Supplementary Figure S3. Distribution of real-world CSO predictions.

Supplementary Figure S1. Tests used along each diagnostic path, per positive individual.

Supplementary Figure S3. Mutational Profile by Cohort and Treatment Group. Distribution of key genomic alterations among patients with metastatic prostate cancer. (Left) Comparison of alteration frequencies between Cohort A and Cohort B. (Right) Comparison of alteration frequencies between treatment groups receiving Apa alone versus Apa + AAP. The most frequently altered genes included TP53, PTEN, SPOP, FOXA1, and AGO2.

PURPOSE:To accelerate prostate cancer drug development and identification of promising therapies, we aimed to establish a framework for a multimodal therapy (MMT) approach using intermediate endpoints of efficacy due to treatment. PATIENTS AND METHODS:In the MetaCURE trial, patients with untreated, high-risk localized (cohort A) or low-volume metastatic (cohort B) disease were randomized 1:1 to apalutamide or apalutamide and abiraterone acetate plus prednisone and androgen deprivation therapy for 10 months. Cohort B also received stereotactic body radiotherapy (RT) at 4 months. All patients underwent a radical prostatectomy (6 months ± postoperative RT at 10 months). The primary endpoint was pathologic complete response (pCR; no residual tumor) or minimal residual disease (MRD; ≤5 mm residual carcinoma), and the secondary endpoint an undetectable PSA following testosterone (T) recovery (T ≥ 150 ng/dL) at 24 months. RESULTS:A pCR or MRD was achieved in 4 [12%; 90% confidence interval (CI), 4%-26%] and 5 (15%; 90% CI, 6%-29%) patients in cohorts A and B, respectively. Undetectable PSA and T-recovery at 24 months occurred in 20 (61%; 95% CI, 42%-77%) patients in cohort A and 13 (39%; 95% CI, 23%-58%) patients in cohort B. CONCLUSIONS:MMT for newly diagnosed high-risk localized and low-volume metastatic prostate cancer is feasible, safe, and provides a rapid readout of efficacy. A significant proportion of patients, including those with oligometastatic disease, maintained an undetectable PSA following T-recovery at the 2-year endpoint. These results have informed the design of an adaptive trial using MMT on a continuous basis to prioritize effective approaches for further study.

Supplementary Figure S2. Effective reduction in WBI for retesting over all PPV and CSO accuracy values, using maximal imaging in the CSO driven pathway and point estimates.

Efficient strategies for diagnostic evaluation of multicancer early detection (MCED) tests are needed to distinguish true-positive from apparent false-positive (FP) test results. Extending a previously published model, we compared 2 post-positive MCED test diagnostic evaluation strategies: a cancer signal origin (CSO)-guided approach with repeat MCED testing to resolve FPs (CSO-retest strategy) versus a whole-body imaging (WBI)-only strategy employing whole-body computed tomography (WBCT) followed by positron emission tomography (PET)/CT scans to resolve FPs. Analyses evaluated 2 scenarios with different test performance characteristics and specificities, with a number of imaging procedures required and radiation exposure for each strategy as outcomes measures. The CSO-retest strategy resulted in 10- to 20-fold reduction in the use of WBCT/PET/CT versus the WBI-only strategy across both scenarios. A 1% reduction in WBI-only test specificity from 99.5% to 98.5% led to a >3-fold increase in FPs and more than doubled WBI requirements. Estimated radiation exposure for initial diagnostic evaluations for the CSO-retest strategy were 0 to 26.1 millisieverts (mSv), whereas all initial diagnostic evaluations for the WBI-only strategy carried an obligatory exposure of 28 mSv. For the 50% of CSO predictions requiring initial imaging, dose exposure ranged from 0.28 mSv (mammography) to 26.1 mSv (triple-phase renal CT), or 1% to 93% of the dose required for the WBI-only strategy. The results suggest that CSO-guided diagnostic strategies incorporating targeted workups and MCED retesting markedly reduce radiation exposure compared with a WBI-only approach, and small changes in MCED test specificity lead to significantly more unnecessary workups. PREVENTION RELEVANCE:Using MCED tests with molecular CSO prediction and MCED retesting to resolve apparent FPs enables targeted evaluations via existing diagnostic pathways, reducing radiation exposure compared with MCED tests without this feature that rely on WBI. These findings have important implications for MCED implementation including safety, cost, and accessibility.

