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Meta-Analysis
. 2022 Feb 7;20(1):54.
doi: 10.1186/s12916-021-02230-y.

Systematic review and meta-analysis of the diagnostic accuracy of prostate-specific antigen (PSA) for the detection of prostate cancer in symptomatic patients

Samuel W D Merriel  1 , Lucy Pocock  2 , Emma Gilbert  2 , Sam Creavin  2 , Fiona M Walter  2 , Anne Spencer  2 , Willie Hamilton  2
Affiliations
Meta-Analysis

Systematic review and meta-analysis of the diagnostic accuracy of prostate-specific antigen (PSA) for the detection of prostate cancer in symptomatic patients

Samuel W D Merriel et al. BMC Med. .

Abstract

Background: Prostate-specific antigen (PSA) is a commonly used test to detect prostate cancer. Attention has mostly focused on the use of PSA in screening asymptomatic patients, but the diagnostic accuracy of PSA for prostate cancer in patients with symptoms is less well understood.

Methods: A systematic database search was conducted of Medline, EMBASE, Web of Science, and the Cochrane library. Studies reporting the diagnostic accuracy of PSA for prostate cancer in patients with symptoms were included. Two investigators independently assessed the titles and abstracts of all database search hits and full texts of potentially relevant studies against the inclusion criteria, and data extracted into a proforma. Study quality was assessed using the QUADAS-2 tool by two investigators independently. Summary estimates of diagnostic accuracy were calculated with meta-analysis using bivariate mixed effects regression.

Results: Five hundred sixty-three search hits were assessed by title and abstract after de-duplication, with 75 full text papers reviewed. Nineteen studies met the inclusion criteria, 18 of which were conducted in secondary care settings with one from a screening study cohort. All studies used histology obtained by transrectal ultrasound-guided biopsy (TRUS) as a reference test; usually only for patients with elevated PSA or abnormal prostate examination. Pooled data from 14,489 patients found estimated sensitivity of PSA for prostate cancer was 0.93 (95% CI 0.88, 0.96) and specificity was 0.20 (95% CI 0.12, 0.33). The area under the hierarchical summary receiver operator characteristic curve was 0.72 (95% CI 0.68, 0.76). All studies were assessed as having a high risk of bias in at least one QUADAS-2 domain.

Conclusions: Currently available evidence suggests PSA is highly sensitive but poorly specific for prostate cancer detection in symptomatic patients. However, significant limitations in study design and reference test reduces the certainty of this estimate. There is very limited evidence for the performance of PSA in primary care, the healthcare setting where most PSA testing is performed.

Keywords: Diagnostic accuracy; LUTS; Lower urinary tract symptoms; PSA; Primary care; Prostate cancer; Prostate-specific antigen; Secondary care.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
PRISMA 2020 flow diagram
Fig. 2
Fig. 2
Summary of QUADAS-2 risk of bias assessments
Fig. 3
Fig. 3
Forest plot of included studies using PSA cut-off of 4 ng/mL
Fig. 4
Fig. 4
Hierarchical summary receiver operator curve (HSROC) of included studies using PSA cut-off of 4 ng/mL
See this image and copyright information in PMC

References

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