel biomarkers to previously developed risk prediction models for prostate cancer. We found that inclusion of these biomarkers resulted in an increase in predictive ability.

Original publication




Journal article


Eur Urol

Publication Date





1109 - 1115


Kallikrein panel (4k-panel), Percentage of free to total PSA, Prostate biopsy, Prostate cancer, Prostate cancer antigen 3 (PCA3), Prostate cancer risk calculator, Validation, Aged, Antigens, Neoplasm, Area Under Curve, Biomarkers, Tumor, Biopsy, Digital Rectal Examination, Early Detection of Cancer, Humans, Kallikreins, Male, Models, Statistical, Multivariate Analysis, Netherlands, Prostate, Prostate-Specific Antigen, Prostatic Neoplasms, ROC Curve, Risk Assessment, Ultrasonography