Health Policy Advisory Committee on Technology

Health Policy Advisory Committee on Technology Technology Brief Molecular testing for prostate cancer prognosis November 2014

State of Queensland (Queensland Department of Health) 2014 This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the authors and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en. For further information, contact the HealthPACT Secretariat at: HealthPACT Secretariat c/o Clinical Access and Redesign Unit, Health Service and Clinical Innovation Division Department of Health, Queensland Level 2, 15 Butterfield St HERSTON QLD 4029 Postal Address: GPO Box 48, Brisbane QLD 4001 Email: HealthPACT@health.qld.gov.au Telephone: +61 7 3646 9100 For permissions beyond the scope of this licence contact: Intellectual Property Officer, Department of Health, GPO Box 48, Brisbane QLD 4001, email ip_officer@health.qld.gov.au, phone (07) 3328 9824. Electronic copies can be obtained from: http://www.health.qld.gov.au/healthpact DISCLAIMER: This Brief is published with the intention of providing information of interest. It is based on information available at the time of research and cannot be expected to cover any developments arising from subsequent improvements to health technologies. This Brief is based on a limited literature search and is not a definitive statement on the safety, effectiveness or costeffectiveness of the health technology covered. The State of Queensland acting through Queensland Health ( Queensland Health ) does not guarantee the accuracy, currency or completeness of the information in this Brief. Information may contain or summarise the views of others, and not necessarily reflect the views of Queensland Health. This Brief is not intended to be used as medical advice and it is not intended to be used to diagnose, treat, cure or prevent any disease, nor should it be used for therapeutic purposes or as a substitute for a health professional's advice. It must not be relied upon without verification from authoritative sources. Queensland Health does not accept any liability, including for any injury, loss or damage, incurred by use of or reliance on the information. This Brief was commissioned by Queensland Health, in its role as the Secretariat of the Health Policy Advisory Committee on Technology (HealthPACT). The production of this Brief was overseen by HealthPACT. HealthPACT comprises representatives from health departments in all States and Territories, the Australian and New Zealand governments and MSAC. It is a sub-committee of the Australian Health Ministers Advisory Council (AHMAC), reporting to AHMAC s Hospitals Principal Committee (HPC). AHMAC supports HealthPACT through funding. This brief was prepared by Benjamin Ellery, Jacqueline Parsons and A/Prof Tracy Merlin from Adelaide Health Technology Assessment (AHTA), School of Population Health, University of Adelaide.

Technology, Company and Licensing Register ID Technology name Patient indication WP205 Molecular testing for prostate cancer prognosis Men diagnosed with prostate cancer Description of the technology The development of molecular and genetic methods for determining the aggressiveness of prostate cancer (PCa) has been ongoing for many years. The available scientific literature reveals that there have been many experimental studies 1-6 to identify genes which are variably expressed in prostate tumour tissue in order to determine whether there is any correlation or association with prostate specific antigen (PSA) level 7a, Gleason score 8b, cancer stage and Cancer of the Prostate Risk Assessment (CAPRA) 9c. The results of these genome wide association studies, often canvassing hundreds of genes, have provided the basis for analytical validation of more focused gene arrays. d In the last few years, commercially available assays have emerged which provide genetic signatures which are purported to predict PCa behaviour, particularly PCa progression. For specific details on individual tests identified during the literature search for this brief, see Table 1. Company or developer Various companies (Table 1) provide genetic assays which provide prognostic information that may be useful for guiding the clinical management of patients with PCa. a PSA level is determined by a blood test. A higher PSA may mean that the likelihood of PCa is elevated compared to a normal PSA result; however a high PSA is not necessarily indicative of PCa, and some men who have PCa do not have elevated PSA levels. As such, PSA alone is a poor prognostic indicator for PCa. b The Gleason score (range 1-10, where a higher number indicates more aggressive cancer) refers to the appearance of prostate biopsy tissue upon histological examination, i.e. under a microscope. Within different areas of a prostate tumour, the appearance may vary, and therefore it is common to provide two grades which are added to give the overall Gleason score, e.g. a score denoted as 3+4=7 indicates that most of the tumour is grade 3 and less is grade 4. c CAPRA is a risk assessment tool developed by the University of California, San Francisco. The tool was based on the results of a cohort of 1,439 prostatectomy patients. It is used to calculate a man s risk of PCa progression on a scale of 0-10: 0-2 indicates low risk (management with active surveillance is likely to be appropriate), 3-5 indicates intermediate risk, and 6-10 indicates high risk. d Among the tests identified, the panel of genes may be as few as three or as many as 46. Molecular testing for prostate cancer prognosis: November 2014 1

