Do you need a DRE if your PSA is undetectable?

[Guest guest]

I posted the following in alt.support.cancer.prostate (a Usenet

group for prostate cancer) and thought it would be of interest

here also.

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Noodling around in Pubmed I found the following articles, all

concluding that a digital rectal exam is unnecessary after

prostatectomy if there is no rise in PSA. Between the three, they

followed 3,571 patients.

Note that the last article in this group of three came from s

Hopkins in 1999 and included Partin and Walsh as co-authors. This was

the largest of the three studies, involving 1,916 patients. Clearly,

some of the " big guns " in prostate cancer surgery are advising doctors

not to do a DRE unless there is a rise in PSA first, and they said it

11 years ago.

I stopped looking after finding those three, but I didn't see any

studies arguing the other way.

Are any of our doctors listening?

Alan

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Eur Urol. 2003 Apr;43(4):333-6.

Digital rectal exam following prostatectomy: is it still necessary

with the use of PSA?

Lattouf JB, Saad F.

Department of Urology, Centre Hospitalier de l'Université de Montréal,

Université de Montréal, Que., H2L 4M1, Montreal, Canada.

STUDY OBJECTIVE: To establish the value of digital rectal exam with

respect to PSA in the follow up of radical prostatectomy for prostate

adenocarcinoma. DESIGN: Retrospective analysis. SETTING: Tertiary care

center. PATIENTS: The charts of 537 patients having undergone radical

retropubic prostatectomy from April 1989 to November 2000 were

reviewed. INTERVENTIONS: The operations took place in one institution.

Follow-up took place at 1 month, 3 months and 6 months and from then

on every 6 months. When patients reached 36 months without relapse,

follow-up was done on a yearly basis. DRE was performed on every

follow-up visit until relapse occurred. Blood samples were collected

on every follow-up visit for PSA measurements. MAIN OUTCOME MEASURES:

Pathological grade and margin status. Digital rectal exam (DRE) on

every visit. PSA levels for each visit. Bone scan and anastomotic

biopsy results when done. Date and cause of death were recorded where

applicable. MEASUREMENTS AND MAIN RESULTS: Of 423 patients with

inclusion criteria, 31 (7.3%) had at least one positive DRE on

follow-up. All of these had at least one detectable PSA measurement

before DRE became positive. Clinically local recurrence took place an

average of 27+/-17 months following surgery (range 1-36 months) PSA

was an average 14+/-11 months earlier in detecting relapse than DRE.

Isolated PSA recurrence was noted in 98 (25.5%) patients. CONCLUSION:

Given our results and those obtained by other authors, it is

acceptable to omit DRE in the follow-up of radical retropubic

prostatectomies until PSA becomes detectable.

PMID: 12667712 [PubMed - indexed for MEDLINE]

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Eur Urol. 2005 Dec;48(6):906-10. Epub 2005 Aug 2.

Digital rectal examination is no longer necessary in the routine

follow-up of men with undetectable prostate specific antigen after

radical prostatectomy: the implications for follow-up.

Chaplin BJ, Wildhagen MF, Schroder FH, Kirkels WJ, Bangma CH.

Department of Urology, CA Rotterdam, Netherlands. b.chaplin@...

OBJECTIVES: We determined the role of Digital Rectal Examination (DRE)

in the follow-up of those patients treated with radical prostatectomy

for clinically localised prostate cancer having an undetectable PSA.

We discuss the implications of our findings. MATERIALS AND METHODS: An

analysis was performed of a prospectively organised data base of 1118

patients treated at our institution by radical prostatectomy after the

introduction of PSA in 1987. A strict definition of PSA progression

was used, that is any elevation above undetectable PSA or lowest

recorded post-operative PSA (nadir), in order not to miss a single

patient who may have recurrent local disease or distant metastases

without PSA progression. We counted local recurrent disease as those

patients having histologically proven adenocarcinoma on TRUS directed

biopsies, and distant disease as those patients having detectable

metastatic disease on radionuclide bone scan. RESULTS: The median

follow-up was 4.0 years (3 months to 15 years). 524 men (46.9%) had a

follow-up of more than 5 years and 88 men (7.9%) of more than 10

years. A total of 397 men (35.5%) had biochemical progression

according to our strict definition. 53 patients (4.7%) developed a

histological local recurrence and 57 men (5.1%) developed bony

metastases; none of these men had an undetectable PSA or a stable PSA

at nadir level at the time of detection. They all demonstrated a

rising PSA. CONCLUSIONS: DRE is no longer necessary in the routine

follow-up of patients with an undetectable PSA after radical

prostatectomy. Following a period of approximately 2 years of

out-patient clinic follow-up post-operatively in which issues such as

incontinence and erectile dysfunction are addressed and treated, it is

possible to restrict follow-up to PSA determinations alone and as long

as the PSA remains undetectable counselling can be carried out by a

nurse practitioner.

PMID: 16126322 [PubMed - indexed for MEDLINE]

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J Urol. 1999 Oct;162(4):1337-40.

Digital rectal examination and imaging studies are unnecessary in men

with undetectable prostate specific antigen following radical

prostatectomy.

Pound CR, Christens-Barry OW, Gurganus RT, Partin AW, Walsh PC.

Buchanan Brady Urological Institute, The s Hopkins Hospital,

Baltimore, land, USA.

PURPOSE: We determine the probability of local or distant recurrence

following radical prostatectomy in men with an undetectable prostate

specific antigen (PSA) level. MATERIALS AND METHODS: The clinical

course of 1,916 consecutive men followed during a 14-year period after

radical prostatectomy was reviewed. Average followup plus or minus

standard deviation is 5.5+/-3.5 years, and 326 men (17%) have been

followed for more than 10 years. In total this population of men has

been followed for 10,540 patient-years. RESULTS: Of 1,916 men 56

(2.9%) had local recurrence an average of 6.1+/-2.7 years (range 1 to

12) after surgery. No man had local recurrence with an undetectable

serum PSA. Mean serum PSA at the time of local recurrence was 5.8

ng./ml. Of the 56 men 13 (25%) who had local disease recurrence had an

undetectable serum PSA at 5 years of followup but had progression to

biochemical and local disease recurrence later. Of 1,916 men 118 had

distant metastases with a mean serum PSA of 28.6 ng./ml. No man has

had distant metastasis with an undetectable serum PSA. CONCLUSIONS:

Disease can recur after radical prostatectomy even after an extended

biochemical disease-free interval. None of the 1,916 men followed for

an average of greater than 5 years after surgery had local recurrence

or distant metastasis with an undetectable serum PSA. Based on these

observations, we recommend no further evaluation, that is digital

rectal examination or imaging studies, in men with an undetectable PSA

following radical prostatectomy.

PMID: 10492192 [PubMed - indexed for MEDLINE]