Use of Digital Rectal Exam?

[Neuronix]

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Anonymous question to me by PM:

This discussion came up between some of the my colleagues...I heard there was a point-counterpoint about it recently, but can't find it. What is the value of doing a digital rectal exam for prostate once the patient is already fully staged and ready for treatment? I can see it for screening, but after workup, it seems archaic and inappropriate. How would it change management?

 

[ramsesthenice]

Anonymous question to me by PM:

This discussion came up between some of the my colleagues...I heard there was a point-counterpoint about it recently, but can't find it. What is the value of doing a digital rectal exam for prostate once the patient is already fully staged and ready for treatment? I can see it for screening, but after workup, it seems archaic and inappropriate. How would it change management?

The main reason to do a DRE was to assess for SV invasion, gross EPE, or capsular bulging. These factors are critical if you are considering highly conformal treatments like brachytherapy. MRI does a better job than DRE most of the time and is fairly standard at a lot of centers. I personally don’t do DREs for PCa anymore unless there is something ambiguous on the MRI or the patient can’t get an MRI and I am considering Brachy. Of course, it’s fair to argue the DRE is much less expensive than an MRI.

 

[metallica81788]

There was a big discussion about it on the Mednet and I want everybody here to guess the average ages of those who argued for and those who argued against...

My GU attending always did DRE and made the resident do one as well. It seemed awfully unnecessary for the patient (they all had at least 1-2 MRIs during planning/workup) and I can't recall a single time over 4 years that it changed any management. I haven't done a single one for prostate since finishing residency and I don't ever plan to.

Insert obligatory "but you young doctors just rely on your scans and never touch patients" etc

 

[RickyScott]

The main reason to do a DRE was to assess for SV invasion, gross EPE, or capsular bulging. These factors are critical if you are considering highly conformal treatments like brachytherapy. MRI does a better job than DRE most of the time and is fairly standard at a lot of centers. I personally don’t do DREs for PCa anymore unless there is something ambiguous on the MRI or the patient can’t get an MRI and I am considering Brachy. Of course, it’s fair to argue the DRE is much less expensive than an MRI.

But how accurate is the DRE if you touch the patient? I believe it is incredibly inaccurate per urology literature.

 

[Chartreuse Wombat]

Waiting for scarb to post his image..."and yet here we are"

 

[communitydoc13]

I do a DRE for two reasons. First, as a data point for nomograms (not sure how many of these nomograms really have T stage by MRI as a data point and a real T3 by clinical exam probably means something), and second, to have a documented baseline in case of local recurrence (extremely rare, I know, but catching a pathologic change in exam can be useful). A final, less significant justification for exam is documenting hemorrhoids.

 

[elementaryschooleconomics]

But how accurate is the DRE if you touch the patient? I believe it is incredibly inaccurate per urology literature.

One of my favorite papers:

Accuracy of Digital Rectal Examination and Transrectal Ultrasonography in Localizing Prostate Cancer

Not all prostate cancers are sonographically hypoechoic or palpable on digital rectal examination, and suspicious areas on transrectal prostatic ultra…

www.sciencedirect.com

"Of the 6,630 subjects enrolled into the study 16% were biopsied. Of 1,002 quadrants that were suspicious on digital rectal examination 110 (11%) had cancer, while 308 of 418 quadrants containing cancer (74%) were not suspicious on digital rectal examination."

 

[ramsesthenice]

But how accurate is the DRE if you touch the patient? I believe it is incredibly inaccurate per urology literature.

It’s not great at picking up subtle changes and there are plenty of false negatives. I would have to say I trust a properly trained radiologist with an MRI far more than a DRE for accurate T staging. But like everything in diagnostic radiology, there is a learning curve for both obtaining good images and properly interpreting them. Neither is perfect and If you really feel like accurate T staging is important, you can always do both. Doesn’t have to be either or.

 

[ramsesthenice]

But how accurate is the DRE if you touch the patient? I believe it is incredibly inaccurate per urology literature.

And keep in mind it depends on what you are looking for. If I am planning to perform Brachy, I am not trying to decide T2a vs T2b or looking for subtle SV invasion. I am making sure there is not gross extraprostatic disease that would be under dosed using standard needle configurations. A DRE is pretty good for that most of the time.

 

[Ray D. Ayshun]

I think if you offer a DRE and the patient is fine with it, he's T2b at most. If he's adamantly against it, he's T3+. All cT2b's are at least T3a's. Hence, actually doing a rectal exam accomplishes nothing.

