“To DRE or not to DRE, that is the question”

With apologies to the Bard of Avon and his character Hamlet, the above-misquoted Prince of Denmark, we bring to your attention the most recent article by our good friend Howard Wolinsky on issues related to prostate cancer.

Howard’s latest article on the MedPage Today web site is actually entitled, “Digital rectal exams: worth the trouble?” It seems highly unlikely that either Hamlet or Shakespeare was ever told by his doctor that he needed a DRE.

Now we don’t always agree with Howard about everything (although we agree about a good deal), and this may be one of those times when we are not in full agreement.

It seems to your sitemaster that men over the age of about 45 divide into three easily characterizable groups:

  • Those who — for any one of several possible reasons — regard the DRE as a massive invasion of their privacy and are adamantly opposed to the whole idea
  • Those who don’t like it but are prepared to put up with it if it is really necessary and
  • Those who are utterly unbothered by the test

Howard appears to fall into the second group. Your sitemaster — who has probably had about 20 DREs conducted by his primary care physician over the past 20 or so years (at annual check-ups) — falls into the third group.

So let’s be clear that we agree with Howard about all of the following:

  • There is no good evidence whatsoever to suggest that — since the availability of PSA testing in the 1980s — having a DRE increases the probability of early diagnosis of prostate cancer for the vast majority of men.
  • There is a lot of evidence that what physicians actually thinks he or she feels on a DRE varies vastly from physician to physician.
  • DREs are very definitely an “uncomfortable subject, one tinged with grade-school sniggers and embarrassed red faces” for the majority of men.
  • The suggestion that every man over 50 should be getting a DRE as an essential part of his annual check-up and as a part of “screening” for prostate cancer is ridiculous and unjustifiable on the basis of any available data.

On the other hand — and this is important, and Howard and I do seem to agree about this although he doesn’t say so explicitly — there is a small subset of men who do get diagnosed early as a consequence of findings on DRE alone. Their PSA is usually stable and low. They have no other reason to suggest a problem. And as Howard points out, their only signal of risk is that they “have more advanced cancers large enough to be felt on the exam.”

For that small subset of men, the DRE is a critical diagnostic test.

So should all men over 45 or so be getting DREs on an annual basis?

No. It can’t be justified. But, as usual, we don’t see this as an “all or nothing” issue.

For the two sets of men who are either unbothered by the DRE or willing to put up with it, it might just save a few lives, really; and so, also as usual, we have a compromise opinion.

The DRE is a test that physicians should offer to their patients, noting that it is not essential but that it can, occasionally, have results that are critically important. No physician should insist on giving this test to a man at no other particular or well-defined risk for prostate cancer. There are much more accurate tests available today, but even most of those aren’t necessary annually for the majority of men.

We should add that the role of the DRE in the monitoring of men on active surveillance (like Howard) or after certain types of treatment for prostate cancer is a little more complex because having a DRE may be relevant to the need for a repeat biopsy, but it seems to your sitemaster that the same general guidance would apply.

12 Responses

  1. Digital Rectal Exam (DRE) Controversy

    I’m a prostate cancer survivor. In the summer of 2013 during a routine yearly medical checkup, my internist performed a digital rectal exam (DRE) and felt what he described as a hard nodule on my prostate. My PSA was only 1.6 ng/ml, which was well below the age-adjusted threshold for concern for someone age 63, which is a PSA < 4.5.

    Without the abnormal DRE, I would never have been sent to a urologist and ultimately undergone a biopsy with a PSA of only 1.6. The short story is that after the biopsy I was diagnosed with Gleason 6 prostate cancer Stage I, in one of the two lobes of the prostate. In November 2013 I had a robot-assisted laparoscopic prostatechtomy. My final pathology showed Gleason 7 prostate cancer in both lobes of the prostate. It was now Stage II adenocarcinoma of the prostate.

    Without the DRE by my internist, I would unknowingly still be walking around with Stage II prostate cancer perhaps progressing to Stage III.

    Since my prostate cancer diagnosis and surgery, I have been urging men to make certain that during their yearly medical checkups, they have their doctors give them a DRE. I would explain to them what happened to me and that without that DRE no red flag would have been waved and who knows if it would have been discovered in time. You see my dad died of prostate cancer at age 66 in 1978 and from initial presentation to a doctor till his passing took less than 1 year.

    My case is not an isolated one. I have received similar stories from many men describing how, without a digital rectal exam, they too would have gone undiagnosed and generally with a higher grade of prostate cancer. We may be "a small subset", but we exist. Food for thought!

  2. I like to think of it as “the fickle finger of fate.” And because prostate cancer detection and treatment is such a weird science, anything that can save lives should not be discarded summarily.

  3. Two reasons to do the DREs:

    (1) Some cancers do not increase one’s PSA, so unless a man wishes to have annual biopsies, the uncomfortable DRE is the only way to potentially discover such anomalies. “Potentially” because doing an informative DRE depends upon the skill and digital dexterity of the doctor.

