DRE Prior to Blood Draw - confused

didn't realize it was a 24 hour study, thought it was 30 minutes I'll have to re-read it.
I will post my numbers in my signature. I wasn't sure if it was appropriate since i am not officially a member of "the club" (yet).
As I said, at the point when he did the DRE, followed by the blood draw, i had already been told by both him, and my previous Uro, whom i had seen 2 weeks earlier, that biiopsy would be recommended. And i had already agreed to do the biopsy. Thats why i dont think his motivation was to get me to agree to it.
My PSA was as follows (dates approximate, i will check them later before i put it in my autosig

Jan 2009 - .7
april 2011 = 1.1
may 2012 - 1.7
Nov 2012 - 2.2
Nov 2012 - 2.7
Tests through the first Nov 2012 (actually i think it was Oct) all done at the same lab, the week before my visit, so blood draw PRIOR to DRE.
At this point my doc recommended biopsy, and after giving it some thought, decided to seek another opinion and ended up at Columbia NY Presbyterian. I was pleased with the amount of time he (Doctor Spencer) spent with me, and what seemed a high level of knowledge. He assured me that it was probably not cancer, but that the PSA trend did indicate a cautious approach, i.e. biopsy. He also told me that even if it was cancer, they have been doing more and more AS so not to worry.
Then he did a thorough DRE, and sent me off for blood, using Columbia - and thats hwen it came back at 2.7, but the jump didnt concern me. (or him)
Then biopsy, which showed 1 core (out of 14) had Hi Grade PIN, and he recommended i return for follow up in 6 months.

So if we had already agreed that i would do a biopsy, why artificially elevate psa?
In any case, i will probably start looking for a new guy.

I Googled for these search terms:

"pubmed The Effect of Digital Rectal Examination on Prostate-Specific Antigen Levels"

and

"Clinical effect of DRE on PSA"

And found the information below. I think some of these may already have been discussed here but I was trying to get a sense for the overall research. The results are a bit all-over-the-map but it seems that if you are going to look at free PSA the DRE will matter, clinically, otherwise not so much. I usually search directly in Pubmed but for some reason I found this search went much better with Google.

The bottom line, from my perspective, is that it is sensible to ask to have your blood drawn first but, given the state of the research, it doesn't seem to be a reason to fire your doctor.


. . . . . . . . . .


http://www.cancer.gov/cancertopics/pdq/screening/prostate/HealthProfessional/page3

2012 National Cancer Institute: Prostate Cancer Screening

Various methods to improve the performance of PSA in early cancer detection have been developed (see below). The proportion of men who have abnormal PSA test results that revert to normal after 1 year is high (65%–83%, depending on the method).[41] This is likely because of a substantial biological or other variability in PSA levels in individual men. Several variables can affect PSA levels in men. Besides normal biological fluctuations that appear to occur,[41,42] pharmaceuticals such as finasteride (which reduces PSA by approximately 50%) and over-the-counter agents such as PC-SPES (an herbal agent that appears to have estrogenic effects) can affect PSA levels.[43,44] Some authors have suggested that ejaculation and DRE can also affect PSA levels, but subsequent examination of these variables have found that they do not have a clinically important effect on PSA.[45] In any case, given this high variability, an elevated PSA should be confirmed by repeat testing before more invasive diagnostic tests are performed.




http://www.ncbi.nlm.nih.gov/pubmed/8791045

1996 Marmara University School of Medicine, Department of Urology, Istanbul, Turkey.

Although the effect of DRE on PSA levels does not appear to be clinically significant, in order to prevent any confusion, it may be the best approach to perform DRE after obtaining serum for PSA analysis.




http://www.ncbi.nlm.nih.gov/pubmed/1372943

1992 Division of Urology, University of Colorado Health Sciences Center, Denver.


No clinically important effects on serum PSA levels were noted after DRE.





http://www.ncbi.nlm.nih.gov/pubmed/1377290

1992 Department of Urology, Mayo Clinic, Rochester, Minnesota 55095.

...although digital rectal examination had a statistically significant effect on the serum PSA concentration, the clinical significance of a 0.4 ng./ml. median increase appears inconsequential. Based on these findings, physicians should be confident that the serum PSA concentration in the immediate post-digital rectal examination period is accurate and does not compromise clinical use of the tumor marker.




http://www.ncbi.nlm.nih.gov/pubmed/7536380

1995 Servicio de Urología, Hospital San Juan de Deu, Martorell, Barcelona.

Though changes are statistically significant they are not clinically so because the 0.84 increase is irrelevant. Based on these data we believe rectal digital examination has no effect on PSA serum levels.




http://www.ncbi.nlm.nih.gov/pubmed/1371553

1992 Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri.