 

[DoctwoB]

I'll weigh in on the GU side. I do them relatively frequently and most urologists still do, though there are a few contrarians that proudly do not. The utility as a screening exam is likely low, though I have had a few patients with PSA < 1 with high grade prostate cancer detected solely on DRE. The number needed to screen, however, is likely extremely high.

The main reasons I do them are:
1. evaluate patients with elevated PSA prior to MRI. DRE is far from perfect. MRI is better, but also not perfect. If a patient has a very suspicious DRE, I will biopsy regardless of the MRI result. If the DRE is normal, usually I defer biopsy after a normal MRI (unless other factors that make the patient very high risk)

2. BPH. It's helpful to know huge prostate from small prostate to know if they'll respond to finasteride and if they're a TURP or if I need to evaluate them for simple prostatectomy or HOLEP

3. Evaluate for cT3 or cT4 disease prior to surgery

4. Some patients come in specifically for "prostate check". Usually of an age where I wouldn't recommend prostate cancer screening regardless. It's usually easier to do a DRE then to go into a detailed explanation of why it can be ommited.

 

[seper]

Bingo! A lot of men expect DRE and thus it adds gravitas to our encounter.

I'll weigh in on the GU side. I do them relatively frequently and most urologists still do, though there are a few contrarians that proudly do not. The utility as a screening exam is likely low, though I have had a few patients with PSA < 1 with high grade prostate cancer detected solely on DRE. The number needed to screen, however, is likely extremely high.

The main reasons I do them are:
1. evaluate patients with elevated PSA prior to MRI. DRE is far from perfect. MRI is better, but also not perfect. If a patient has a very suspicious DRE, I will biopsy regardless of the MRI result. If the DRE is normal, usually I defer biopsy after a normal MRI (unless other factors that make the patient very high risk)

2. BPH. It's helpful to know huge prostate from small prostate to know if they'll respond to finasteride and if they're a TURP or if I need to evaluate them for simple prostatectomy or HOLEP

3. Evaluate for cT3 or cT4 disease prior to surgery

4. Some patients come in specifically for "prostate check". Usually of an age where I wouldn't recommend prostate cancer screening regardless. It's usually easier to do a DRE then to go into a detailed explanation of why it can be ommited.

 

[Ray D. Ayshun]

DRE fellowship?

 

[salubalu]

I have been pushing our hospital to upgrade to digital rectal exams but were still on analog. Administration just doesn’t get it. It’s 2020!

 

[RickyScott]

I'll weigh in on the GU side. I do them relatively frequently and most urologists still do, though there are a few contrarians that proudly do not. The utility as a screening exam is likely low, though I have had a few patients with PSA < 1 with high grade prostate cancer detected solely on DRE. The number needed to screen, however, is likely extremely high.

The main reasons I do them are:
1. evaluate patients with elevated PSA prior to MRI. DRE is far from perfect. MRI is better, but also not perfect. If a patient has a very suspicious DRE, I will biopsy regardless of the MRI result. If the DRE is normal, usually I defer biopsy after a normal MRI (unless other factors that make the patient very high risk)

2. BPH. It's helpful to know huge prostate from small prostate to know if they'll respond to finasteride and if they're a TURP or if I need to evaluate them for simple prostatectomy or HOLEP

3. Evaluate for cT3 or cT4 disease prior to surgery

4. Some patients come in specifically for "prostate check". Usually of an age where I wouldn't recommend prostate cancer screening regardless. It's usually easier to do a DRE then to go into a detailed explanation of why it can be ommited.

by the time they get to radonc they have a dre by urologist, biopsy, and often an mri.

 

[elementaryschooleconomics]

DRE fellowship?

I'm starting a fellowship program where you combine DRE with a 4-core biopsy:

Accepting applications for summer 2021!

 

[Ray D. Ayshun]

I'm starting a fellowship program where you combine DRE with a 4-core biopsy:

View attachment 325767

Accepting applications for summer 2021!

Lemmiwinks might be the one to ask about the feasibility of this

 

[xrt123]

Helpful to know if they have hemorrhoids ahead of time in case they say I’m having blood in the toilet during treatment.

 

[DoctwoB]

I'm starting a fellowship program where you combine DRE with a 4-core biopsy:

View attachment 325767

Accepting applications for summer 2021!

Don’t joke about this. I’ve had to do finger guided transrectal prostate biopsies at the behest of my attending in residency. (usually the inpatient consult with a PSA of 1000 that heme onc won’t treat until he’s got tissue). Odds of a finger biopsy are quite high.

 

[RadOncDoc21]

Don’t joke about this. I’ve had to do finger guided transrectal prostate biopsies at the behest of my attending in residency. (usually the inpatient consult with a PSA of 1000 that heme onc won’t treat until he’s got tissue). Odds of a finger biopsy are quite high.

