Screening for prostate cancer: are digital rectal examinations being performed?

Evaluation of the frequency of incidental findings and their clinical significance in multiparametric prostate magnetic resonance imaging examination

Purpose

Conventional diagnostic methods have limitations in the diagnosis of prostate cancer (PCa); therefore, the use of multiparametric magnetic resonance imaging (mpMRI) in PCa has become widespread. We aimed to determine the frequency of IF detected in the mpMRI examination according to organ distribution and clinical significance.

Material and methods

mpMRI examinations performed between January 2015 and 2020 based on the diagnosis or suspicion of PCa were retrospectively evaluated. IFs were divided into 2 groups, as genitourinary system and non- genitourinary system findings. In addition, IFs were also evaluated in 2 groups, as clinically significant and clinically non-significant. The patient population was divided into age ranges, and the frequency of IFs in these age ranges and their clinical significance were recorded.

Results

The mpMRI examinations of 426 patients revealed a total of 321 Ifs, comprising 212 (49.8%) genitourinary (41.1%) and 189 (58.9%) extragenitourinary findings. The mean age of the patients was 63.53 ± 7.89 years. As the age increased, the rate of IFs increased (p = 0.001). However, there was no increase for the 75-year-old group compared to the 65-74-year-old age range (p = 0.853). There were a total of 22 (6.9%) clinically significant Ifs – 4 associated with the genitourinary system and 18 extragenitourinary.

Conclusions

Although the rate of clinically significant IF was only 6.9%, this rate was high in patients, especially in those over the age of 65 years. It should be kept in mind that the early detection of these findings in the asymptomatic period will increase the survival and successful treatment of patients.

Knowledge of prostate cancer presentation, etiology, and screening practices among women: a mixed-methods systematic review

BACKGROUND

With the burden of prostate cancer, it has become imperative to exploit cost-effective ways to tackle this menace. Women have demonstrated their ability to recognize early cancer signs, and it is, therefore, relevant to include women in strategies to improve the early detection of prostate cancer. This systematic review seeks to gather evidence from studies that investigated women's knowledge about (1) the signs and symptoms, (2) causes and risk factors, and (3) the screening modalities of prostate cancer. Findings from the review will better position women in the fight against the late detection of prostate cancer.

METHODS

The convergent segregated approach to the conduct of mixed-methods systematic reviews was employed. Five databases, namely, MEDLINE (EBSCOhost), CINAHL (EBSCOhost), PsycINFO (EBSCOhost), Web of Science, and EMBASE (Ovid), were searched from January 1999 to December 2019 for studies conducted with a focus on the knowledge of women on the signs and symptoms, the causes and risk factors, and the screening modalities of prostate cancer.

RESULTS

Of 2201 titles and abstracts screened, 22 full-text papers were retrieved and reviewed, and 7 were included: 3 quantitative, 1 qualitative, and 3 mixed-methods studies. Both quantitative and qualitative findings indicate that women have moderate knowledge of the signs and symptoms and the causes and risk factors of prostate cancer. However, women recorded poor knowledge about prostate cancer screening modalities or tools.

CONCLUSIONS

Moderate knowledge of women on the signs and symptoms and the causes and risk factors of prostate cancer was associated with education. These findings provide vital information for the prevention and control of prostate cancer and encourage policy-makers to incorporate health promotion and awareness campaigns in health policies to improve knowledge and awareness of prostate cancer globally.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework (OSF) registration DOI: https://doi.org/10.17605/OSF.IO/BR456.

Is it possible to automatically assess pretreatment digital rectal examination documentation using natural language processing? A single-centre retrospective study

OBJECTIVES

To develop and test a method for automatic assessment of a quality metric, provider-documented pretreatment digital rectal examination (DRE), using the outputs of a natural language processing (NLP) framework.

SETTING

An electronic health records (EHR)-based prostate cancer data warehouse was used to identify patients and associated clinical notes from 1 January 2005 to 31 December 2017. Using a previously developed natural language processing pipeline, we classified DRE assessment as documented (currently or historically performed), deferred (or suggested as a future examination) and refused.

PRIMARY AND SECONDARY OUTCOME MEASURES

We investigated the quality metric performance, documentation 6 months before treatment and identified patient and clinical factors associated with metric performance.

