Does a screening digital rectal exam provide actionable clinical utility in patients with an elevated PSA and positive MRI?
Courtney M. Chang, Andrew G. McIntosh, Daniel D. Shapiro, John W. Davis, John F. Ward, Justin R. Gregg
Abstract
Objective: To define the value of a digital rectal exam (DRE) in the prostate-magnetic resonance imaging (MRI) era. Prostate MRI is increasingly used in men with elevated prostate-specific antigen (PSA) prior to biopsy. Methods: A retrospective study was performed in men with elevated PSA undergoing MRI followed by MRI fusion with systematic biopsy and men with elevated PSA/active surveillance with negative MRI followed by biopsy. Baseline clinicopathologic characteristics and DRE findings were collected. We examined performance of a positive DRE on sensitivity and specificity of diagnosing clinically significant prostate cancer (CSPC). Results: A total of 339 patients had elevated PSA and positive MRI followed by MRI fusion guided with systematic biopsy. Pre-biopsy DRE was documented in 286/339 patients, who were included in further analysis. About 81.6% positive, 78.7% questionable, and 55.8% negative DRE patients had CSPC. Positive DRE had 21.8% sensitivity and 91.3% specificity for CSPC. Positive or questionable DRE had 42.1% sensitivity and 81.5% specificity. Among 148 men with non-CSPC (GG1)-targeted biopsy, 28 had systematic biopsy with CSPC. About 5/28 had positive DRE and 8/28 had positive or questionable DRE. Twenty-seven patients were included who had elevated PSA/on active surveillance with negative MRI and biopsy done within 2 years. About 77.8% had negative, 7.4% had questionable, and 14.8% men had positive DRE. About 7.4% had CSPC and all had a negative DRE. Conclusions: Our study provides limited evidence for the value of a DRE. However, it does show occasional benefit in detecting GG2 or higher disease and given the lack of cost and side effects, should still be considered.