Table 1 Summary of tests that determine the prognosis and clinical management of prostate cancer Test name Company Gene panel / markers involved Sample source Description, stage of development, regulatory status Confirm MDx for Prostate Cancer* MDxHealth, Inc., Irvine, California, USA GSTP1, APC, RASSF1 FFPE prostate tissue specimens collected during 12-core biopsy Detection of an epigenetic field effect based on DNA methylation, intended to distinguish patients who have a true negative biopsy from those who may have occult cancer which appears histologically benign Oncotype DX Prostate Cancer Assay Genomic Health, Inc., Redwood City, California, USA 12 genes with known role in prostate tumour formation; AZGP1, KLK2, SRD5A2, FAM13C, FLNC, GSN, TPM2, GSTM2, TPX2, BGN, COL1A1 and SFRP4, plus 5 reference genes FFPE prostate tissue (length 1 mm) obtained via needle biopsy Measures expression levels of the 12 cancer related genes in an algorithm to generate a GPS; together with NCCN risk criteria, GPS is intended to discriminate PCa into very low, low and modified intermediate risk, thereby assisting clinicians to appropriately select candidates for active surveillance Not FDA approved; offered as an LDT in the USA as per the laboratory s CLIA certificate under governance of CMS Prolaris ** Myriad Genetics, Inc., Salt Lake City, Utah, USA 31 cell cycle progression genes and 15 housekeeping genes FFPE tissue obtained from biopsy or prostatectomy Based on a total of 46 genes, this molecular test directly quantifies tumour cell growth characteristics to stratify risk of PCa progression; high expression suggests higher risk of progression, indicating the requirement for close monitoring or management with radiation therapy / surgery Not FDA approved; offered as an LDT in the USA as per the laboratory s CLIA certificate under governance of CMS Prostarix Metabolon, Inc., Durham, North Carolina, USA Proprietary signature of four metabolites determined by LC-MS Pellet obtained from centrifuged urine specimen collected immediately after DRE Test is intended to help clinicians determine the need for initial or repeat prostate biopsy in men with negative DRE and moderately elevated PSA Not FDA approved; offered as an LDT in the USA as per the laboratory s CLIA certificate under governance of CMS Prostatype ** Chundsell Medicals AB VGLL, IGFBP3, F3 FFPE prostate tissue Analyses the RNA expression level of three PCa-associated genes; using specialised software, estimates are provided for overall survival and other prognostic factors, including differentiation between low, intermediate and high risk categories for PCa progression Patent granted in Sweden CLIA, Clinical Laboratory Improvement Amendments; CMS, Centers for Medicare and Medicaid Services; DRE, digital rectal examination; FDA, United States (US) Federal Drug Administration; FFPE, formalin fixed paraffin embedded; GPS, Genomic Prostate Score; LC-MS, liquid chromatography-mass spectrometry; LDT, laboratory developed test; NCCN, National Comprehensive Cancer Network (US); PCa, prostate cancer; PSA, prostate specific antigen; RNA, ribonucleic acid *Previously evaluated for the February 2013 HealthPACT meeting by the Australian Safety and Efficacy Register of New Interventional Procedures Surgical (ASERNIP-S) **According to the EuroScan website (http://euroscan.org.uk/) these tests are under evaluation by the National Institute for Health Research Horizon Scanning Centre (NIHR-HSC), as of 8 September 2014. Molecular testing for prostate cancer prognosis: November 2014 2

Reason for assessment Molecular tests used to determine PCa prognosis have the potential to help clinicians differentiate between indolent and aggressive tumours, thereby guiding clinicians to select the most appropriate management strategy for their patient. These tests, if accurate, would therefore decrease the requirement for repeat invasive prostate biopsy. In addition, some tests could help to diagnose PCa in patients who have biopsy samples that appear histologically normal. Depending on the accuracy of these tests, there is the potential for cost savings to be realised and patient adverse events to be reduced if these tests replace a prostate biopsy. Stage of development in Australia Yet to emerge Experimental Investigational Nearly established Established Established but changed indication or modification of technique Should be taken out of use Licensing, reimbursement and other approval Prognostic PCa assays would be classified as in vitro diagnostics (IVDs) in Australia and would therefore need to be listed on the Australian Register of Therapeutic Goods(ARTG) prior to marketing. 10 In the US, individual laboratory developed tests (LDTs) do not require Food and Drug Administration (FDA) approval for marketing. Human laboratory testing is nationally regulated by the Clinical Laboratory Improvement Amendments (CLIA) for the Centers for Medicare and Medicaid Services (CMS). Australian Therapeutic Goods Administration approval Yes ARTG number (s) No Not applicable Technology type Technology use Genetic test / molecular test Prognostic, clinical management guidance (discriminating between indolent and aggressive prostate cancer) Molecular testing for prostate cancer prognosis: November 2014 3

