title: Screening for prostate cancer at low PSA range: the impact of digital rectal examination on tumor incidence and tumor characteristics.
abstract: OBJECTIVE
  To compare tumor characteristics of screen-detected prostate cancers (PCs) either by digital rectal examination (DRE) or by prostate-specific antigen (PSA) as biopsy indication at low PSA.
  
  
  METHODS
  Two populations with PSA between 2.0 and 3.9 ng/ml were studied. Group-1 was biopsied if DRE was suspicious (1st screening round, N = 1877). In group-2 all men were offered biopsy, regardless of DRE result (side-study in 2nd screening-round, N = 801). We compared cancer detection rates (CDRs) and tumor characteristics.
  
  
  RESULTS
  In group-1 abnormal DRE prompted biopsy in 253 (13.5%) men (236 (93.3%) actually biopsied). Forty-nine PCs were detected, CDR 49/1877 = 2.6%. In group-2 we found 120 cancers in 666 (83.1%) men actually biopsied, CDR = 120/801 = 15.0%. Of all cancers detected, organ confinement (clinical T2) was found in 77.5% (group-1) and 96.6% (group-2; of which 99 T1c). Of all PCs 46.9% in group-1 and 15.0% in group-2 had biopsy Gleason score (GS) > or = 7. In the latter, 15.2% of T1cs were classified GS > or = 7. Considering only PCs with organ confinement or GS > or = 7 for each group, CDRs amounted to 2.0% versus 14.5% and 1.2% versus 2.3% for group-1 and group-2, respectively.
  
  
  CONCLUSIONS
  PSA-based screening detected a considerable amount (15.2%) of potentially aggressive tumors as T1cs, but in addition large numbers of possibly insignificant cancers (T1c, GS = 6) were diagnosed. DRE seemed to detect more selectively high-grade cancers, but also missed many of these. Considering both populations and the need to detect aggressive but confined cancers, PSA as biopsy indication outperformed DRE at the price of more biopsies (13.5% vs. 100% if all would comply).
authors.affiliation: Department of Urology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands. c.gosselaar@erasmusmc.nl
authors.forename: Claartje
authors.initials: C
authors.lastname: Gosselaar
authors.forename: Monique J
authors.initials: MJ
authors.lastname: Roobol
authors.forename: Stijn
authors.initials: S
authors.lastname: Roemeling
authors.forename: Theo H
authors.initials: TH
authors.lastname: van der Kwast
authors.forename: Fritz H
authors.initials: FH
authors.lastname: Schröder
mesh_terms: D000368:Aged; D001706:Biopsy; D051517:Digital Rectal Examination; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D017430:Prostate-Specific Antigen / Q000097:blood*; D011471:Prostatic Neoplasms / Q000097:blood / Q000175:diagnosis* / Q000453:epidemiology; D012016:Reference Values; D015203:Reproducibility of Results; D011795:Surveys and Questionnaires
chemical_list: D017430:Prostate-Specific Antigen