The prognostic value of digital rectal exam for the existence of advanced pathologic features after prostatectomy

Abstract

Background Accurate staging at the time of prostate cancer diagnosis is fundamental to risk stratification and management counseling. Digital rectal exam (DRE) is foundational in clinical staging of prostate cancer, even with a known limited interexaminer agreement and poor sensitivity for detecting extraprostatic disease. We sought to evaluate the prognostic value of DRE for the presence of advanced pathologic features (APFs) following radical prostatectomy (RP). Methods All patients undergoing RP as primary treatment for clinically localized prostate cancer in the National Cancer Database between 2008 and 2014 were identified. Patients with additional malignancies, prior treatment with radiation or systemic therapy, incongruent clinical staging and DRE findings or without fully evaluable clinical staging were excluded. The primary outcome was the presence of postsurgical APFs, defined as positive surgical margins, nodal disease, or pathologic stage T3 or greater. Multivariable logistic regression analysis was performed to account for prostate‐specific antigen (PSA), biopsy grade group, percent of positive biopsy cores, and clinical stage. Results In total, 91,525 patients consisting of 69,182 cT1, 20,641 cT2, and 1702 cT3–T4 were included. The average age was 61.1 ± 7.0 years, and the average PSA was 8.6 ± 10.3 ng/ml. On multivariable analysis, cT3 and T4 were associated with the presence of APFs (odds ratio [OR] 11.12, p < .01 and 5.28, p = .04), however, cT2 was only slightly associated with the presence of APFs when compared with cT1 (OR 1.15, p < .01). Furthermore, cT2 was associated with more node‐positive disease (OR 1.63, p < .01), positive margins (OR 1.06, p < .01), and more than or equal to pT3 disease (OR 1.22, p < .01). Conclusions Overall, advanced clinical stage as assessed by DRE was independently associated with an increasing risk of APFs. For individual APFs, the greatest effect is noticed between clinical stage and nodal positivity and less so between clinical stage and positive margins. DRE continues to hold value, particularly for patients with locally advanced disease and potential lymph node disease.

Multiparametric MRI for Staging of Prostate Cancer: A Multicentric Analysis of Predictive Factors to Improve Identification of Extracapsular Extension before Radical Prostatectomy

“…Currently, the clinical stage of PCa before surgery is based only on DRE [ 19 ]. A DRE that suggests extension outside of the prostate capsule is classified as a high-risk disease, according to d’Amico’s classification groups for biochemical recurrence of PCa [ 20 ].…”

Impact of prebiopsy MRI on prostate cancer staging: Results from the Norwegian Prostate Cancer Registry

“… 18 However, Prebay et al claim the predictive value of cT2 differed little from cT1c, which demonstrates the poor reliability of DRE. 18 Clinicians tend to adopt the method deemed most reliable, even if the principle of TNM staging is to choose the lower stage if unclear. Currently, cT‐MRI is usually available to the clinician when performing DRE.…”

“…Many clinicians feel that DRE holds limited predictive value regarding tumour extent. However, if DRE indicates an advanced clinical stage, the association with PCa ≥ pT3 or positive lymph nodes is present 18 . However, Prebay et al claim the predictive value of cT2 differed little from cT1c, which demonstrates the poor reliability of DRE 18 .…”

“…However, if DRE indicates an advanced clinical stage, the association with PCa ≥ pT3 or positive lymph nodes is present 18 . However, Prebay et al claim the predictive value of cT2 differed little from cT1c, which demonstrates the poor reliability of DRE 18 . Clinicians tend to adopt the method deemed most reliable, even if the principle of TNM staging is to choose the lower stage if unclear.…”

Stability of Prognostic Estimation Using the CAPRA Score Incorporating Imaging-based vs Physical Exam–based Staging

“…The DRE, traditionally the sole factor to define clinical staging, has significant interexaminer variability and poor sensitivity for detecting extraprostatic disease. [5][6][7] TRUS and MRI have emerged as contemporary tools in the clinical evaluation of prostate cancer given the high-resolution anatomical visualization, but have yet to be widely incorporated into prostate cancer tumor staging standards or risk-stratification models. 8 While there is currently no guideline consensus on which patients should undergo imaging as part of their initial staging evaluation, a gradual trend of incorporating MRI data, backed by PI-RADS (the Prostate Imaging Reporting & Data System), 9 in the management of prostate cancer exists.…”