Disease description and associated mortality and morbidity The prostate is a walnut sized gland situated immediately below the male bladder. It surrounds the urethra through which urine and semen pass, and produces the majority of the fluid making up the semen. Benign enlargement of the prostate commonly occurs in association with ageing. This enlargement may be noted upon digital rectal examination (DRE). Enlargement of the prostate may cause a variety of urinary symptoms, especially frequent urination and difficulty initiating and maintaining the flow of urine. Mild enlargement is usually associated with mild symptoms; however, as the extent of enlargement increases, symptoms may worsen, and may require some form of treatment. There are a variety of drugs that may be used in the first instance; if these are ineffective, a number of procedures are available to 11, 12 manage moderate to severe symptoms. PCa develops when abnormal cells in the prostate gland grow more quickly than in the normal prostate, forming a malignant tumour. Usually, PCa is a slowly progressing cancer. Treatment differs depending on whether the disease is in an early or late stage at diagnosis. In the early, localised phase, the cancer is contained within the prostate. In advanced PCa, the cancer cells may spread to the nearby bladder, regional and distal lymph nodes, and the bones. The causes of PCa have not been established. The major known risk factors are age and family history. Early prostate cancer is often asymptomatic because the cancer usually grows in the outer part of the gland, and is not large enough to cause any compression of the urethra. However where PCa is symptomatic, the symptoms are similar to benign prostate enlargement, thus it is necessary to discriminate between the presence of benign or malignant disease. 11 The most recent data on cancer prevalence in Australia indicates that PCa is the most common cancer among Australian men, followed by skin melanoma and colorectal cancer. The Australian Institute of Health and Welfare estimated that at the end of 2007, PCa had affected 72,582 men within the previous five years (5-year prevalence rate), which accounted for 39 per cent of all males living with cancer. In 2010, there were 3,235 Australian deaths with PCa registered as the cause (Table 2), making PCa the second highest cause of cancer death, after lung cancer, for males alone and for cancer overall. The mean age at death from PCa was 80 years. PCa was the principal diagnosis for 16,935 overnight hospital admissions for the year 2010-11, representing eight per cent of all overnight hospitalisations for cancer for that year. There were 18,241 same day admissions, the second highest cause of same-day admissions with cancer as the principal diagnosis. Molecular testing for prostate cancer prognosis: November 2014 4

Table 2 Number of deaths and age-standardised mortality rate for prostate cancer and all cancers combined, Australia, 2010 13 No. of deaths ASR[95%CI] per 100,000 Prostate cancer 3,235 30.6 [29.6, 31.7] All cancers 24,328 221.7 [218.9, 224.5] ASR, age-standardised rate (Australian standard population as at 30 June 2001) per 100,000; CI, confidence interval For the year 2012, the predicted incidence of PCa in Australia was 18,560 cases e, which equates to an age-standardised incidence rate of 147.9 cases per 100,000 f. Yearly fluctuations in the incidence of PCa are thought to reflect changes in diagnostic methods over time. Following the introduction of publicly funded PSA testing in Australia in 1989, a diagnostic peak was observed in the early 1990s. This is considered to be consistent with a large group of new diagnoses that may have gone undetected, or been diagnosed at a later date, in the absence of PSA testing. A second rise in the age-standardised incidence was observed in 2008 (peaking at 191 cases per 100,000), which would appear to correlate with further changes to diagnostic procedures, particularly the lowering of the PSA threshold, at which further investigation was considered to be warranted. This led to a proportionate increase in number of biopsies performed around that time. In an analysis of PCa incidence across more than 20 countries and world regions, Australia was found to have the highest incidence of prostate cancer of all countries and regions considered. 13 Despite the importance of PCa as common and serious health condition, there is a lack of evidence to support population based screening for prostate cancer 14. A national screening program for prostate cancer has not been implemented in Australia, nor elsewhere in the world. Currently available evidence suggests that PSA testing is not suitable for use in population based screening programs. It is also considered that the high potential for harms resulting from screening, which leads to unnecessary prostate biopsy and overtreatment, outweighs the benefits. 13 The PSA test is commonly used to test asymptomatic men on a case-by-case basis. In New Zealand, the diagnosis of PCa is nearly as common as in Australia, where the effect of PSA testing, introduced in the mid-1980s, has significantly influenced trends in incidence. Incidence projections are currently based on data from 1984 to 1988, a constraint imposed in order to avoid discontinuity in the data resulting from widespread use of PSA testing. It is intended that projections based on recent data will be available once PCa incidence returns to levels resembling those prior to the introduction of PSA testing. 15 For the year 2010, PCa was the most commonly registered cancer in New Zealand; 2,988, registrations, representing 14 per cent of all cancer registrations, and equivalent to an agee 2012 estimates calculated from 2000-09 incidence data. f Standardised to the Australian population as at 30 June 2001. Molecular testing for prostate cancer prognosis: November 2014 5

