Tuesday, September 23, 2014

Historical Contribution: 1956, Jewett, Palpable Prostatic Nodule



Jewett HJ. Significant of the Palpable Prostatic Nodule. J Am Med Assoc. 1956. 160(10):838-9.

Prior to PSA testing (only prevalent in the late 1980's), the diagnosis of prostate cancer relied on clinical examination – namely the digital rectal examination (DRE). The presence of a palpable nodule on DRE was not specific for prostate cancer as "the malignant nodule has no palpable characteristics that can be relied upon to distinguish it from the benign." In fact, only 50% of nodules contained cancer. Based on the examination of over 200 men (and their palpable nodules) over a 50 year period, Dr. Jewett and researchers at the Brady Urological Institute were able to note a few patterns in the diagnosis of prostatic nodules:

  • Benign and malignant nodules occupied the same anatomic areas of the prostate with the exception of the "median furrow" or central zone – no cases of cancer were noted in this area.
  • There was no difference in palpable characteristics between benign and malignant tumors.
    • Characteristics examined included: elevated vs. flat, smooth vs. irregular, sharp edges, and stony induration.
    • Of note, stony induration was believed to be indicative of cancer, however 75% of cases with stony induration were demonstrated to be benign.
Importantly, Jewett recognized that DRE was not sufficient for staging in many cases. In fact, in 72% of cases, the DRE understaged or "underestimated" the presence of disease including seminal vesicle invasion. In patients with seminal vesicle invasion or involvement of perivesicular tissues, the prognosis was notably poor. Therefore, Jewett emphasized the danger of "watchful waiting" in cases of malignancy as the current state of prostate cancer diagnostics did not allow for accurate staging. He did hedge, stating that "the greater the distance from the nodule to the seminal vesicles the less likely the latter are to be involved."

The last point to be taken from this manuscript is the commentary of prostate cancer epidemiology in the US in the mid-1900's. Between 1905-1945, 72 patients were "biopsied" for a palpable nodule; from 1945-1955 that number doubled to 139 patients. Jewett credited family physicians with increasing awareness of prostate cancer and the benefit or early intervention (radical prostatectomy) for localized disease with the dramatic increase in prostate cancer diagnoses. With an eerie resemblance of current controversies regarding PSA screening and prostate cancer mortality, Jewett was vexed by the underappreciation of prostate cancer incidence and death by the major health organizations in the US (Federal Security Agency and US Public Health Services). These organizations noted that prostate cancer was the 3rd leading cause of cancer death in the US (preceded by stomach and lung) but did not acknowledge the importance of DRE screening. Jewett felt these was easily preventable and that a dramatic improvement in prostate cancer mortality could be made:
"Since prostatic cancer is within easy reach of the examining finger and generally commences as a small, operable cancer, the responsibility of the general practitioner for the early detection of this disease, in a curable stage, is plainly evident."
To read the entire manuscript: follow the link above, visit the Centennial Website or click here.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy! 

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