The role of the digital rectal examination in prostate cancer today

The question of whether digital rectal examinations (DREs) retain value in testing men for risk for prostate cancer (individual “screening”) has been controversial for many years now. Some men flatly refuse to have DREs for socio-cultural reasons. Others will put up with them, but they don’t like the idea. This is utterly unsurprising.

A new paper by Cui et al. in the journal Current Medical Research and Opinion argues, on the basis of a reanalysis of data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Screening Trial, that the benefit of adding a DRE to PSA data in testing men for risk of prostate cancer

subjects a large number of men to invasive, potentially uncomfortable examinations for relatively minimal gain.

However, as the authors themselves acknowledge, there are so many problems with the data from the PCLO trial that using such data to justify almost anything related to how to test men well for risk of prostate cancer may be questionable.

Cui et al. showed that, based on their analysis of the PCLO data, adding a DRE to PSA data led to the diagnosis of just 99/5,064 men found to have clinically significant prostate cancer (2 percent) — all 99 of whom who had an abnormal DRE but a “normal” PSA level. However, other data have suggested that men who have an abnormal DRE in conjunction with a “normal” PSA level are actually at significant risk for aggressive forms of prostate cancer … and if that is true then the value of a DRE is really quite clear.

The “New” Prostate Cancer InfoLink has believed for some time that the clinical situation here is a simple one that is easy for any primary care physician or urologist to understand and implement.

Faced with a man who either wants to be tested or who the physician feels should be tested for his risk for prostate cancer, the physician should:

  • Ensure that the patient provides a blood sample for a PSA test (or any such other test as the doctor feels is appropriate)
  • Inform the patient that by carrying out a DRE and palpating the prostate, the physician will gain additional information about the prostate which will (or at least may) help him or her to
    • Identify nodules or hard areas that will suggest increased risk for prostate cancer
    • Identify a “spongy” prostate that is suggestive of benign prostatic hyperplasia
  • Explain that a DRE may feel embarrassing, difficult, or “uncomfortable” for the patient, but it is not painful and takes a matter of a few seconds
  • Ask the patient whether he is willing to have a DRE and then give it or not depending on the patient’s response and note whether the DRE was carried out or whether the patient refused a DRE in the patient’s medical record.

For that small percentage of patients who are diagnosed early only because they had a positive DRE, the DRE may be a life-saving procedure. Conversely, for those men who are utterly unwilling or unable to consider the DRE (regardless of their reasons), it is perfectly reasonable that they should be allowed to exercise their free will on this topic.

Frankly, we don’t understand why this is an issue at all any more. The DRE is an easy and cheap test to carry out. And for many men it isn’t even a big deal at all. Why wouldn’t we want to offer DREs to men who might benefit from this test — with the full recognition that it is not “essential” and that (like almost every other test used in medicine today) its value may be limited to a subset of the target population?

As we have seen numerous times before, some people insist in turning clinical issues into “black vs. white” dichotomies when it is perfectly reasonable to think in terms of “shades of grey.” No one should “have to have” a DRE if they are categorically opposed to this. On the other hand, every man should be at least offered such a test because they may fall into that 2 percent for whom an early positive result might be life-saving.

11 Responses

  1. “there are so many problems with the data from the PCLO trial”

    There was a lot more PSA screening in the screening arm of PLCO than the control arm. Lots more PSA screening -> lots more prostate cancers detected -> Nada additional lives saved

    PSA and DRE screening: both useless disasters.

  2. Good advice — ask the patient. Another area of discussion that seems forbidden or maybe simply unknown is how to do a DRE. My own physician had me lie on my side and the process was kind of awkward. Another physician asked (or told, I can’t remember) me to bend over. The bent over process was much easier, more comfortable and quicker.

  3. I am old enough now to be able to remember the late Dr. Thomas Stamey (then Chairman of the Department of Urology at Stanford University) telling a roomful of urologists that “the best” way to do a DRE was to ask the patient to kneel on the exam table and then lean forward and place his head on the exam table too.

    Whether there is really a “best” way to position the patient to do an DRE may actually depend on just how thorough the physician wishes to make the DRE, and also on the age and health of the patient. I can imagine that the position recommended by Dr. Stamey might be a little difficult for some older patients.

  4. My DRE suggested an abnormality with the prostate. … My PSA suggested there was no need to do a biopsy … just wait and see. We did that for one year and when [the urologist] finally did a biopsy, it was definitive that I had a large number of proliferated cells that were malignant! Too bad more value wasn’t placed on the DRE initially. The DRE is a small invasion that should not be discarded as unimportant. It is one of a few indicators that raise the red flag!

  5. Compared to a biopsy, it’s a walk in the park!

  6. With a strong family history of prostate cancer (father, brother) and a rising PSA and a Gleason of 3+3, I consulted with several teaching hospitals in Boston. All confirmed the initial diagnosis and recommended active surveillance. Except one specialist who “felt something” during the DRE. He recommended MRI guided biopsy which resulted in a Gleason 4+3=7. Surgery confirmed Gleason 7. Better to “explore” every avenue, so to speak.

  7. PSA was 2.6 — not alarming for a 60-year-old. But DRE was positive (small nodule). Clinical stage T2a; pathologic stage pT3a; Gleason 3 + 4 = 7.
    I would never have gone for treatment without the DRE. Good catch by the GP!

  8. My new doctor did not even mention DRE at my physical. I’m 60 and have had several DREs for BPH.

  9. Greg: Did you say anything to him about that?

  10. You used poor grammar — You said “it’s value” and it should be “its value” — “its” is possessive … “it’s” is a contraction.

    Second — the American Academy of Family Physicians has declared the DRE and PSA test as unnecessary.

    Also — I could not print this article — nothing works on your website.

  11. Dear Mr. Franks:

    (1) You are partially correct. There was a typo” (“it’s” when it should have been “its”). Typos happen. That’s life. A typo, however, is not necessarily a grammatical error.

    (2) Nowhere in this article does it state that the DRE test is “necessary”. However, medicine is not engineering. There are plenty of men who only ever got diagnosed with high-risk prostate cancer before it metastasized because they had a DRE. The entire point of the article was that making absolute statements about what is appropriate medical practice depends on what is appropriate for the individual patient. My own primaryt care physician (for example) does not agree with the AAFP at all. The appropriate use of the digital rectal exam remains a highly controversial issue, and has been for most of the past 15 years.

    (3) I think you have either a software problem or a printer problem. I was just able to print this article with no problem at all.

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