standardised rate of nearly 100 per 100,000 g. PCa was the third most common cause of death from cancer for males (589 deaths) and fourth most common cause overall, accounting for 14.1 per cent of cancer deaths in 2010. There are notable differences in PCa registration and mortality rates between Māori and non-māori New Zealanders. Historically, Māori registration rates for PCa have generally been lower than rates observed for non-māori. However, mortality from PCa is higher among Māori than non-māori; in 2010, the PCa mortality rate for Māori was 72.1 per cent higher than for non-māori. 16 Selected registration and mortality data for PCa by Māori / non-māori status are shown in Table 3. Table 3 Age-standardised registration and mortality data for prostate cancer in New Zealand, by ethnicity, 2010 16 Māori n Rate per 100,000 Non-Māori N Rate per 100,000 Registrations 169 86.4 2,819 100.2 Deaths 46 28.7 543 16.7 Total n Rate per 100,000 2,988 99.0 589 17.4 Rates shown are standardised to the WHO world population and expressed as the number registrations/deaths per 100,000 Speciality Technology setting Oncology and radiology, urology General hospital or private specialist care Impact Alternative and/or complementary technology Based on the available evidence, prognostic tests that are intended to guide the clinical management of PCa will complement the current methods used in prostate cancer diagnosis and staging and prognosis of patients with prostate cancer. Prognostic genetic tests are positioned to provide additional information for use in clinical care, but are not intended to replace PSA testing and the initial biopsy, but may be used to avoid repeat prostate biopsies. The role of PSA testing and biopsy, and their limitations, are briefly discussed below. Current technology PSA testing and the biopsy of prostate tissue, which usually follows an abnormal finding upon DRE, are the recognised methods for the diagnosis of PCa. Biopsy is also used during g Approximated from graphical data, based on the World Health Organization (WHO) world standard population. Molecular testing for prostate cancer prognosis: November 2014 6

the preliminary grading of PCa (i.e. prior to / in the absence of surgery). However these methods have certain limitations. In particular, PSA has a 75 per cent false positive rate 17 and a recent retrospective cohort study found that Gleason score 18h following needle biopsy provides only an inexact prediction of the final grade assigned upon histological assessment of radical prostatectomy (RP) i specimens. Thus, PSA and prostate biopsy are not reliable for clinical differentiation between indolent and aggressive PCa. Diffusion of technology in Australia Yet to emerge. International utilisation Country Level of Use Trials underway or Limited use completed Sweden UK USA Widely diffused Cost infrastructure and economic consequences Pricing information was sought on the assays provided by Myriad Genetics, Chundsell Medicals and Genomic Health. Only Genomic Health could be successfully contacted. Genomic Health, the provider of the Oncotype DX assay, operates in the USA as an innetwork provider with the majority of health insurance plans, i.e. insurers are billed directly for the cost of performing the assay, US$4,180 (approximately AU$4,641), avoiding large up-front costs for patients. Genomic Health has advised that the company is working toward commercialisation of Oncotype DX in Australia, but that no price for the Australian market has been decided to date. j Given all but one of the PCa prognostic assays identified requires biopsied tissue, their use will not avoid an initial prostate biopsy for men suspected of having PCa, but will provide information that may be helpful in avoiding repeat biopsies. Despite the substantial cost of these assays they maybe cost saving if they can be found to reliably identify men with low risk disease, enabling these men to avoid aggressive treatment which they may have otherwise undergone in the absence of prognostic testing. h Gleason score refers to a grading system which is used to predict prognosis of prostate cancer in conjunction with the American Joint Committee on Cancer TNM system of cancer staging. i Radical prostatectomy refers to the surgical procedure which removes the entire prostate, the seminal vesicles, and potentially some other nearby tissue. j Personal communication via email with head business representative for Genomic Health, Asia Pacific, 29 August 2014. Molecular testing for prostate cancer prognosis: November 2014 7

Ethical, social, cultural or religious considerations Men living in rural areas may be less able or less likely to access prognostic PCa testing, as there is currently evidence indicating disparity in PCa outcomes between men living in rural settings and men in urban areas. It is thought that men in rural areas have poorer outcomes than their urban counterparts due to comparative lack of awareness about primary care providers, distance from testing and treatment / tertiary services k, and lack of PCa education. 19 In a descriptive study using Australian population-based data collected between 1982 and 2009, Baade et al reported that mortality rates due to PCa among men aged 50 to 79 years in rural and urban locations were 56.9 and 45.8 deaths per 100,000, respectively (p<0.01); five year survival was 87.8 and 91.4 per cent for rural and urban men, respectively. Data also showed that PSA testing was accessed by fewer men living in rural areas (21,267 per 100,000) versus men in urban areas (24,606 per 100,000)(p<0.01); rural and urban rates of RP were 182.2 per 100,000 and 239.2 per 100,000, respectively (p<0.01). 20 Despite the possibility of greater difficulty experienced by rural men in accessing prognostic tests, the potential to avoid repeat biopsy may be an advantage outweighing the initial inconvenience of accessing a prognostic test. There is also a potential issue with the cost of the test, which, based on the US experience, is expensive. Depending on how the testing is funded, this could create inequality between those who can and cannot afford the test. No cultural or religious issues were identified. Evidence and Policy Safety and effectiveness Safety No studies reporting specifically on safety were identified, however prognostic molecular tests have the potential to reduce adverse events, both physical and psychological, associated with repeat biopsies. Effectiveness Klein et al 2014 Klein and colleagues assed the clinical validity of the Oncotype DX assay (Genomic Health, Inc) in a prospective cohort of 514 men with low to intermediate risk PCa, i.e. all were potential candidates for active surveillance based on clinical characteristics (level II prognostic evidence).however, for the purposes of the pre-specified analysis, only those who elected to have RP within six months of diagnosis were selected for the study. Median k Notable examples would include urology, oncology, radiation oncology. Molecular testing for prostate cancer prognosis: November 2014 8