RESULTS

The cohort included 7215 patients with prostate cancer and 426 227 unique clinical notes associated with pretreatment encounters. DREs of 5958 (82.6%) patients were documented and 1257 (17.4%) of patients did not have a DRE documented in the EHR. A total of 3742 (51.9%) patient DREs were documented within 6 months prior to treatment, meeting the quality metric. Patients with private insurance had a higher rate of DRE 6 months prior to starting treatment as compared with Medicaid-based or Medicare-based payors (77.3%vs69.5%, p=0.001). Patients undergoing chemotherapy, radiation therapy or surgery as the first line of treatment were more likely to have a documented DRE 6 months prior to treatment.

CONCLUSION

EHRs contain valuable unstructured information and with NLP, it is feasible to accurately and efficiently identify quality metrics with current documentation clinician workflow.

Is it time to abandon the digital rectal examination? Lessons from the PLCO Cancer Screening Trial and peer-reviewed literature

OBJECTIVE

In 2012 the US Preventive Services Task Force released recommendations against prostate specific antigen (PSA) based screening for prostate cancer, but did not fully address screening via digital rectal exam (DRE). As such, many practitioners continue to perform DRE in attempts to identify men with clinically significant prostate cancer (CSPC). This study seeks to determine the value of DRE in detecting CSPC in the era of PSA-based screening.

METHODS

Data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Screening Trial, a nationwide population-based study evaluating cancer screening programs and their impact on cancer mortality, was analyzed for PSA, DRE, and cancer status. In the screening arm of the PLCO, 38,340 men received annual PSA and DRE examinations for the first 3 years. Those with an abnormal test result were referred to their individual care provider for biopsy. The ability of DRE to detect CSPC, defined as intermediate risk or higher based on National Comprehensive Cancer Network guidelines and age ≤75, was evaluated in the context of both normal and abnormal PSA.

RESULTS

A total of 5064 men had abnormal DRE in the setting of normal PSA, of whom 99 (2%) were diagnosed with CSPC. When both PSA and DRE were abnormal, 218 (20%) participants were diagnosed with CSPC (RR = 2.06 [1.78-2.39] versus abnormal PSA alone).

CONCLUSIONS

DRE screening in the setting of normal PSA captured an additional 2% of men with CSPC. This incremental gain suggests that routine DRE screening subjects a large number of men to invasive, potentially uncomfortable examinations for relatively minimal gain. Key limitations: Our conclusions are based on data derived from the PLCO study which has been criticized on the basis of inconsistent biopsies following positive screening tests, lack of end of study biopsies to determine population disease burden, and low numbers of black men.

New Paradigms for Patient-Centered Outcomes Research in Electronic Medical Records: An Example of Detecting Urinary Incontinence Following Prostatectomy

Introduction:

National initiatives to develop quality metrics emphasize the need to include patient-centered outcomes. Patient-centered outcomes are complex, require documentation of patient communications, and have not been routinely collected by healthcare providers. The widespread implementation of electronic medical records (EHR) offers opportunities to assess patient-centered outcomes within the routine healthcare delivery system. The objective of this study was to test the feasibility and accuracy of identifying patient centered outcomes within the EHR.

Methods:

Data from patients with localized prostate cancer undergoing prostatectomy were used to develop and test algorithms to accurately identify patient-centered outcomes in post-operative EHRs – we used urinary incontinence as the use case. Standard data mining techniques were used to extract and annotate free text and structured data to assess urinary incontinence recorded within the EHRs.

Results

A total 5,349 prostate cancer patients were identified in our EHR-system between 1998–2013. Among these EHRs, 30.3% had a text mention of urinary incontinence within 90 days post-operative compared to less than 1.0% with a structured data field for urinary incontinence (i.e. ICD-9 code). Our workflow had good precision and recall for urinary incontinence (positive predictive value: 0.73 and sensitivity: 0.84).

Discussion.

Our data indicate that important patient-centered outcomes, such as urinary incontinence, are being captured in EHRs as free text and highlight the long-standing importance of accurate clinician documentation. Standard data mining algorithms can accurately and efficiently identify these outcomes in existing EHRs; the complete assessment of these outcomes is essential to move practice into the patient-centered realm of healthcare.