Context:Whether circulating testosterone, dihydrotestosterone, and estradiol levels or testosterone replacement therapy (TRT) affects the risk of COVID-19 and whether COVID-19 affects response to TRT remains unknown. Objective:The study evaluated whether baseline testosterone, dihydrotestosterone, and estradiol levels or TRT are associated with risk of developing COVID-19 and whether COVID-19 affects treatment response to TRT. Methods:Among 5204 men, aged 45 to 80 years, with hypogonadism in the TRAVERSE trial, 379 developed COVID-19. We compared baseline and on-treatment hormone levels, and safety and efficacy in participants with and without COVID-19 diagnosis. Results:Neither baseline nor on-treatment testosterone, estradiol, and dihydrotestosterone levels prior to COVID-19 differed significantly between men with and without COVID-19 diagnosis. Incidence of COVID-19 was similar in participants randomized to TRT or placebo groups (3-year Kaplan-Meier incidence 8.0% in TRT and 8.6% in placebo group, P = .823). Incidences of COVID-19-related hospitalizations (38.5% vs 32.8%, P = .222) and deaths (12.8% vs 8.9%, P = .247) were similar in the TRT and placebo groups. Changes in hypogonadal symptoms, libido, energy, and hemoglobin/hematocrit in response to TRT were attenuated in testosterone-treated men who developed COVID-19. Incidences of major adverse cardiovascular events, venous thromboembolism, and acute kidney injury were similar in those with COVID-19 diagnosis and those without. Conclusion:In men with hypogonadism and cardiovascular disease (CVD) or increased risk of CVD, baseline and pre-COVID-19 on-treatment testosterone, dihydrotestosterone, and estradiol levels were similar in those who developed COVID-19 and those who did not. TRT did not affect the risk of COVID-19. COVID-19 attenuated the treatment response to TRT.

In recent years, there has been a surge in the development of new, blood-based, single- and multi-cancer detection tests (SCD and MCD), which can detect cancer signals prior to the onset of symptoms or clinical diagnosis of cancer. Recognizing the need for consensus definitions and standardized evidence development frameworks for these new types of blood tests, the Early Detection and Screening Working Group of the Blood Profiling Atlas in Cancer Consortium, a collaborative initiative dedicated to advancing standards and best practices, developed and published a lexicon for liquid biopsy-based SCD and MCD tests. During the preparation of the lexicon, the group recognized challenges with regard to the definitions of key terms and concepts describing absolute and RR assessment of intended use populations for cancer screening tests. This article captures the working group's discussions on (i) risk assessment including considerations for adapting historical SCD risk terminology like "average risk" and "elevated risk" to MCD tests, (ii) the implications of this terminology for describing intended use populations, and (iii) the existing gaps in evidence for determination of absolute risks.

Relationship between PPV and diagnostic tests to save a life for post-CSO-directed workups, shown stratified by cancer signal origin, colored by sex