and mean age were both 58 years (range 53-64 years). Logistic regression methods were used to test for an association between a Genomic Prostate Score (GPS), based on the expression of 12 PCa-specific genes, and pathologic stage and grade at RP. The authors also evaluated the potential clinical utility using decision-curve analysis, together with clinical and pathology characteristics. The Oncotype DX protocol used reverse transcription of RNA obtained from formalin-fixed, paraffin-embedded (FFPE) prostate biopsy tissue, with five reference genes as quality control for each RNA sample. Each sample reaction was performed in triplicate using preamplification of RNA to improve the yield from biopsy specimens. The GPS was scaled between 0 to 100, with higher scores indicating more aggressive disease. All gene expression analyses were performed blinded to clinical and pathological status of the patients. Samples from 395 men provided sufficient RNA for whom the required clinical data was also available for analysis. In the multivariate analyses, adjusting for significant clinical covariates, the GPS was mostly consistent in predicting high-grade and / or non-organ confined pathology, as were the clinical predictors of these outcomes. Table 4 shows the odds ratio for each 20-point increase in GPS across three models, adjusting for: (A) Cancer of the Prostate Risk Assessment (CAPRA) score; (B) National Comprehensive Cancer Network (NCCN) risk group; and (C) age, PSA level, clinical stage and biopsy Gleason score. Several of the reported p- values showed high significance for odds ratios with confidence intervals that indicate ranges including and very close to 1, possibly explained by combined effect of a large patient sample and use of continuous scales. The strongest effect size was observed for the comparison of NCCN intermediate versus NCCN very low, with little appreciable difference for the other comparisons. Importantly, statistical significance does not represent clinical significance, and given an R-squared statistic was not reported for any of the three models, judgment about the clinical use of these prediction models is limited. In the decision-curve analysis (graphical data only), the results suggested that the GPS would be expected to lead to fewer treatments of patients who would otherwise be subsequently found to have favourable pathology at RP, without an increase in the number of patients with adverse pathology left untreated. It was also concluded that within each clinical risk category, as per CAPRA or NCCN, GPS scores were distributed in a way such that they could differentiate risk over a wide range, and the authors further suggested that among individuals with a CAPRA score of 1 and estimated 77 per cent average likelihood of favourable pathology at RP, the estimate would be as high as 86 per cent with a GPS of 10 or as low as 66 per cent with a GPS of 40. Molecular testing for prostate cancer prognosis: November 2014 9

Table 4 Multivariate analyses of Genomic Prostate Score and clinical / pathology covariates for prediction of adverse pathology 21 Model Variable OR [95%CI] p-value A GPS (per 20 unit increase*) 2.1 [1.4, 3.2] <0.001 CAPRA (continuous**) 1.6 [1.2, 2.0] <0.001 B GPS (per 20 unit increase) 1.9 [1.3, 2.8] 0.001 NCCN low vs very low 1.8 [0.7, 4.6] 0.201 NCCN intermediate vs very low 3.6 [1.4, 9.2] 0.004 C GPS (per 20 unit increase) 1.9 [1.2, 2.8] 0.003 Age (continuous) 1.1 [1.0, 1.1] 0.004 PSA (continuous) 1.1 [1.0, 1.2] 0.002 Clinical stage (T2 vs T1) 1.6 [1.0, 2.5] 0.059 Biopsy Gleason score (3+4 vs 3+3) 1.7 [1.0, 2.9] 0.050 CI, confidence interval; CAPRA, Cancer of the Prostate Risk Assessment; GPS, Genomic Prostate Score; NCCN, National Comprehensive Cancer Network; OR, odds ratio; PSA, prostate specific antigen * 0 to 100 scale, where a higher number indicates more aggressive PCa ** 0 to 10 scale, where a higher number indicates higher risk of PCa progression T refers to the size and / or extent of a primary tumour, where T4 indicates the largest and / or most extensive tumour and T0 indicates no evidence of primary tumour The main strength of the study by Klein and colleagues was the prospective design, and the selection of outcomes that are relevant to the likelihood of treatment success. In addition, the ability to predict when active surveillance is appropriate, rather than focus on the likelihood of PCa-specific death (as reported elsewhere 22 ), has clinical application. Despite these study strengths, the reporting issues noted above make conclusions about the predictive ability of the test uncertain. In addition, the potential effect of tumour undersampling, common during standard biopsy procedures 23, cannot be ruled out. At this time there is insufficient evidence on whether or not the gene expression signature used by the Oncotype DX assay is consistent across the entire prostate, regardless of tumour distribution; in other words, whether or not the biopsy tissue available for analysis generates a GPS representative of the highest grade of tumour tissue in a prostate. Clinical interpretation of the assay would need to be approached cautiously. Cuzick et al 2012 A retrospective cohort study (level III-3 prognostic evidence) conducted in the United Kingdom investigated the ability of a cell cycle progression (CCP) signature to predict death from PCa. 22 The study author s methodology used the 46 genes which have since been adopted for the commercial assay, Prolaris (Myriad Genetics). The study was populated (n=442) from six UK-based cancer registries. Men under the age of 76 years were included in the study if they had clinically localised prostate cancer (diagnosed by needle biopsy between 1990 and 1996) that was conservatively treated. Molecular testing for prostate cancer prognosis: November 2014 10

