THE "NEW" PROSTATE CANCER INFOLINK

Until very recently, all available guidelines for the early assessment of risk for prostate cancer clearly recommended the use of a physical examination (a digital rectal exam or DRE) in addition to a prostate-specific antigen (PSA) test. However, recent guidance from the American Cancer Society states only that, “The digital rectal exam (DRE) may also be done as a part of screening” — implying that this test is now (at best)  “optional” and may be completely unnecessary. (This guidance was last updated in June 2011.)

Many men are uncomfortable about having a digital rectal examination. As we have pointed out before, if this makes you uncomfortable, you may want to find out what is involved in a standard gynecologic examination for women each year. Having a DRE does not make you “gay.” It is just a physical exam like any other. However, people have the right to refuse any test they choose to, and The “New” Prostate Cancer InfoLink does not consider any test to be “obligatory.” One’s willingness to have any type of medical test is going to depend on all sorts of factors, including one’s degree of concern about individual risk for the condition in question (in this case prostate cancer).

It is worth noting, however, that other guidance documents do explicitly still recommend the use of the DRE as a method to assess risk for prostate cancer.  These documents include:

• The American Urology Association’s policy statement on the early detection of prostate cancer (last updated April 2009)
• The AUA Foundation’s guidance on prostate cancer screening for patients (last updated October 2009)
• The NCCN Guidelines for physicians on the early detection of prostate cancer (last updated June 2011)
• The NCCN Patient Guidelines on prostate cancer (last updated December 2010)

A new study by Chu et al. has recently suggested that the continued use of the DRE test may be particularly important to the early diagnosis of high-risk prostate cancer in obese men.

The multi-center study looked at 2,794 men undergoing initial prostate biopsy at three centers. The objective was to assess risk for prostate cancer that could be attributable to abnormal DRE findings across body mass index (BMI) categories.

The research team found that:

• Across all cohorts, obese men were less likely to have abnormal DRE findings than non-obese men.
• As BMI category increased, abnormal DREs became stronger predictors for
• Overall risk for prostate cancer in individual and combined BMI cohorts
• Risk of high-grade prostate cancer in the Italian and combined cohorts
• The inclusion of DRE data
• Significantly improved the predictive accuracy for detection of overall and high-grade prostate cancer among all obese men but not normal-weight men
• Nearly significantly improved the overall detection of prostate cancer in obese men with a PSA value < 4 ng/ml.

The authors of this study conclude that the predictive value of DRE data is dependent on obesity and is significantly higher among obese men than normal-weight men.

The “New” Prostate Cancer InfoLink would encourage any man who is having a PSA test to assess potential risk for prostate cancer to also ask for a DRE. Although this test is recognized as being a poor tool for predicationr of prostate cancer risk on its own, it can also be a good indicator for risk in some patients — particularly when there is no clear indication of risk from the PSA test results.

Having a DRE may well be “optional”today — but it is an option that it is well worth saying “Yes” to.

Filed under: Diagnosis, Risk | Tagged: digital rectal examination, DRE, guideline, PSA, risk |