OBJECTIVE To compare the rate of diagnosing clinically significant prostate cancer (csPCa) in men with elevated prostate-specific antigen (PSA) stratified by baseline IsoPSA Index, thus assessing IsoPSA's intermediate-term predictive ability for csPCa. MATERIAL AND METHODS Single-center retrospective review of consecutive patients (n = 1578) who underwent IsoPSA testing from November 2016-August 2022. Data dichotomized into patients with low (<= 6) and high IsoPSA Indices (> 6). Most recent subsequent IsoPSA and PSA tests, prostate biopsy, and magnetic resonance imaging (MRI) collected. Time-to-event Kaplan-Meier estimates generated for the risk of csPCa stratified by baseline IsoPSA Index. RESULTS Among 541 patients with initial low IsoPSA Indices (<= 6), 23 (4.3%) were diagnosed with csPCa on a subsequent biopsy. Also, among these 541 patients, 204 had an MRI, of which 48/204 (23.5%) showed suspicious lesions (PIRADS >= 4). Among 1037 patients with initial high IsoPSA Indices, 366 (35.3%) were diagnosed with csPCa on a subsequent biopsy. Also, among these 1037 patients, 712 had an MRI, of which 342/712 (48.0%) showed suspicious lesions (PIRADS >= 4). After 12, 24, and 30 months, respectively, the risk of developing csPCa was 0.4% (95% CI 0.1%-1.6%), 2.5% (1.4%-4.4%), and 6.3% (4%-9.6%) in patients with low IsoPSA Indices, compared to 5.9% (4.6%-7.6%), 31.7% (28.3%-35.4%), and 49.5% (45.3%-53.9%) in patients with high IsoPSA Indices. Limitations include the retrospective review of prospectively collected data and unknown true csPCa rates as not all patients were biopsied. CONCLUSION The risk of developing csPCa was smaller in patients with initial low vs high IsoPSA Indices over the ensuing 30 months, which supports using IsoPSA to safely avoid follow-up testing. UROLOGY 201: 69-75, 2025. (c) 2025 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

LPS is essential in most Gram-negative bacteria, but mutants of several species have been isolated that can survive in its absence. Caulobacter crescentus viability in the absence of LPS is partially dependent on the anionic sphingolipid ceramide diphosphoglycerate (CPG2). Genetic analyses showed that ccna_01210, which encodes a nucleotidyltransferase, is required for CPG2 production. Using purified recombinant protein, we determined that CCNA_01210 (CpgD) is a phosphoglycerate cytidylyltransferase that uses CTP and phosphoglycerate to produce CDP-glycerate, which we hypothesize is the phosphoglycerate donor for CPG2 synthesis. CpgD had optimum activity at pH 7.5 to 8 in the presence of magnesium. CpgD exhibited Michaelis-Menten kinetics concerning 3-phosphoglycerate, D-2-phosphoglycerate, and L-2-phosphoglycerate. By contrast, CTP followed Michaelis-Menten kinetics in the presence of 3-phosphoglycerate and L-2-phosphoglycerate but exhibited cooperativity with D-2-phosphoglycerate. Overall, D-2-phosphoglycerate was the preferred substrate in vitro. The characterization of this enzyme uncovers another step in the pathway toward CPG2 synthesis.

Blood-based multicancer early detection (MCED) tests represent a new approach for cancer detection. To gain insights into the utility of various approaches of evaluating a cancer signal detected (CSD) test result, we evaluated diagnostic journeys of a subset of 6,662 participants in PATHFINDER who had a CSD on both an initial and refined version of an MCED test that also provided a prediction of cancer signal origin (CSO). We sought to determine whether CSO prediction-guided diagnostic evaluations led to diagnostic resolution; whether participants with known risk factors for cancer beyond age alone and a negative initial diagnostic evaluation had a cancer diagnosis during study follow-up; the utility of whole-body imaging in reaching diagnostic resolution; and differences in the diagnostic journeys needed to reach diagnostic resolution for both true- and false-positive results. Of the 39 participants in this analysis, 82% (32/39) achieved diagnostic resolution after the initial evaluation, including 78% (25/32) who reached resolution specifically with a CSO prediction-directed workup. Eighteen percent (7/39) required additional evaluation for persistent clinical suspicion of cancer, all of whom achieved resolution (3 with and 4 without cancer). Whole-body imaging contributed to diagnostic resolution in only 49% of CSD cases. Approximately 90% of true- and false-positive cases had imaging tests; more true positives versus false positives (81.0% vs. 38.9%) had nonsurgical and/or surgical procedures. In conclusion, CSO prediction-directed evaluations enabled diagnostic resolution for most participants, although some with negative initial evaluations but persistent suspicion of cancer required additional testing.Prevention Relevance: MCED testing has the potential to increase detection of cancer at earlier stages. As MCED testing is a new technology, there are few data on the diagnostic journeys patients undergo following testing. We observed that for most patients, CSO prediction-directed workups were efficient, leading to diagnostic resolution after initial evaluation.

