DRE is still a key diagnostic tool in assessing risk for prostate cancer

A new study just published in the Canadian Journal of Urology has reminded us of the importance of the digital rectal emamination (DRE) in the initial diagnosis of prostate cancer.

The paper by Palmerola et al. used chart reviews to look at data from 806 men, all evaluated for risk of prostate cancer at their Pennsylvania-based, academic medical center in the recent past. In other words, this was a contemprary cohort of patients (but the study time frame is not given in the paper’s abstract). All patients had received an ultrasound-guided biopsy (with 12 to 18 biopsy cores being taken), a DRE, and assessment of their PSA level.

The research team divided the men into those with a relatively “normal” PSA level or an “abnormal” PSA level by using age-specific PSA guidelines. They alspo classified the patients into two groups based on the DRE results: smooth, age-appropriate, asymmetric, or uniformly enlarged prostates were defined a “normal” and any type of nodule or induration on the prostate led to a classification as “abnormal.”

Here are the core study findings:

  • 516/806 patients (64 percent) had a normal DRE.
  • 290/806 patients (36 percent) had an abnormal DRE.
  • 306/806 patients (38 percent) were found to have prostate cancer.
  • Of these 306 patients,
    • 136 (44 percent) had an abnormal DRE.
    • 43 (14 percent) had an isolated DRE abnormality.
  • Of the 136 patients with an abnormal DRE and prostate cancer, 43 (31 percent) had a normal age-specific PSA value.
  • In this series of patients, for the detection of prostate cancer, an abnormal DRE was associated with
    • A sensitivity of 44 percent
    • A specificity of 68 percent
    • A positive predictive value (PPV) of 46 percent
    • A negative predictive value (NPV) of 67 percent
  • The type of DRE abnormality appeared to have no impact on the cancer detection rate.

Palmero et al. point out that, in this series, 43/806 men were diagnosed with prostate cancer (31 percent of the 306 men diagnosed) had an isolated abnormality found during DRE despite the fact that their PSA was within the normal, age-specific range.

The accuracy and importance of the DRE when carried out by primary care physicians is certainly debatable (because primary care physicians may not be sufficiently skilled to conduct a prostate DRE bwith sufficient skill). What is not debatable is the importance of the DRE when the patient is being evaluated by a urologist either prior to biopsy or as part of a full urological examination.

5 Responses

  1. Though it is unlikely to occur, it would be interesting to compare the aggressiveness of the DRE cancers to the PSA/biopsy findings. If it does not feel right, it probably isn’t.

  2. Dear Mike:

    Just because a urologist believes s/he can feel an abormality on DRE does not mean a patient has prostate cancer at all, nor does it imply anything about the aggressiveness of the cancer if it is cancer.

    A non-aggressive but palpable Gleason 6 tumor near to the capsule of the prostate may be way less aggressive that a non-palpable Gleason 8 tumor much deeper within the gland. Or what the doctor can feel may be some calcification or some other non-maligant abnormality.

    As the authors noted above, “The type of DRE abnormality appeared to have no impact on the cancer detection rate.” My guess would be that it also demonstrated no correlation to the Gleason score or to the risk level.

  3. My primary care doctor felt nothing. I was referred to a urologist due to a PSA of 4.1 at age 63 (by a substitute doctor). He felt “something abnormal” — didn’t think it would be cancer. But, I already had extracapsular extension by that time, as noted in the pathology report following a radical prostatectomy … Gleason 7 (3 + 4). Later I had radiation due to rising PSA.

    When we go in for surgery, etc., we are cautioned to look for “experience.” I think the same holds true for the DRE. Many of us owe our lives to a urologist with an experienced finger. My PSA was 4.1 in December 2000 and still 4.1 when re-tested (as indicated above) in December 2001. I’m glad to see a study confirming the importance of the DRE as a key diagnostic tool for prostate cancer.

  4. I have a palpable nodule with Gleason 6 cancer, <5% in one of 12 cores. I'm only 53, and very tempted to go with active surveillance, but the nodule and my age seem to indicate surgery is the smarter option for me. Any thoughts?

  5. Dear Hayekian:

    If you join our social network, it is designed to discuss issues like this in detail on an individual basis.,

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