Sample preparation involved the excision of tumour tissue from needle biopsy blocks embedded in paraffin (e.g. stored histopathology samples that had been retrospectively acquired), followed by total extraction of RNA and synthesis of complementary single strand DNA (cdna) using the High-Capacity cdna Archive Kit (Applied Biosystems, Foster City, CA, USA). The authors acknowledge that the quality of the RNA was not ideal, given the sample age, and this was reflected in failure to amplify all genes in several samples. A CCP score was calculated for each individual, where sufficient cdna was available. Of the 442 patients who provided adequate biopsy material for assay, 349 (79%) were able to have a CCP score calculated and had complete baseline and follow-up information (median time 11.8 years). The median CCP score was 1.03 (interquartile range 0.41-1.74), and in a univariate Cox proportional hazards analysis, a one-unit increase in CCP score was associated with a twofold increase in the risk of dying from PCa; hazard ratio (HR) of 2.02 (95%CI 1.62, 2.53) was estimated. The Kaplan-Meier plot indicated that an increasing CCP was associated with a higher 10-year death rate (see Table 5), although this was likely affected by the sample size for each CCP score category. Table 5 Kaplan-Meier estimates for prostate cancer death according to CCP score 22 CCP score n 10-year death rate, % 0 36 19.3 0<1* 133 19.8 1<2 114 21.1 2<3 50 48.2 >3 16 74.9 CCP, cell cycle progression *denotes greater than 0, less than 1, etc. A pre-specified Cox proportional multivariate analysis was performed which yielded hazard ratios for death from PCa, as predicted by CCP, Gleason score and PSA l. The hazard ratio reported for each variable was adjusted for the remaining variables. Results are shown in Table 6. l Extent of disease (<50%, 50<100%, 100%), age at diagnosis, clinical stage and hormone use were omitted as they were not found to vary significantly. Molecular testing for prostate cancer prognosis: November 2014 11

Table 6 Multivariate analysis for death from prostate cancer 22 Variable n HR [95%CI] p-value CCP score 349 1.65 [1.31, 2.09] <<0.05 Gleason score <7 7 >7 106 152 91 0.61 [0.32, 1.16] 1 (reference) 1.90 [1.18, 3.07] <<0.05 Log (1+PSA), ng/ml** 349 1.37 [1.05, 1.79] <0.05 *<< denotes p-values much less than 0.05, avoiding the need for excessive use of decimal placing **Nanograms per millilitre CCP, cell cycle progression; CI, confidence interval; HR, hazard ratio The authors suggested that these results, taken together with the finding that CCP score was not significantly correlated with other prognostic factors, indicates that the Prolaris assay will enable better identification of patients at very low risk of death from PCa, helping to select those who may be safely managed using active surveillance and avoiding aggressive treatment. The likelihood of whether such results are a basis for changes to clinical practice is examined in the study described below. The retrospective design is not a cause for great concern regarding the classification of death from PCa versus other causes, because misclassification would be expected to weaken any real association between CCP and PCa death. However, it should be noted that because death from PCa is rare (many men die of other causes after a PCa diagnosis) larger cohorts would be beneficial to provide greater certainty regarding the value of CCP as a clinical decision-making tool. Shore et al 2014 A recent cross-sectional survey (level IV evidence) 24 of fifteen US-based urologists provided information on the likelihood of change to clinical management for patients who are tested with the Prolaris assay. m Results of the multivariate analysis based on the urologist s responses are presented in Table 7. m The authors cite their clinical trial, not yet published, in which an unknown number of patients were tested. Molecular testing for prostate cancer prognosis: November 2014 12