I’m curious as to what else would cause that high of a PSA. I know they need tissue for some random drug possibly who knows. A finger targeted biopsy without gloves is the way to go!

 

[medgator]

I’m curious as to what else would cause that high of a PSA. I know they need tissue for some random drug possibly who knows. A finger targeted biopsy without gloves is the way to go!

Before lunch, of course

 

[DoctwoB]

I’m curious as to what else would cause that high of a PSA. I know they need tissue for some random drug possibly who knows. A finger targeted biopsy without gloves is the way to go!

Nothing. Nothing else causes it. Asking a hemeonc to treat without tissue gives them panic attacks.

Meanwhile we take out kidney tumors all the time without tissue. “Diagnostic and therapeutic FTW!”

 

[ramsesthenice]

Nothing. Nothing else causes it. Asking a hemeonc to treat without tissue gives them panic attacks.

Meanwhile we take out kidney tumors all the time without tissue. “Diagnostic and therapeutic FTW!”

First, does a finger biopsy involve a gag ball and hand cuffs? It sounds horrifying.

Second, I am sad to say it’s not just med oncs that get overly obsessed with tissue. I’ve worked with a few younger rad oncs from top programs who won’t treat a cord compression from patients with obvious pathological fractures and PSAs in the 1000s or massive lung tumors (Etc) until they get path confirming cancer without one of us talking sense into them.

On the other hand, you have Gyn Oncs who routinely resect anything in the pelvis without getting imaging or path confirmation. Easily the leading cause of non-TME rectal resections. On the spectrum, I usually prefer the former.

 

[Neuronix]

I thought DRE was mostly useful to upstage patients from low risk and active surveillance to treatment or to other more aggressive workups and therapies. Just kidding, I don't treat prostate, but this definitely goes on out there.

 

[Reaganite]

Had an old guy who did locums work for me who would dre everybody and their brother and would call all sorts of whacky stuff based on DRE. I remember one patient with psa of like 5, 1 core positive for 3+3, negative mri who he called gross svi and ece based on physical exam. Had already recommended orchiectomy and xrt by the time I got back from vacation.

 

[scarbrtj]

Anonymous question to me by PM:

This discussion came up between some of the my colleagues...I heard there was a point-counterpoint about it recently, but can't find it. What is the value of doing a digital rectal exam for prostate once the patient is already fully staged and ready for treatment? I can see it for screening, but after workup, it seems archaic and inappropriate. How would it change management?

Here's the reference you're looking for

 

[RickyScott]

Had an old guy who did locums work for me who would dre everybody and their brother and would call all sorts of whacky stuff based on DRE. I remember one patient with psa of like 5, 1 core positive for 3+3, negative mri who he called gross svi and ece based on physical exam. Had already recommended orchiectomy and xrt by the time I got back from vacation.

Sounds like he is a master of the lost art of the physical exam.

 

[elementaryschooleconomics]

Second, I am sad to say it’s not just med oncs that get overly obsessed with tissue. I’ve worked with a few younger rad oncs from top programs who won’t treat a cord compression from patients with obvious pathological fractures and PSAs in the 1000s or massive lung tumors (Etc) until they get path confirming cancer without one of us talking sense into them.

My (pessimistic) hypothesis is that:

1) At "top" programs, you're more likely to have teaching faculty with significant academic responsibility, and their clinical load has little effect on their salary and promotion
2) This de-incentivizes them to "go hard" in clinic
3) Thus, when referrals/consult requests come in, they're going to drag their feet (especially if it's same-day inpatient)
4) But, the optics of refusing/procrastinating consults is bad, and needs to be justified to the impressionable residents
5) So, this ethos of "never ever ever treat anything without a tissue diagnosis" is just absolutely hammered into resident "teaching"

Obviously, there's a huge spectrum from "new 0.9cm brain lesion with no known cancer history" to "multiple lytic lesions with PSA of 1500 with no known cancer history", and clinical judgement needs to be employed. But...I have seen some slippery behavior used to protect academic time.

 

[scarbrtj]

My (pessimistic) hypothesis is that:

1) At "top" programs, you're more likely to have teaching faculty with significant academic responsibility, and their clinical load has little effect on their salary and promotion
2) This de-incentivizes them to "go hard" in clinic
3) Thus, when referrals/consult requests come in, they're going to drag their feet (especially if it's same-day inpatient)
4) But, the optics of refusing/procrastinating consults is bad, and needs to be justified to the impressionable residents
5) So, this ethos of "never ever ever treat anything without a tissue diagnosis" is just absolutely hammered into resident "teaching"

Obviously, there's a huge spectrum from "new 0.9cm brain lesion with no known cancer history" to "multiple lytic lesions with PSA of 1500 with no known cancer history", and clinical judgement needs to be employed. But...I have seen some slippery behavior used to protect academic time.

