Early detection of high-grade prostate cancer using digital rectal examination in men with a normal PSA and risk of death.

Abstract

147 Background: A digital rectal examination (DRE) is less commonly practiced in the PSA screening era. Whether detection of high-grade prostate cancer (PC) while still clinically localized on DRE can improve survival in men with a normal PSA is unknown. Methods: From the Surveillance, Epidemiology and End Results database, 166,498 men with PC diagnosed between 2004-2008 were identified. Logistic regression was used to identify factors associated with the occurrence of palpable, PSA-occult (PSA <2.5 ng/ml) and Gleason score (GS) 8-10 PC. Factors examined included age at and year of diagnosis and race. Fine and Grays and Cox multivariable regression were performed to analyze whether these factors, treatment and known prognostic factors were associated with the risk of PC-specific mortality (PCSM) and all-cause mortality (ACM), respectively. Results: Of 166,498, 685 men (0.4%) had palpable, PSA-occult and GS 8 to 10 PC. Median age and PSA at diagnosis in this group were 68 years [IQR: 61-75] and 1.5 ng/ml [IQR: 1-2], respectively. Most (83%) men were white. Both increasing age (adjusted odds ratio (AOR): 1.02 [95% confidence interval (CI) 1.01-1.03]; p<0.0001) and white race (AOR: 1.26 [95% CI 1.03-1.54]; p =0.03) were associated with palpable, Gleason 8 to 10 PC with normal PSA. Significant factors associated with an increased risk of PCSM and ACM in this cohort are shown in the table. For these 685 men, detecting locally advanced as compared to localized PC on DRE was associated with a significantly lower survival (p = 0.0001). Conclusions: Detecting PSA-occult high-grade PC with DRE while disease remains clinically localized amongst high-risk men (over age 68 and white race) has the potential to improve survival. [Table: see text]