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Thread: Digital Rectal Examination Remains a Key Prognostic Tool for PCa (Review)

  1. #1

    Digital Rectal Examination Remains a Key Prognostic Tool for PCa (Review)

    Digital Rectal Examination Remains a Key Prognostic Tool for Prostate Cancer: A National Cancer Database Review [2019, JNCCN, Review, Full Text]

    Abstract

    Background: Prostate cancer clinical stage T2 (cT2) subclassifications, as determined by digital rectal examination (DRE), are a historic method of staging prostate cancer. However, given the potential discomfort associated with prostate examination and the wide availability of other prognostic tests, the necessity of DRE is uncertain. This study sought to determine the prognostic value of the prostate cancer cT2 subclassifications in a contemporary cohort of patients. Methods: The National Cancer Database was used to identify a cohort of men with high-risk clinical T2N0M0 prostate cancer treated with external-beam radiotherapy and androgen deprivation therapies ± surgery from 2004 to 2010. We assessed overall survival from a landmark time of 10 months using Kaplan-Meier and log-rank test analysis. A multivariate proportional hazards model was used to estimate the simultaneous effects of multiple factors, including cT2 subclassification and other well-established prognostic indicators of overall survival in prostate cancer. Results: A total of 5,291 men were included in the final analysis, with a median follow-up of 5.4 years. The cT2a, cT2b, and cT2c subclassifications demonstrated increasing hazard ratios of 1.00 (reference), 1.25 (95% CI, 1.07–1.45; P=.0046), and 1.43 (95% CI, 1.25–1.63; P<.0001), respectively, reflecting a higher probability of death with each incremental increase in cT2 subclassification. This finding was independent of other known prognostic variables on multivariate analysis. Conclusions: Results show that cT2 subclassifications had independent prognostic value in a large and contemporary cohort of men. cT2 classification remains an important, low-cost prognostic tool for men with prostatic adenocarcinoma. The clinical relevance of this test should be appreciated and accounted for by providers treating prostate adenocarcinoma.
    From the Full Text:

    Demonstration of the prognostic significance of the cT2 subclassifications has important clinical and cost-effectiveness implications. In an era in which physicians have come to rely on new and expensive diagnostic tests, such as multiparametric MRI and genomic prognostics assessments, it is critical to highlight that traditional DRE remains a simple and valuable clinical tool for predicting prostate cancer outcome. Literature on how MRI compares with DRE for T2 subclassification is sparse, but MRI has been shown to outperform DRE in localization of cancer within the gland.20 Data show that for clinical detection of T3 disease, subsequently confirmed on pathology, MRI has higher sensitivity than DRE; however, DRE has higher specificity.21 Given the inexpensive, efficient, and widely available nature of DRE, we feel this physical examination component remains critical for oncologists to consider in evaluation of patients with prostate cancer.

    Unfortunately, studies suggest that DRE is an underused component of the physical examination, and may not be emphasized as a critical skill in the training of future physicians.12–14 We believe that DRE should continue to be performed and documented as a key component of the physical examination for all patients with prostate cancer and should be recognized as a low-cost prognostic tool for men with adenocarcinoma of the prostate. DRE also continues to have an important role in screening for prostate cancer, because abnormal findings in conjunction with abnormal PSA levels have been shown to increase detection of clinically significant prostate cancer.22
    It is often pointed out that the retina is the only part of the central nervous system that can be directly seen and examined. I see an analogy in the DRE for the prostate: while only a small part of it can be felt, why pass up any advantages that can afford? I doubt there are many uros who have eliminated the DRE; so why should other docs who provide the only uro-genital screening for their patients skip it? (The DRE can also detect rectal cancer.)

    All those whose clinically significant pT2 cancer was caught by a DRE raise your hands. If I remain cancer-free, I will have to attribute it in large part to early DRE detection and diagnosis.

