Abstract
Background and objective Prostate cancer (PCA) is the most prevalent cancer among males. The National Institute for Health and Care Excellence (NICE) recommends referral to PCA diagnostic pathway based on two criteria: (1) abnormal digital rectal examination (DRE) and (2) elevated prostate-specific antigen (PSA). This study evaluates the diagnostic value of routine DRE in patients undergoing PCA assessment with pre-biopsy MRI. Methods We conducted a retrospective analysis of 436 patients on the PCA diagnostic pathway between September 2019 and June 2020, focusing on those with normal MRI [Prostate Imaging Reporting and Data System (PI-RADS) 1-2, n=147] and documented DRE results. Patients were categorised by their DRE status: normal vs. abnormal. The detection of prostate cancer and clinically significant prostate cancer (CSPC, i.e., Gleason score ≥7) was then compared between the two groups. Results The overall PCA detection rate was 10.2%, while it was 4.67% for CSPC. PCA and CSPC detection were higher with abnormal DRE (19.35% and 6.45% respectively) compared to normal DRE (7.76% and 4.31%). Among 23 patients biopsied, 65% (n=15) had PCA, with CSPC found in 30% (n=7). Of note, 61% (n=14) of biopsied patients had normal DRE, with nine PCA cases, five being CSPC, whereas 39% (n=9) with abnormal DRE had six PCA cases, two being CSPC. Statistical analysis using McNemar's test showed no significant association between DRE and PCA diagnosis (p=0.146) or CSPC (p=0.774). Even though abnormal DRE was associated with higher PCA and CSPC detection rates, this finding was not statistically significant. Conclusions Based on our findings, PCA diagnostics can be effectively performed without DRE. This finding is pertinent when performing remote PCA diagnostic consultations, and it reevaluates DRE's value within the diagnostic pathway while emphasising a PSA- and MRI-based approach.