EAU 2017: A positive digital rectal examination (DRE) does not predict prostate cancer in 45 yr old men - results from the German risk-adapted PCA Screening Trial (PROBASE)

London, England (UroToday.com) Digital rectal examination (DRE) has been a standard part of the urologists’ exam for many generations, often cited to be a key component of the screening for prostate cancer. Meta-analyses have reported abnormal DRE findings in 5-20% and positive predictive values (percent of positive biopsies/total positive DRE) of 5-33% in screening populations (Mistry et al. 2003). However, these historical study populations predominantly included older men. However, the authors of this study aimed to examine its efficacy and predictive value in men 45 year old (younger men). To answer this question, they utilized an ongoing clinical trial, PROBASE, an ongoing German risk adapted prostate cancer screening study.

In this study, men are normalized to either routine screening with PSA at age 45 or delayed screening starting at age 50. However, in the delayed screening at age 50, they are offered a DRE at age 45 – if abnormal, they are offered a biopsy.

The sequencing is detailed below:

chart 8

Overall 21,816 45 yr old men have been enrolled until 30th September 2016. In trial arm A and B, 10,914 and 10,902 men were randomized, respectively. Arm B was the delayed surveillance arm.

The rate of men complying with the offered DRE in arm B was 34.5% (3,761 out of 10,902). Overall, 42 out of these 3,761 men (1.1%) had a suspicious DRE finding. PSA values are available from 35 men with suspicious DRE. The large majority of men with a positive DRE had low PSA values with a median value of 0.72 ng/ml (interquartile range 0.57-1.14).

A flowchart / piechart demonstrates the breakdown:

chart 8b

Of these 42 men, 23 biopsies were performed – only 1 patient had a positive biopsy! Final pathology was Gleason 3+3=6 disease. Thus, the positive predictive value of a positive DRE was 4.3% (1 out of 23).

As such, the authors conclude that routine DRE screening in 45-year-old male subjects to unnecessary further diagnostics. Due to this unfavorable cost/benefit ratio, DRE for PCa early detection should be critically discussed in young men.

In their practice, the presenting author notes that they have moved primarily to MRI and PSA for active surveillance, indicating that their confidence in DRE is quite low. I would tend to agree with their opinion.

Speaker: C. Arsov

Co-Author(s): Becker N., Herkommer K., Gschwend J., Imkamp F., Kuczyk M., Hadaschik B., Hohenfellner M., Siener R., Kristiansen G., Antoch G., Albers P.

Institution(s):
1. University of Düsseldorf, Dept. of Urology, Düsseldorf, Germany
2. German Cancer Research Center Heidelberg, Division of Cancer Epidemiology (C020), Heidelberg, Germany
3. Technische Universitaet Muenchen, Dept. of Urology, Munich, Germany
4. Hanover Medical School, Dept. of Urology, Hanover, Germany
5. University of Heidelberg, Dept. of Urology, Heidelberg, Germany
6. University of Bonn, Dept. of Urology, Bonn, Germany
7. University of Bonn, Dept. of Pathology, Bonn, Germany
8. University of Düsseldorf, Dept. of Diagnostic and Interventional Radiology, Düsseldorf, Germany

Written By: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto
Twitter: @tchandra_uromd

at the #EAU17 - March 24-28, 2017- London, England
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