PURPOSE:Artificial intelligence (AI) tools that identify pathologic features from digitized whole-slide images (WSIs) of prostate cancer (CaP) generate data to predict outcomes. The objective of this study was to evaluate the clinical validity of an AI-enabled prognostic test, PATHOMIQ_PRAD, using a clinical cohort from the Cleveland Clinic. METHODS:We conducted a retrospective analysis of PATHOMIQ_PRAD using CaP WSIs from patients who underwent radical prostatectomy (RP) between 2009 and 2022 and did not receive adjuvant therapy. Patients also had Decipher genomic testing available. WSIs were deidentified, anonymized, and outcomes were blinded. Patients were stratified into high-risk and low-risk categories on the basis of predetermined thresholds for PATHOMIQ_PRAD scores (0.45 for biochemical recurrence [BCR] and 0.55 for distant metastasis [DM]). RESULTS:The study included 344 patients who underwent RP with a median follow-up of 4.3 years. Both PathomIQ and Decipher scores were associated with rates of biochemical recurrence-free survival (BCRFS; PathomIQ score >0.45 v ≤0.45, P <.001; Decipher score >0.6 v ≤0.6, P = .002). There were 16 patients who had DM, and 15 were in the high-risk PathomIQ group (Mets Score >0.55). Both PathomIQ and Decipher scores were associated with rates of metastasis-free survival (PathomIQ score >0.55 v ≤0.55, P <.001; Decipher score >0.6 v ≤0.6, P = .0052). Despite the low event rates for metastasis, multivariable regression demonstrated that high PathomIQ score was significantly associated with DM (>0.55 v ≤0.55, hazard ratio, 10.10 [95% CI, 1.28 to 76.92], P = .0284). CONCLUSION:These findings independently validate PATHOMIQ_PRAD as a reliable predictor of clinical risk in the postprostatectomy setting. PATHOMIQ_PRAD therefore merits prospective evaluation as a risk stratification tool to select patients for adjuvant or early salvage interventions.

Overall PPVs modeled for each CSO prediction by age. Cancer incidence increases with age, and in this model, FPs are constant across age groups, so the PPV increases with age. Importantly, despite minor changes in relative incidence of cancer types with age, the PPV still indicates a noticeable risk of cancer within each age range. The dashed line represents a threshold PPV of 7%, typically justifying workup.

PURPOSE:Cancer survivors are at risk for recurrence and second primaries, yet often lack clear guidance for long-term surveillance. METHODS:We assessed the performance of a blood-based multicancer early detection (MCED) test in 1,609 survivors who participated in PATHFINDER, a prospective study of adults without current suspicion of cancer. RESULTS:Previous cancers included breast (47%), melanoma (10%), prostate (9%), colorectal (4%), and lymphoma (4%). Average time since diagnosis was 11.2 years, and a cancer signal was detected in 1.2% (20/1,609). Ten new cancer diagnoses occurred: 5 second primaries (stage I uterine, stage II sarcoma, stage III ovarian, stage IV lymphoma, and stage IV colorectal) 8-15 years after original diagnosis and five recurrences (breast cancer) 4-11 years after original diagnosis. Test performance metrics were similar in those with and without previous cancer history. CONCLUSION:These findings highlight the potential of MCED tests to address a significant unmet need in long-term surveillance of survivors.

Diagnostic tests per lives saved for CSO-directed workups, age bands covering 50-80 years, incidence as default for SEER (“any” smoking status as smoking status is unknown in SEER)

Extrapolated prevalence performance numbers

State transition diagram for the interception model, expanded to show the five possible trajectories of cancer detectability by stage, and the potential detection by MCED or by usual care