06-28-2024 No DRE-No Clinical T, a cT BLANK is better than an assumption
We have seen a trend where Urologists are not performing or not documenting the information about the Digital Rectal Exam (DRE) prior to biopsy, but as a reminder, the cT category is based only on the DRE. Hopefully, this will be addressed with Version 9, but until then, if you do not know the information about the DRE-assign a cT BLANK. It is important we do not assume anything and potentially skew the data. This concept was reinforced during Aleisha Williams, MBA, ODS-C presentation entitled “AJCC Staging-Critical Staging Clarifications,” during the NCRA Annual Conference this year. This is not really new information, and it is clearly spelled out in the AJCC Manual 8th Edition Prostate Chapter 58, page 726 Rules for Clinical Classification. The DRE is required to assign cT, and should reflect DRE findings only, do not use biopsy or imaging information to assign a cT. A cT BLANK is better than an assumption of what you think it should be assigned. Below are common scenarios you might encounter.
| Scenario | How will cT be assigned | Discussion |
| Registrar can find no documentation of DRE | cT BLANK | Registrar does not know if DRE done or not, assign a BLANK |
| Registrar can find no documentation of DRE, however managing physician staged as cT1c | cT BLANK | Registrar does not know if DRE done or not, assign a BLANK. We cannot assume a DRE was done, if it is not stated, then we leave it blank. |
| Prostate cancer found during TURP <5% of tissue | cT BLANK | Registrar does not know if DRE done or not, assign a BLANK. We cannot assume a DRE was done, if it is not stated, then we leave it blank. |
| Referred to Urologist from primary care doctor for elevated PSA.
Telemedicine Surgical Consult Biopsy: Gleason 7/4+3 in 12/12 cores both lobes of the prostate, PSA 7.7, MRI 2.3cm suspicious area throughout majority of right gland & peripheral zone, extension into seminal vesicles, Pi-Rads 5, Urologist recommend prostatectomy. Patient goes onto have radical prostatectomy staged pT3a pN0 cM0 Stage 3B |
cT BLANK | Can not use the information from the MRI, it is based on the DRE only.
Why not a cTX- well, you know a DRE was not done during the televisit, however you don’t know for a fact that a DRE was never performed during any part of the work up and since the physician did not state the DRE was not done, do not assume leave it BLANK. When in doubt, blank it out. |
| Patient refuses DRE in office. Later patient goes to biopsy no information on whether a DRE was performed prior to procedure or not | cT BLANK | If you know for a fact a DRE was not performed, then you can assign a cTX, but just because the patient refused during the office visit, it does not mean one was not done just prior to biopsy, if in doubt, blank in out. |
| Physician States NO DRE Done
|
cTX | If the physician states DRE not performed, then you can assign a cTX |