    Djin (raising my hand)
    Last edited by DjinTonic; 07-19-2019 at 04:25 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3 -
    2013 TURP (90→30 g) path neg. then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day check)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015

  2. #2
    Top User
    Join Date
    Aug 2016
    Posts
    1,653
    No, but my internist made it a part of my annual exam in accordance with current guidelines meaning he went to every three years instead of annually (which he had been doing) when that change came out. That change was right in the middle of my critical diagnoses time period. Uro's DRE right before surgery showed only enlargement consistent with no future adverse conditions after RP.

    It is critically important for the simple procedure it is. I remember an attempt to promote it as a self exam down to instructions on how to go about it while you were in the shower. It was promoted to be an important tool much like women's breast self exam. It never caught on, obviously.
    Born 1953
    family w/PCa; grandfather, 3 brothers
    07-12-04 PSA 1.90
    07-10-06 PSA 2.02
    08-30-07 PSA 3.20
    12-01-11 PSA 5.69 Internist recommends urologist, I say no
    05-16-12 PSA 4.76 manipulate w/diet & supplements
    12-11-12 PSA 5.20, Health system changes to 3 years on testing
    03-07-16 PSA 7.20 Internist adamant on urologist
    DRE smooth, enlarged
    03-14-16 TRUS biopsy-prostatic adenocarcinoma 1%-60% across 8 of 12 samples, Gleason 3+3=6
    03-31-16 MRI pelvis w/o dye
    05-04-16 DaVinci prostatectomy, nerve sparing, Dr. Kent Adkins - recommend
    Final Path; weight 65g, lymph nodes, seminal vesicles, capsule, margin all negative, Gleason 3+4=7, Tumor volume 35%, +pT2c
    Catheter out - 16 days
    Incontinence at 6mos is minimal – no pad
    Cialis 3x/wk & Viagra on occasion
    Begin self-injection needle therapy for erections, stop after 6 due to onset of Peyronie’s
    Erections 100% - 14 months
    5-21-19 PSA <0.02, Zero Club 3.5 years

  3. #3
    I agree that if you are in family medicine and actually know what you are feeling for you could be a man's only medical contact that has a chance of catching PCa. Presumably however regular PSAs would indicate an issue so I have mixed thoughts about this.

    Over the course of my journey, I had more DRE's than I care to remember including by a couple of different doctors at Memorial Soan-Kettering Cancer Center. One was an hour before surgery and no one ever felt anything. I guess I can make allowance for that since it took 3 biopsies to finally find it and then only 2 of 12 cores were positive. I am certainly glad I did not have to wait for a positive DRE but I guess it would be better than waiting for bone pain to tell you something was wrong.
    History: age 53 It took 3 biopsies (34 cores) to find 2 cores 4+4 Gleason 8
    Lap RP at MSKCC Apr 2004, age 54 All neg margins, nodes & structures. (T2a).
    Post RP PSA: <.1 until Feb, 08 (46 mos) PSA 0.1 - I then got sensitive tests -> 2008: Feb 0.06,
    May-08 0.09 - Jun-08 0.10, - Aug-08 0.10, - Nov-08 0.15
    SRT Dec-2008 ---Post SRT PSA 2009, Feb-09 0.10, May-09 0.09, Aug-09 0.06, Dec-09 .04, - 2010 Mar-09 0.04, 2011 .02, 2012 .02,
    STARTED UP Feb 2014-0.06, Jul-2015 0.10, Oct-2015 0.10, Feb-2016 0.15, Jun-2016 0.17, Dec-2016 0.25, Jan-2019 0.74, Jun -2019 0.72
    Aug 2018 Auximin scan - nothing
    Had an inflatable penile implant 2018 for ED. Best decision ever https://www.peyroniesforum.net/index...oard,56.0.html

  4. #4
    Top User
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    Aug 2016
    Posts
    1,653
    He was also doing PSA annually and that switched to 3 years as well during that period. I was a denial and delayer and manipulating my PSA. So, the switch to 3 year screening played to my demons.

  5. #5
    What is the proper technique for DRE?

    My PCP was giving it to me for years with me lying on my side.

