Herrera-Caceres Jaime O, Wettstein Marian S, Goldberg Hanan, Toi Ants, Chandrasekar Thenappan, Woon Dixon T S, Ahmad Ardalan E, Sanmamed-Salgado Noelia, Alhunaidi Omar, Ajib Khaled, Nason Gregory, Tan Guan Hee, Fleshner Neil, Klotz Laurence
Division of Urology, Department of Surgical Oncology, University of Toronto and University Health Network, Toronto, ON, Canada.
Department of Medical Imaging, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada.
Can Urol Assoc J. 2020 Sep;14(9):E453-E457. doi: 10.5489/cuaj.6341.
Digital rectal examination (DRE) is part of the clinical evaluation of men on active surveillance (AS). The purpose of the present study is to analyze the value of DRE as a predictor of upgrading in a population of men with prostate cancer (PCa) treated with AS.
We used the prostate biopsy (PBx) database from an academic center, including PBx from 2006-2018, and identified 2029 confirmatory biopsies (CxPBx) of men treated with AS, of which 726 men had both diagnostic (initial) and CxPBx information available. We did a descriptive analysis and evaluated sensitivity, specificity, and predictive values of DRE for the detection of clinically significant PCa (csPCa). Multivariable regression analysis was done to identify predictors of csPCa. The primary outcome was to evaluate DRE as a predictor of the presence of csPCa at CxPBx.
Among the 2029 patients with a CxPBx, 75% had PCa, and of these, 30.3% had upgrading to International Society of Urologic Pathologists (ISUP) grade ≥2. Thirteen percent of men had a suspicious DRE (done by their treating physician). Sensitivity, specificity, negative and positive predictive values of DRE to detect csPCa were best with a prostate-specific antigen (PSA) <4 ng/ml (27%, 88%, 31%, and 87%, respectively). A suspicious DRE at CxPBx, particularly if the DRE at diagnosis was negative, was a predictor of csPCa (odds ratio [OR] 2.34, p=0.038). The main limitation of our study is the retrospective design and the lack of magnetic resonance imaging.
We believe DRE should still be used as part of AS and can predict the presence of csPCa, even with low PSA values. A suspicious nodule on DRE represents a higher risk of upgrading and should prompt further assessment.
直肠指检（DRE）是对接受主动监测（AS）的男性进行临床评估的一部分。本研究的目的是分析在接受AS治疗的前列腺癌（PCa）男性人群中，DRE作为升级预测指标的价值。
我们使用了一个学术中心的前列腺活检（PBx）数据库，包括2006年至2018年的PBx，并确定了2029例接受AS治疗男性的确诊活检（CxPBx），其中726名男性同时有诊断性（初始）和CxPBx信息。我们进行了描述性分析，并评估了DRE对检测临床显著前列腺癌（csPCa）的敏感性、特异性和预测价值。进行多变量回归分析以确定csPCa的预测因素。主要结果是评估DRE作为CxPBx时csPCa存在的预测指标。
在2029例有CxPBx的患者中，75%患有PCa，其中30.3%升级为国际泌尿病理学会（ISUP）≥2级。13%的男性DRE可疑（由其主治医生进行）。当前列腺特异性抗原（PSA）<4 ng/ml时，DRE检测csPCa的敏感性、特异性、阴性和阳性预测值最佳（分别为27%、88%、31%和87%）。CxPBx时DRE可疑，特别是如果诊断时DRE为阴性，则是csPCa的预测因素（优势比[OR] 2.34，p = 0.038）。我们研究的主要局限性是回顾性设计和缺乏磁共振成像。
我们认为DRE仍应作为AS的一部分使用，即使PSA值较低时也能预测csPCa的存在。DRE上可疑结节代表升级风险较高，应促使进一步评估。
