br There are several limitations to the
There are several limitations to the current study. The sample size is modest due to the requirement that patient must have post-DRE urine supernatant available since we did not have sufficient quantities of urinary cell sediment available for miRNA analysis. Although the 3-marker panel requires additional validation, the main purpose of this study is the exploration of combining urinary epigenetic biomarkers for prediction of reclassification. We have suc-cessfully shown that assessing 2 different epigenetic markers from post-DRE urine are possible and predictive of CaP progression. However, further investigation is required for validation of these findings. Also, there is no consensus on an endogenous control for urinary miRNAs. Therefore, we opted to use a spike-in RNA as previously described to control for technical variability among samples during proc-essing and analysis. This may not account for endogenous MCC950 differences among patients. Lastly, as AS is a continuing process, we do not know if patients with high 3-marker panel score who were not reclassified were truly indolent. However, ongoing follow-up for these patients will address this issue. It is possible that some or all these patients may experience reclassification in the future.
We have shown that it is possible to detect miRNAs in the urinary supernatant and that combining urinary cell-free miRNA and sediment DNA methylation is a valid approach to identify AS patients at increased risk for reclassification. Once validated, our 3-marker panel, with its high NPV, could be used to identify AS patients who are unlikely to reclassify so that they may be monitored less intensely,
decreasing morbidity and costs, but further prospective con-firmation will be required.
 Scosyrev E, Wu G, Mohile S, Messing EM. Prostate-specific antigen screening for prostate cancer and the risk of overt metastatic disease at presentation: analysis of trends over time. Cancer 2012;118 (23):5768–76.
 Womble PR, Dixon MW, Linsell SM, Ye Z, Montie JE, Lane BR, et al. Infection related hospitalizations after prostate biopsy in a statewide quality improvement collaborative. J Urol 2014;191
 Nam RK, Saskin R, Lee Y, Liu Y, Law C, Klotz LH, et al. Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol 2010;183(3):963–8.
 Ladjevardi S, Auer G, Castro J, Ericsson C, Zetterberg A, Haggman M, et al. Prostate biopsy sampling causes hematogenous dissemina-tion of epithelial cellular material. Dis Markers 2014;2014:707529.
 Morash C, Tey R, Agbassi C, Klotz L, McGowan T, Srigley J, et al. Active surveillance for the management of localized prostate cancer: guideline recommendations. Can Urol Assoc J 2015;9(5-6):171–8.
 Hayes JH, Ollendorf DA, Pearson SD, Barry MJ, Kantoff PW, Stew-art ST, et al. Active surveillance compared with initial treatment for men with low-risk prostate cancer: a decision analysis. JAMA 2010;304(21):2373–80.
 Klotz L, Loblaw A, Sugar L, Moussa M, Berman DM, Van der Kwast T, et al. Active surveillance magnetic resonance imaging study (ASIST): results of a randomized multicenter prospective trial. Eur Urol 2019;75 (2):300–9.
 Liu RSC, Olkhov-Mitsel E, Jeyapala R, Zhao F, Commisso K, Klotz L, et al. Assessment of serum microRNA biomarkers to predict reclassification of prostate cancer in patients on active surveillance. J Urol 2018;199(6):1475–81.
 Wu C, Ding X, Li H, Zhu C, Xiong C. Genome-wide promoter meth-ylation profile of human testis and epididymis: identified from cell-free seminal DNA. BMC Genomics 2013;14:288.