Table 7 Multivariate modelling of ability of Prolaris assay to predict definite/possible change in treatment of prostate cancer patients, based on urologists responses 24 Covariate Method used for covariate modelling OR for change in treatment [95%CI]* p-value** Prolaris result vs expected result As expected Lower than expected Higher than expected Qualitative coding 1.00 (reference) [NA] 3.62 [1.65, 7.94] 6.46 [1.64, 25.45] <0.001* <0.001 <0.007 Actual treatment received RP Radiation ADT Active surveillance Radiation + ADT Other Qualitative coding 1.00 (reference) [NA] 2.45 [0.99, 6.10] 7.07 [1.63, 30.57] 3.07 [0.52, 18.11] 7.03 [1.45, 34.18] 2.44 [0.71, 8.37] <0.05* NS 0.014 NS 0.021 NS Lower CCP score Continuous 0.44 [0.27, 0.73] 0.001 * OR >1 indicates a greater likelihood of changing treatment; OR <1 indicates a reduced **Overall p value for a response other than the reference standard Unclear which clinical or other factors urologist expectations were based upon ADT, androgen deprivation therapy; CCP, cell cycle progression; CI, confidence interval; NA, not applicable; NS, not significant; OR, odds ratio; RP, radical prostatectomy Notably, the observed confidence intervals were wide indicating that the lack of an observed statistically significant result could be due to a lack of statistical power to find an effect. Only three per cent of urologists responded that test results would definitely lead them to change treatment, compared to 29 per cent who indicated a possible change to treatment. The authors explained that a patient s risk tolerance and preferences would strongly influence treatment decisions. It is therefore understandable that physicians would hesitate to respond in favour of a definite change to patient management. Economic evaluation No economic analyses were identified. Ongoing research A search of ClinicalTrials.gov identified two potentially relevant studies (Table 8Table 8). Searching the Australian and New Zealand Clinical Trials Registry online did not yield any relevant results. Molecular testing for prostate cancer prognosis: November 2014 13

Table 8 Ongoing studies investigating biomarkers or specific tests for determining prostate cancer prognosis and / or guiding clinical decision making, pre or post prostate cancer diagnosis Trial identifier, country Study design Status Study aim Estimated completion date NCT01350180 Canada Prospective cohort study Recruiting To assess the prognostic value of TMPRSS2-ERG gene fusion and PTEN deletion in high risk prostate cancer patients March 2015 NCT00966095 USA Case control study Unknown* To develop and validate a blood-based test that will predict prostate biopsy outcome as positive or negative for prostate cancer, thereby reducing the number of unnecessary prostate biopsies Unknown* The information has not been verified recently Other issues The investigation of PCa biomarkers and the development of genetic tests intended to guide PCa management is a rapidly evolving area or research. To some extent, the currently emerging biomarkers / tests may not be relevant in the future, and it is possible they will be replaced as new markers are discovered for clinical use. 25 The search conducted to identify evidence on this technology also identified a plethora of literature (seven meta-analyses) 26-32 investigating a variety of biomarkers / genes that are potentially associated with increased risk of PCa development, particularly increased familial risk, and early versus late onset of disease. However, none of the studies identified were related to new proprietary methods or commercial assays; rather, these studies described the investigation of a variety of genes that may or may not have a role in PCa using established generic methods of molecular / genetic analysis. Of particular note are two meta-analyses 33, 34 which explored the potential role of the HOXB13 gene in PCa. This gene appears to be a candidate for quantifying PCa risk, including familial risk and predicting late versus early onset, and for differentiating aggressive versus indolent PCa. Summary of findings The available clinical studies described two commercial tests, positioned as prognostic tools for used in PCa management. These purport to provide additional information for clinicians and patients to arrive at a decision for active surveillance or more radical treatment, with greater confidence afforded by traditional prognostic information alone. However, there is uncertainty about the clinical utility of these tests, even when taking into account the highest level of evidence available; it remains to be verified whether genetic expression of the unique gene panels involved are robust to heterogeneous sampling of prostate tissue at the time of biopsy. Also, the need for tissue which has previously been fixed for histological analysis is of some concern. This is the most obvious reason for the relatively high number Molecular testing for prostate cancer prognosis: November 2014 14

of patients for whom a valid test results could not be obtained. Together with dependence on reverse transcription of RNA, it would appear that this is a contributor to the potentially prohibitive cost of at least one of these assays for which pricing was available. HealthPACT assessment Molecular prognostic tests are designed to guide and manage the treatment pathway of patients; however there is currently uncertainty around the clinical utility of tests such as those described in this Brief. Based on a small study of clinician preferences and the uptake of similar tests for the prognosis of breast cancer, it would appear that there is hesitancy about the use of the technology in clinical practice, and it appears that changes to clinical management based on the prognostic information provided by these genetic tests are unlikely to occur. Therefore HealthPACT recommends that no further research be conducted on their behalf at this point in time. Number of studies included All evidence included for assessment in this Technology Brief has been assessed according to the revised NHMRC levels of evidence. A document summarising these levels may be accessed via the HealthPACT web site. Total number of studies 3 Total number of Level II studies: 1 Total number of Level III-3 studies: 1 Total number of Level IV studies: 1 Search criteria to be used (MeSH terms) Prostatic Neoplasms Biological makers Prostate Prognosis Text: multigene classifier, prostate cancer References 1. Bolton, E. M., Tuzova, A. V. et al (2014). 'Noncoding RNAs in prostate cancer: the long and the short of it'. Clinical cancer research : an official journal of the American Association for Cancer Research, 20 (1), 35-43. 2. Cheng, W., Zhang, Z.& Wang, J. (2013). 'Long noncoding RNAs: new players in prostate cancer'. Cancer letters, 339 (1), 8-14. 3. Choudhury, A. D., Eeles, R. et al (2012). 'The role of genetic markers in the management of prostate cancer'. European urology, 62 (4), 577-87. Molecular testing for prostate cancer prognosis: November 2014 15

