Prostate dre

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I have detected gross ECE and SVI in the past. The Department does not do prostate MRI routinely, though.
 
Thinking out loud but only management decision really make is to give hormones or not
seper said:
I have detected gross ECE and SVI in the past. The Department does not do prostate MRI routinely, though.
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Have also felt this but without mri don’t think would commit pts to long term hormones based just on what I felt.
 
RickyScott said:
anyone ever performed a dre that changed/affected management of a prostate ca. (I don’t do brachy and I get mris) have not found them helpful in follow up either.
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Have seen concurrent anal cancer caught because of DRE that would have otherwise been missed

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I typically do it in up front patients but if the urologist clearly documents a negative DRE and they come rolling in with an MRI showing no ECE I skip it.

I don't do it in follow ups unless rising PSA.
 
The crux is whether our patient satisfaction scores will be higher if we deliver on patient's expectations (being digitized) or whether we attempt to disabuse them of the necessity of this intrusion.

I've had some follow-ups that seemed disappointed when they learned I wouldn't DRE them if the PSA was reassuring. (No laughter, please.) Given that the value of a placebo is directly proportional to the discomfort associated with it, I believe they found the very invasiveness of the exam to confirm the thoroughness with which a physician was following them. Not a good reason to continue DREs, however.

Quality metrics in healthcare! You can't argue with numbers. Of course, free doughnuts and decent coffee would probably put satisfaction scores through the roof.
 
RickyScott said:
“70% of abnormal dre’s were normal the following year” even in pts with prostate cancer (presumably being watched)?
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BobbyHeenan said:
I typically do it in up front patients but if the urologist clearly documents a negative DRE and they come rolling in with an MRI showing no ECE I skip it.

I don't do it in follow ups unless rising PSA.
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The DRE for prostate cancer has such low specificity/sensitivity for SV+ or ECE that it’s worthless. It may have better metrics than that for CaP screening but the biopsy and a PSA even renders that moot. One must point out though that AJCC AFAIK only allows DRE for preop staging; imaging (MRI/US) not allowed. (Last time I checked.) Which surely to goodness will be changed one day but is a historical holdover. I of course use MRI for staging, and now we have PI-RADS etc. But in practice, esp for follow up, it’s useless/superfluous. In my whole career I have never made a treatment decision based solely on DRE. All data points to a +DRE being wrong when PSA not rising, it being confirmatory to a rising PSA, or a -DRE being worthless with rising PSA.
Doing no DRE in f/u post-tx comports w/ NCCN guidelines.
 
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I don't do it for surveillance.

New patients (either intact or salvage) I do it once. I don't routinely get MRIs or Auxumin scans on salvage patients, especially if PSA is 0.1-0.2. I do get MRIs on intact patients I suppose but clinical exam can affect risk classification.

I think that's a nice balance.
 
How in the world can anyone detect SVI on a DRE? Wasn't there a study that looked at avg size of urologist finger and avg position of prostate in relation to anal canal length and determined you can only palpated bottom 20% or so of prostate?
 
KHE88 said:
How in the world can anyone detect SVI on a DRE? Wasn't there a study that looked at avg size of urologist finger and avg position of prostate in relation to anal canal length and determined you can only palpated bottom 20% or so of prostate?
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Urologist here. There’s a reason we say “you’re going to feel a lot of pressure”. To do a proper DRE and assess the prostate base You have to push in pretty hard. And even then you can’t always get to the base.

It’s an interesting topic and debated in our field. It’s well known to be inaccurate for judging prostate size, neither sensitive nor specific for prostate cancer, etc. Some of our faculty omit it in favor of MRI, most still perform one. As a caveat MRI is also neither sensitive nor specific for ECE or SV involvement. I perform them in a fair number of patients to assess for fixed disease preoperatively, or more commonly in patients referred for urinary symptoms to get a rough sense of prostate size (nothing exact, just small vs big vs massive) to guide treatment decisions as well as make sure I’m not missing an obvious tumor. I don’t do them in follow up of prostate cancer, PSA will be Much much more sensitive.
 