Speaking of references that can’t be found... I read one time that the number one cause of malpractice cases in rad onc (it was an article, in some throwaway “Proceedings of the Georgia Medical Society” or some such, by a lawyer at a firm that had a niche in rad onc malpractice) is treating without a tissue diagnosis. And the number one scenario there is WBRT without a tissue diagnosis. I will treat without a tissue diagnosis; but, it has to be rational, and my referring has to go on record as recommending it.

 

[elementaryschooleconomics]

Speaking of references that can’t be found... I read one time that the number one cause of malpractice cases in rad onc (it was an article, in some throwaway “Proceedings of the Georgia Medical Society” or some such, by a lawyer at a firm that had a niche in rad onc malpractice) is treating without a tissue diagnosis. And the number one scenario there is WBRT without a tissue diagnosis. I will treat without a tissue diagnosis; but, it has to be rational, and my referring has to go on record as recommending it.

I always beat the younger residents over the head with this:

https://www.nejm.org/doi/full/10.1056/nejm199002223220802

I'm very popular with the PGY-2s.

 

[ramsesthenice]

Speaking of references that can’t be found... I read one time that the number one cause of malpractice cases in rad onc (it was an article, in some throwaway “Proceedings of the Georgia Medical Society” or some such, by a lawyer at a firm that had a niche in rad onc malpractice) is treating without a tissue diagnosis. And the number one scenario there is WBRT without a tissue diagnosis. I will treat without a tissue diagnosis; but, it has to be rational, and my referring has to go on record as recommending it.

I am very skeptical that is the number 1 source of malpractice. But the point is valid. If you don’t have tissue it has to be rationale. There are not many true rad onc emergencies and we usually have time on our side to get our ducks in a row. But there are clearly those times that the potential consequences of delaying treatment are greater than treating without tissue if the diagnosis is really not in doubt. Of course, you have to clearly document that you discussed the small chance it’s not cancer. Another skill that is wholly lacking in a large contingency of our field. If it’s not documented, it didn’t happen, legally speaking.

 

[scarbrtj]

I always beat the younger residents over the head with this:

Beat 'em over the cranium with that intracranial data!... but it happens. No good deed goes unpunished. That said, I bet a fair number of us are "empirically" SBRT'ing lung nodules, aka "Stage I lung cancer," in old folks with iffy lung function. BTW, that ~10% of WBRT patients could be getting kinda/sorta inappropriately irradiated could be a good ABR OLA question hint hint cough cough.

 

[Ray D. Ayshun]

Beat 'em over the cranium with that intracranial data!... but it happens. No good deed goes unpunished. That said, I bet a fair number of us are "empirically" SBRT'ing lung nodules, aka "Stage I lung cancer," in old folks with iffy lung function.

Anecdotally, biopsying those stage I lung cancers before treatment makes them less likely to be cured with SBRT...

 

[scarbrtj]

I always beat the younger residents over the head with this:

https://www.nejm.org/doi/full/10.1056/nejm199002223220802

View attachment 325889

I'm very popular with the PGY-2s.

Speaking of Patchell.

I guess Dwight left Roxanne behind. And surely he doesn't mean "cordotomy" here does he?

 

[elementaryschooleconomics]

Speaking of Patchell.

I guess Dwight left Roxanne behind. And surely he doesn't mean "cordotomy" here does he?

Ah interesting - he was leading one of the ACRO calls on APM recently so I figured he was back. Posting MedNet answers on Christmas? Thanks, COVID.

A cordotomy huh...I don't think I've seen that one attempted in my neck of the woods. Or, more likely, those patients weren't dangled under our noses to begin with.

 

[drewdog1973]

@elementaryschooleconomics I almost always agree with you, but remember the imaging in that study.

I would guess <1% with modern brain MRI. I want to say most of the patients were enrolled in mid 80s on that study. Don’t use that to justify not treating with tissue. It’s no longer valid.

 

[elementaryschooleconomics]

@elementaryschooleconomics I almost always agree with you, but remember the imaging in that study.

I would guess <1% with modern brain MRI. I want to say most of the patients were enrolled in mid 80s on that study. Don’t use that to justify not treating with tissue. It’s no longer valid.

Oh definitely! That's just one number that I keep in the back of my mind (pun intended) to avoid premature requests to fire up the linacs.

This thread is very apt for me right now, as I finish palliative volumes...on a dude with a PSA in the thousands with painful lytic lesions and no tissue diagnosis.