Yonsei Medical Journal Vol. 46, No. 3, pp. 414 - 424, 2005 Prostate-Specific Antigen, Digital Rectal Examination and Transrectal Ultrasonography: A Meta-Analysis for This Diagnostic Triad of Prostate Cancer in Symptomatic Korean Men Jae Mann Song1, Chun-Bae Kim2,3, Hyun Chul Chung1, and Robert L. Kane3 Departments of 1Urology and 2Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea; 3Clinical Outcomes Research Center, University of Minnesota School of Public Health, Minneapolis, USA. We conducted a meta-analysis using results from the Korean literature to determine whether prostate-specific anti- gen (PSA) or digital rectal examination (DRE) or transrectal ultrasonography (TRUS) provides a better diagnostic outcome for possible prostate cancer patients. An extensive literature search of MedRIC database et al. (1980 to 2003) was per- formed using the medical subject headings "PSA", "DRE", "TRUS" and "prostate cancer". Of the 108 articles that we retrieved, 13 studies (2,029 subjects) were selected for this meta-analysis. The criteria for quality evaluation were as fol- lows: the study subjects must have been compared clinically for suspected prostate cancer, and the articles must have included individual data about sensitivity and specificity for this diagnostic triad based on the biopsy results as a reference standard. For the quantitative meta-analysis process the Hasselblad method was utilized. The pooled sensitivity and specificity for a PSA level greater than 4 ng/mL were 91.3% and 35.9%, respectively; and those for a PSA level greater than 10 ng/mL were 77.3% and 67.5%, respectively; and those for DRE were 68.4% and 71.5%, respectively; and those for TRUS were 73.6% and 61.3%, respectively. According to the results in a fixed effect model for PSA criteria, the estimates of d̅for PSA4 and PSA10 were 0.8517 [95% confidence interval (CI): 0.6694, 1.0340] and 1.0996 (95% CI: 0.9459, 1.2534), respectively. Also, according to the results using a random effect model for both DRE and TRUS criteria, the estimates of d̅for DRE and TRUS were 0.8398 (95% CI: 0.7169, 0.9627) and 0.8002 (95% CI: 0.6714, 0.9289), respec- Received May 20, 2004 Accepted December 21, 2004 This work was supported by a grant from the Korean Urological Association (2003). Reprint address: requests to Dr. Chun-Bae Kim, Department of Preventive Medicine, Yonsei University Wonju College of Medi- cine, Wonju 220-701, Korea. Tel: 82-33-741-0344, Fax: 82-33-747- 0409, E-mail: kimcb@wonju.yonsei.ac.kr Yonsei Med J Vol. 46, No. 3, 2005 tively. The detection rate for combination testing of PSA, DRE and TRUS for the diagnosis of prostate cancer jumped further to 68.3% or to 76.8%. In conclusion, this study suggests that this diagnostic triad for prostate cancer was noneffective when they were used separately. Therefore, we recommend that the urologists should use PSA together with DRE and TRUS for the primary diagnosis of prostate cancer in men with lower urological symptoms. Key Words: Prostate-specific antigen, digital rectal examina- tion, transrectal ultrasonography, prostate cancer, meta-analysis INTRODUCTION Prostate cancer among adult males is the most common neoplasm after skin cancer in most developed countries. Over 200,000 men in the United States are diagnosed annually with pros- tate cancer and 30,000 men still die from this dis- ease each year.1 The age-standardized incidence of prostate cancer in the European Union is 65/ 100,000 and the EU's mortality rate is 26/100,000 per year.2 In South Korea the incidence rate of this disease increased from 0.41 per 100,000 during 1985-1989 to 3.38 per 100,000 during 1995-1999. The crude incidence rate of prostate cancer among Korean men estimated to be 10.09 per 100,000. After 50 years old, the age-specific incidence rate increases three or four-fold for every 10-year increase in age.3 These trends have been shown to be related to diet (i.e. the high consumption of meat, dairy products and fats) by Whittemore et al.4 and Kolonel et al.,5 and also to the improved diagnostic techniques6,7 [including prostate-spe-