We detected no clinically significant difference between serum PSA levels obtained immediately before and at 5 or 90 minutes after rectal examination in 43 men.




http://www.ncbi.nlm.nih.gov/pubmed/8976249

1997 Division of Urologic Surgery, Washington University School of Medicine, St. Louis Missouri, USA.

Digital rectal examination causes a modest increase in total and percentage of free PSA. Prostate needle biopsy causes more dramatic increases in both forms of PSA. Free PSA is preferentially released into the serum after prostatic manipulation and appears to be cleared more rapidly than complexed PSA. The differential return of the different PSA forms to baseline levels after biopsy could affect the use of measurements of the percentage of free PSA in clinical practice.

Jeff, i never said the DRE had me sore for a week, i've never had any pain from any DRE. I said that it was an aggressive exam.

All i can say now, is that if this forum had a "confused" emoticon available, i would now add 3 of them to my post, because i am more confused than ever.
There is obviously a lot of controversy on this topic, more than many realize. And it leads me to believe that the doc had good ground to stand on (whether we/i agree or not) in saying that he/they (not sure which to be honest) believe in the theory or not.
With that said, it would seem to me, if there is controversy, and an equal number of studies on each side, why not err on the side of caution, and do the blood draw first?

So now i dont know what the hell to do.
Peter thanks for the post, i was googling and couldn't find much of what you did, i guess i was using wrong terms.

I love this place!

Jeff:

I luvs ya too, buddy.

I hear ya. I would normally totally agree with you.

But, as I said, given a prestigious doctor and institution, before condemning them I would try and ascertain the facts. Perhaps something is lost in the translation.

Mel

Mel, you must have a "Bat-Phone" in order to have actually gotten through! I also called today, same bat-number, same bat-time, and I was transferred 3 times and on hold for a combined sum of 40 minutes, with the result being the service took a message and told me someone would call me back!

I'm guessing that you, like many others out here, wanted to get it straight from the horse's mouth - which is why I called too!

Congrats for getting through and putting some fact to all of this debate-junk!

When (IF) I get a call back I'll follow-up back here as well.

Thanks Mel.

I had a PSA check last year after the doc did a DRE. It came back at 14 and the doc wanted another PSA test done. Sure enough it came down to 10 which was about 1 more than the PSA two months back.

I believe DRE before blood draw does affect the PSA level. Does it make a difference? I think it does if you're watching the PSA level and it jumps like that.

OK, so the phone number didnt look familiar. So i did some research. Its a different hospital. The number you called is the Brady Urological Institute / Urology Dept, at Cornell Weill Medical Center/NY Presbyterian Hospital. The one i went to is the Urology Dept at Columbia/NY Presbyterian.

They are both part of the same organization, and ranked #5 as one organization by U.S. News and World Report.....
New York-Presbyterian University Hospital of Columbia and Cornell
New York, NY
Two different facilities. Same organization. So now we know it IS an organizational policy, not one doctor or one office doing things differently.

Very puzzling.

Have you considered taking charge of your health. In a calm and quiet manner talk to your doctor about having the dre after the blood test. After all it is your body and you know it best. I would try an approach of, I am uncomfortable with the dre before the blood test, and even if the current thinking is that it doesn't matter, I would like to have the test done before the dre.

After all it is your body and you are not asking for anything outrageous or unethical. You are just requesting that the protocol be done in a way that makes you more at ease, isn't that what doctors are supposed to do?

Pratoman
You wrote: "i am going to ask for the paperwork for blood draw to be mailed to me prior to my visit, so that i can do the blood draw, THEN see the doc. If they say yes, problem solved. If they say no, then i will change docs."

Perfect! My work is done!
Now we need others to stand up for themselves.


I believe some of the post DRE PSA variation is due to variability in the intensity of the DRE. The fingering is subjective and dependent upon the doc's fingers, strength, and technique. When my GP poked around in there, I felt nothing. (Obviously neither did he for so many years - which is why my very first PSA was 17! )
When the Uro examined me, he did it with such intensity that I actually ejaculated on the table. I have no doubt his DRE would have elevated my PSA.
Sadly, I can never be a volunteer for this worthwhile study.
Jeff