Declining use of the DRE at a large VA medical center: is this a national trend?

Once upon a time (not so very long ago) the digital rectal examination or DRE was the only non-invasive test that a physician could use to assess whether a patient was at risk for localized prostate cancer and/or other prostate problems. Alas, the use of this test appears to be falling out of favor, which is probably not a good thing.

Few men (or women) actually want to have a DRE. There are all sorts of reasons for that, which aren’t worth going into here because they are pretty obvious. However, there are all sorts of good reasons why a DRE can be an important form of medical assessment of a patient’s clinical status. From the point of view of prostate cancer, it provides the ability for a physician to feel some (but not all) of a patient’s prostate and determine whether there are any clearly hard areas or nodules (lumps) that might be indicative of prostate cancer.

“But,” we hear you say, “If you have prostate cancer your PSA will be elevated, so why would one need a DRE?”

Unfortunately, that assumption is not correct. It is perfectly possible to have prostate cancer that is suggested only by a nodule or a hard area on the prostate, with a PSA level that is well within the “normal” range (i.e., less than 4 ng/ml and sometimes less than 2.5 ng/ml). This has been shown over and over again.

Is prostate cancer that is suggested only by as positive DRE common? No, it is not — but when it exists it can be relatively aggressive.

Why do we bring this up?

Because an article by Federman et al. in the journal Hospital Practice has confirmed something we have suspected for quite a while now: that DREs are no longer being recommended routinely to men between the ages of 50 and 74 (at least at one Veterans Administration medical center).

Federman et al. conducted a careful retrospective review of data in the electronic medical records of the VA Connecticut Healthcare System, looking for for male patients with no known history of prostate cancer who were aged between 50 and 74 years and who underwent PSA testing. They identified all such patients and then also determined whether these patients were either given a DRE within 12 months of the PSA test or were offered one and refused.

Here are their core findings:

  • 47.6 percent of patients given a PSA test were also given a DRE.
  • 6.9 percent of patients given a PSA test were offered DRE and refused.
  • Patients with a PSA > 4.0 ng/ml were more likely to have a DRE than patients whose PSA was ≤ 4.0 ng/ml (P = 0.002).
  • There was no association between the gender of the clinician and the likelihood of a patient having and/or being offered a DRE, but …
  • Resident physicians (i.e., physicians still in clinical training) were less likely to perform DREs than non-resident (fully trained) physicians (P = 0.01).
  • Patients with a body mass index (BMI) > 40 kg/m2 were less likely to be given a DRE than those patients with a BMI < 30 kg/m2 (P = 0.04).

It would appear — based on these data — that younger physicians who are still in training today are less aware than physicians used to be of the potential value of the DRE.

We also find it interesting that less than 7 percent of the patients in this study actually refused a DRE. In other words, the widely held belief that a relatively large proportion of men reject DREs when these are appropriately offered was not substantiated in this study.

The fact that severely obese patients were less likely to be given a DRE is not surprising. Giving DREs to such patients can be extremely difficult and may well be of limited value as a consequence.

Frankly, The “New” Prostate Cancer InfoLink is very concerned by the fact that a test as simple and relatively benign as a DRE is not being given to half the men at a large VA Medical Center. It raises questions about whether the same trend is being seen in the primary care community on a national basis. We have previously expressed concern that American Cancer Society recommendations on testing for risk of prostate cancer don’t mention the DRE at all.

There is no doubt that mass, population-based screening for prostate cancer is controversial, but having a DRE at one’s annual physical exam is still a good idea for many reasons. A PSA test is no substitute for a DRE. Is the DRE a better test for risk of prostate cancer than a PSA test? Of course it isn’t: it is a different test. It is valuable because it is a different test. The two tests provide your doctor with distinct (and potentially useful) types of information, and for some men that DRE may be key to the early detection of aggressive forms of prostate cancer.

9 Responses

  1. Interesting … I never thought of the DRE as “non invasive”.

  2. Doug:

    An invasive test is one that actually requires sampling of tissue and the breaking of the skin to do so (e.g., a biopsy). A DRE doesn’t meet that standard. Assuming that the physician has washed his or her hands and is using sterile gloves, a DRE is no riskier than having a otoscope placed in your ear to look for problems associated with hearing or a thermometer placed in your mouth to take your temperature. The rectum is a perfectly normal body cavity (just like the mouth, the ears, the nose, and the vagina). Indeed, having a PSA test is actually more invasive and dangerous than a DRE because you have a needle placed in a vein to withdraw blood (a form of tissue).

    The fact that there are perceived taboos associated with rectal penetration doesn’t make the DRE an invasive test.

  3. One vet almost lost his life because of this. See this recent article in the Denver Post.

  4. How does the DRE signify a more aggressive cancer?

  5. Dear Gerald:

    I didn’t say that the DRE necessarily signifies a more aggressive cancer. However, a man with a low PSA (< 2.5 ng/ml) who already has a clearly palpable nodule on his prostate is certainly at significant risk for a more advanced form of prostate cancer than he would be if there was no nodule, simply because it is large enough to be able to feel it (if the nodule does turn out to be caused by cancer).


    I too have had the impression that guideline groups are downplaying the DRE. I’m wondering if this is another fallout of the blundering US Preventive Services Task Force recommendation against PSA screening. After all, we know that PSA is usually much better at signaling a likelihood of cancer than the DRE, so if you are going to dump PSA screening, it’s understandable that you would also dump the DRE. Both developments are unfortunate and no doubt will ultimately be tragic for many men!

    SIZE: Experienced urologists are pretty good at getting a rough but good size estimate based on the DRE.

    PSA DENSITY (PSAD): Research has indicated the importance of a PSAD value of less than 0.15 as one important piece of evidence that the patient likely does not have aggressive cancer, and a low density value can also aid in figuring out whether a biopsy is worthwhile. Without a DRE, in practical terms there is no way to calculate density (unless you move on to a scan such as an ultrasound, which seems unlikely just to assess density). Therefore, without a DRE, the thickness of the fog increases.

    EXPERTISE LOWER: Another concern Sitemaster obliquely raised is that expertise in assessing the prostate with a DRE is likely to fall as the medical community becomes more comfortable with this omission. Having had enough DREs for my challenging case to form some opinion on expertise levels, I’ll just say my layman’s impression is there is considerable variation, so decreasing expertise is not a good thing.

  7. Having a DRE by our primary care physician was the first indication my husband had a problem. His PSA was in the normal range. He was immediately sent to a urologist for further evaluation. This was in 2004 and further testing and biopsies revealed prostate cancer. I sincerely hope this quick, noninvasive exam continues to be offered. It can save lives and initiate treatment faster.

  8. My husband goes to private, non-VA doctors and hospitals. He was never offered a DRE and was treated for prostatitis for 2 years. His PSA was never higher than 2.0. He wasn’t offered a DRE until his PSA shot up to 120. By then, his cancer (Gleason score 8) had metastasized to his lungs and bones. Following only three treatments of hormone therapy, he has now been diagnosed as hormone refractory. He always had regular checkups, and this should have been caught when it was localized. If DREs are not recommended as a routine screening this puts men’s lives in danger.

  9. I am a 67-year-old male. All my previous doctor’s performed a DRE as part of my annual exam. My new doctor (the practice was sold) says DREs are ineffective. I disagree. I am going back to my doctor to ask for a referral to a urologist who will do it for me. No good reason not to!

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