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Digital rectal examination in primary care is important for early detection of prostate cancer: a retrospective cohort analysis study

Br J Gen Pract. Dec 2014; 64(629): e783–e787.

Br J Gen Pract. 2014 Dec;64(629):e783-7

Abstract

BACKGROUND:

Currently, there is no standardised screening for prostate cancer in Europe. Assessment of risk is opportunistically undertaken in consultation with the GP or urologist. Evaluation of the prostate gland consists of a prostate-specific antigen (PSA) serum level and a digital rectal examination (DRE) of the gland. DRE is an essential part of the assessment that can independently predict prostate cancer in the setting of a normal PSA level.

AIM:

To evaluate the clinical usefulness of the DRE in general practice and urology clinics, and to ascertain its positive predictive value and sensitivity.

DESIGN AND SETTING:

A retrospective analysis study of a cohort of Irish men who underwent TRUS guided biopsy of the prostate in a single Irish tertiary referral centre, despite a normal PSA level. Patients were identified from a Rapid Access Prostate Clinic patient database. Pathological biopsy results were correlated with clinical DRE findings.

METHOD:

Patient demographics, PSA levels, and DRE findings from a prospectively established database and hospital data systems from May 2009 to October 2013 were analysed.

RESULTS:

Of 103 men referred over a 53-month period with a normal age-adjusted PSA level, 67% were referred on the basis of an abnormal DRE alone. Thirty-five per cent of males with a normal PSA had prostate cancer. DRE alone had a sensitivity and specificity of 81% and 40% respectively in diagnosing prostate cancer, with a positive predictive value of 42%. Seventy-six per cent of these men had high-grade disease.

CONCLUSION:

DRE is a key part of the assessment for prostate cancer. It can independently identify patients at risk of prostate cancer, with a substantial proportion of these having clinically significant disease requiring treatment. This study reinforces the importance of DRE in the primary care setting in the assessment for prostate cancer. An abnormal DRE, even in the setting of a normal PSA level, necessitates referral.

© British Journal of General Practice 2014.

KEYWORDS:

digital rectal examination; opportunistic screening; primary care; prostate cancer

Comment from Henk van der Poel: In this study from Ireland the incidence of prostate cancer in men with a normal serum PSA but suspicious DRE by the general physician was 65%. High grade prostate cancer was found in 76% of these men. Larger cancers seem to be detected more readily using DRE. However, cure rates of these cancers are limited, and it remains unclear whether survival of men with DRE-detected high risk cancers with a normal PSA is significantly altered by treatment.

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