I suppose the one argument you can make is in patients with low psa very high risk disease (Gleason 9 or 10). Disease so aggressive it just doesn’t or barely produces psa.
 
gmsquid said:
I suppose the one argument you can make is in patients with low psa very high risk disease (Gleason 9 or 10). Disease so aggressive it just doesn’t or barely produces psa.
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A DRE would be irrelevant in this population where you’re just watching the clock for distant failure.
 
Church of Radiontology said:
The crux is whether our patient satisfaction scores will be higher if we deliver on patient's expectations (being digitized) or whether we attempt to disabuse them of the necessity of this intrusion.

I've had some follow-ups that seemed disappointed when they learned I wouldn't DRE them if the PSA was reassuring. (No laughter, please.) Given that the value of a placebo is directly proportional to the discomfort associated with it, I believe they found the very invasiveness of the exam to confirm the thoroughness with which a physician was following them. Not a good reason to continue DREs, however.

Quality metrics in healthcare! You can't argue with numbers. Of course, free doughnuts and decent coffee would probably put satisfaction scores through the roof.
Click to expand...
I new a doc n
KHE88 said:
How in the world can anyone detect SVI on a DRE? Wasn't there a study that looked at avg size of urologist finger and avg position of prostate in relation to anal canal length and determined you can only palpated bottom 20% or so of prostate?
Click to expand...
PhotonBomb said:
A DRE would be irrelevant in this population where you’re just watching the clock for distant failure.
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dre not needed in high risk because they are getting hormones anyway so it can’t change managembt
 
Forgot to add an old urologist joke.

What are the only reasons not to do a DRE?

The patient doesn’t have an anus or you don’t have a finger.

Joking aside though, it’s an exam skill whose usefulness is mostly superseded by modern imaging, not unlike auscultation, and like auscultation it gets less useful by the year as doctors become less skilled at it. It’s main benefit is to quickly assess a prostate for size or nodules without the cost or inconvenience of sending the patient from your office for imaging. Mostly it hangs around from inertia, and the old guard teaching it as part of doing a good exam
 
DRE by RO - meh.

I quit doing them after the local urologist the NCI designated center "nearby" stopped doing them...
 
How do you document T staging with no DRE? Everyone is a T1c?
 
If it was PSA diagnoses would any thing on exam change what you do? I don’t think it has ever changed what I do, but i keep doing it... maybe time to stop?
 
Maybe we shouldn’t be taking as residents those doctors who don’t have long enough digits to fully palpate 100cc prostates? Think of the false negatives! </s>
 
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taserlaser said:
Maybe we shouldn’t be taking as residents those doctors who don’t have long enough digits to fully palpate 100cc prostates? Think of the false negatives!
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I would not make it in then.

I always have worried about false negatives with my Trump fingers, so I qualify my exam findings with "at the apex of prostate".
 
Ive mostly stopped doing them. I have short fingers and I really don’t find it ever changes my management. I don’t boost index lesions and the probability of discovering a “large tumor that has de-differentiated to the point of not producing PSA” that is missed by biopsy but yet clearly evident on DRE is, realistically, non existent. It is a relic of the pre-PSA/imaging era.
 
wiring can make sense so it can help you draw if there is an exophytic component distal to the external sphincter, certainly

I don't see how the finger in the bum helps though.
 
PhotonBomb said:
wiring can make sense so it can help you draw if there is an exophytic component distal to the external sphincter, certainly

I don't see how the finger in the bum helps though.
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You get to see how high they can jump.
 
PhotonBomb said:
wiring can make sense so it can help you draw if there is an exophytic component distal to the external sphincter, certainly

I don't see how the finger in the bum helps though.
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DRE can be useful in cases where there is discrepancy between the MRI/PET/endoscopy report, though this is a pretty rare instance. But as you can imagine, if a tumor is digitally palpable then the most inferior extent is probably lower than the "7 cm from the AV" reported by the radiologist/colonoscopist, which can change your field borders/volumes.

Not sure if we just have inconsistent radiologist/endoscopists, but I've seen MRI reports that say the tumor is 4 cm from AV but the colonoscopy report says 10 cm.
 
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