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18. Sved, P. D., Gomez, P. et al (2004). 'Limitations of biopsy Gleason grade: implications for counseling patients with biopsy Gleason score 6 prostate cancer'. The Journal of urology, 172 (1), 98-102. 19. PCFA (2013). Annual Report 2012-2013, Prostate Cancer Foundation of Australia. [Internet]. PCFA. Available from: www.prostate.org.au/articlelive/attachments/1/prostatenews/pcfa_annual_repor t_2012-13.pdf [Accessed 10 September 2014 20. Baade, P. D., Youlden, D. R. et al (2011). 'Urban-rural differences in prostate cancer outcomes in Australia: what has changed?'. The Medical journal of Australia, 194 (6), 293-6. 21. Klein, E. A., Cooperberg, M. R. et al (2014). 'A 17-gene Assay to Predict Prostate Cancer Aggressiveness in the Context of Gleason Grade Heterogeneity, Tumor Multifocality, and Biopsy Undersampling'. European urology. 22. Cuzick, J., Berney, D. M. et al (2012). 'Prognostic value of a cell cycle progression signature for prostate cancer death in a conservatively managed needle biopsy cohort'. British journal of cancer, 106 (6), 1095-9. 23. Bjurlin, M. A., Meng, X. et al (2014). 'Optimization of Prostate Biopsy: the Role of Magnetic Resonance Imaging Targeted Biopsy in Detection, Localization and Risk Assessment'. The Journal of urology, 192 (3), 648-58. 24. Shore, N., Concepcion, R. et al (2014). 'Clinical utility of a biopsy-based cell cycle gene expression assay in localized prostate cancer'. Current medical research and opinion, 30 (4), 547-53. 25. Sartori, D. A.& Chan, D. W. (2014). 'Biomarkers in prostate cancer: what's new?'. Current opinion in oncology, 26 (3), 259-64. 26. Ding, X., Cui, F. M. et al (2012). 'Variants on ESR1 and their association with prostate cancer risk: a meta-analysis'. Asian Pacific journal of cancer prevention : APJCP, 13 (8), 3931-6. 27. Li, X., Huang, Y. et al (2011). 'Meta-analysis of three polymorphisms in the steroid-5- alpha-reductase, alpha polypeptide 2 gene (SRD5A2) and risk of prostate cancer'. Mutagenesis, 26 (3), 371-83. 28. Pan, Z. J., Huang, W. J. et al (2012). 'The GSTT1 null genotype contributes to increased risk of prostate cancer in Asians: a meta-analysis'. Asian Pacific journal of cancer prevention : APJCP, 13 (6), 2635-8. 29. Wang, F., Zou, Y. F. et al (2011). 'CYP17 gene polymorphisms and prostate cancer risk: a meta-analysis based on 38 independent studies'. The Prostate, 71 (11), 1167-77. 30. Wei, B., Xu, Z. et al (2012). 'RNASEL Asp541Glu and Arg462Gln polymorphisms in prostate cancer risk: evidences from a meta-analysis'. Molecular biology reports, 39 (3), 2347-53. 31. Wei, B., Zhou, Y. et al (2013). 'GSTP1 Ile105Val polymorphism and prostate cancer risk: evidence from a meta-analysis'. PloS one, 8 (8), e71640. Molecular testing for prostate cancer prognosis: November 2014 17

32. Xiao, L., Tong, M. et al (2013). 'The l58val/met polymorphism of catechol-o-methyl transferase gene and prostate cancer risk: a meta-analysis'. Molecular biology reports, 40 (2), 1835-41. 33. Huang, H.& Cai, B. (2014). 'G84E mutation in HOXB13 is firmly associated with prostate cancer risk: a meta-analysis'. Tumour biology : the journal of the International Society for Oncodevelopmental Biology and Medicine, 35 (2), 1177-82. 34. Shang, Z., Zhu, S. et al (2013). 'Germline homeobox B13 (HOXB13) G84E mutation and prostate cancer risk in European descendants: a meta-analysis of 24,213 cases and 73, 631 controls'. European urology, 64 (1), 173-6. Molecular testing for prostate cancer prognosis: November 2014 18