    However, the urologist performs it with the patient standing and bent over.
    Nov 2013 PSA 4.2 Biopsy Jan 2014- 1 core positive, 20% Gleason 6, doctor highly reco'ed robotic RP - 2nd opinion at UPMC April 2014, put on active surveillance. 2nd biopsy Feb 2015, results negative. PSA test Feb 2016, 3.5. 3rd Biopsy Feb 2016. 3 positive cores less than 5%, Gleason 6. Octotype DX done April 2016, GPS Score of 24--rated "Low risk". PSA test 8/2016, 3.2. PSA test 1/2018 2.2 (after 7 months of proscar) PSA test 7/2018 2.3, PSA test 7/2019 2.0


    DOB 1956, in Pittsburgh, USA

  6. #6
    Quote Originally Posted by Southsider View Post
    What is the proper technique for DRE?

    My PCP was giving it to me for years with me lying on my side.

    However, the urologist performs it with the patient standing and bent over.
    The are multiple positions that can be used. My uro has the patient standing bent forward from waist, forearms on exam table. The important thing is that whoever does it buys you dinner first.

  7. #7
    Once when I complained that it was not exactly my favorite exam the Uro said, "trust me, I have the worst end of this deal." I had to agree so I never complained after that
    History: age 53 It took 3 biopsies (34 cores) to find 2 cores 4+4 Gleason 8
    Lap RP at MSKCC Apr 2004, age 54 All neg margins, nodes & structures. (T2a).
    Post RP PSA: <.1 until Feb, 08 (46 mos) PSA 0.1 - I then got sensitive tests -> 2008: Feb 0.06,
    May-08 0.09 - Jun-08 0.10, - Aug-08 0.10, - Nov-08 0.15
    SRT Dec-2008 ---Post SRT PSA 2009, Feb-09 0.10, May-09 0.09, Aug-09 0.06, Dec-09 .04, - 2010 Mar-09 0.04, 2011 .02, 2012 .02,
    STARTED UP Feb 2014-0.06, Jul-2015 0.10, Oct-2015 0.10, Feb-2016 0.15, Jun-2016 0.17, Dec-2016 0.25, Jan-2019 0.74, Jun -2019 0.72
    Aug 2018 Auximin scan - nothing
    Had an inflatable penile implant 2018 for ED. Best decision ever https://www.peyroniesforum.net/index...oard,56.0.html

  8. #8
    Experienced User
    Join Date
    Feb 2019
    Posts
    90
    As long as he doesn't have a hand on each shoulder when giving the exam you shouldn't complain. I used to think, Yess when the doc didn't probe me but now am telling others if you didn't get probed you better be asking why.
    DOB 9/6/59
    1/21/19 PSA 7.5.
    Bx 2/8/19
    G7 (4+3), 60% pattern 4
    Reffered to Mayo Clinic Rochester, MN
    RALP 4/3/19 Igor Frank
    Adenocarcinoma G8 (4+4)
    Mass (3 x 1.5 x 1.2 cm)
    Tumor involves both seminal vesicles.
    Extraprostatic soft tissues, SM, EPE, BNI, LNI (24): neg., SVI+
    pT3b pN0 Mx
    7/19 3mo PSA 0.74
    7/24 retest PSA 0.78
    8/14 3 mo. Lupron inj.

  9. #9
    Experienced User
    Join Date
    Sep 2017
    Posts
    67
    Quote Originally Posted by Southsider View Post
    What is the proper technique for DRE?

    My PCP was giving it to me for years with me lying on my side.

    However, the urologist performs it with the patient standing and bent over.
    Did you glance back to confirm that your Urologist was in fact the person behind you?

  10. #10
    Quote Originally Posted by mostth View Post
    As long as he doesn't have a hand on each shoulder when giving the exam you shouldn't complain. I used to think, Yess when the doc didn't probe me but now am telling others if you didn't get probed you better be asking why.
    My exact sentiment.

    However, despite having a very large prostate (would have been found during a DRE), all of my DRE have been fine....no bumps or abnormalities.

    Defensive medicine, know it....practice it. Doctors aren't always on point.

 

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