    (2) One’s PSA can be a function of prostate size, as benign prostate tissue may produce from 0.1 to 0.15 ng/ml of PSA per cubic centimeter of prostate tissue. Unless a man is willing to have an annual ultrasound or MRI, the DRE is the only way to at least estimate the prostate size to evaluate a potentially abnormal PSA.

  4. Nice job, Shakespeare. Actually, I am unbothered by the DRE. But I think it was worth discussing because I know some men don’t like it. I spoke to a couple doctors about it. Actually three. One, an academic at the Cleveland Clinic, said he thought we could dispense with it. The other two felt it was important.

  5. In my case a DRE did not find my Gleason 9, stage pT3b prostate cancer because no prostate cancer existed in the small area of the prostate reached with this exam. So IMHO it’s a bogus, painful, humiliating, worthless exam.

  6. I seem to recall a Canadian study last year — maybe a meta-study, that found no value in DREs.

    Anecdotally, my issue lies around men with aggressive disease who make minimal PSA. There are men like that. I have a good friend I have been supporting for 10 years who had a PSA of 1.6 on diagnosis, and was found to have Gleason 4 + 4 disease based on post-RP pathology. Since surgery, his PSA has increased in small amounts to this day; it is still less than 0.2.

    It is clear to me that for some men a DRE does serve its purpose; moreover, while subjective, the test does not involve anything more than the invasion of personal privacy that many women are subjected to annually.

    My suggestion to men who decline a DRE is to at least get a PSA test — and hope you make PSA normally.

  7. In my 22+ years as a mentor to prostate cancer patients and their caregivers, I have known of several (albeit not multitudes) who, despite having low PSA level that would appear to not warrant a DRE, when the DRE was administered, hardness and/or nodules were found, indicating further concern to determine actual prostate cancer activity.

    Among these men were those with already advanced prostate cancer. I personally find it ridiculous that grown men abhor the DRE. It costs them nothing, takes only a few minutes, is not that uncomfortable, and might save them from finding later that, by not having had the DRE earlier, they were then found to have metastasized/advanced prostate cancer that could shorten their lives.

  8. My situation was similar to Jody’s, and although I was thankfully found to have only Gleason 6 (so far…), without the gentle ministrations of my urologist this would never have come to light.

    My internists have been doing this to me for years and I’ve always found it neither painful nor humiliating. It’s 10 seconds of your life. Compared to harboring more serious cancer that you might otherwise not find, it’s the quintessential no brainer.

  9. The DRE is what caught my Gleason 8 prostate cancer. The PSA was still very low but rising and standard protocol at the time would have been wait until the next annual physical and rerun the PSA test. I’d be dead now if we had done that.

    The DRE is simple and easy. I don’t understand how such a debate exists over something that can save a life.

  10. To say “… it ridiculous that grown men abhor the DRE” and “…is not that uncomfortableOne…” is very disrespectful, shows lack of compassion, and victim blaming. One in six men have been sexually abused or assaulted (source: 1in6.org).

    That does not even take into account men abused in a medical setting which is not considered assault (source: RAINN.org). Men are not going to disclose these incidents, instead they will avoid healthcare altogether.

    RIDICULING and GASLIGHTING them does NOTHING to increase screening rates.

    For some, the psychological trauma is worse than the risk of cancer.

  11. Archie Banterings is quite correct in that the entire scope of this discussion is myopic at best. I have colitis, diverticulosis, horrendous internal and external hemorrhoids, and celiac disease, I have had two perianal abscesses surgically removed (one without any pain killer whatsoever), I also have pain with every bowel movement, blood in the water after every bowel movement, and just had a discussion with my doctor about my prostate. I am very high risk, but if they feel torture and very prolonged pain (weeks to heal back to where I am now) is necessary as part of cancer screening, then why did they do an ultrasound on my liver? Wouldn’t it have been more appropriate to poke a hole in my rib cage and feel around with a finger?

    I’m okay with having a DRE, but they better anesthetize me first, and inject me with loads of lidocaine every few hours for a month thereafter. I will NOT be tortured by a doctor yet again. Pain. Excruciating, lasting pain! Not “discomfort” is what MANY of us face by having a finger put up our behinds. Yet somehow we’re being relegated by the article and commenters as people who can’t handle something very “simple and easy.” For you, maybe. I’d rather die (of cancer) than be tortured and humiliated again. Try having a deep, infected perirectal abscess drained and stuffed with gauze using scalpels, huge needles and no pain relief of any kind, then get back to me on why “simple and easy” is YOUR description of this, and not everybody’s description of this. I have enough pain as it is. If they can’t find a way to examine a prostate without using their finger, then they need to talk to my cardiologist to figure out how he learned that I have heart failure without having to jam his finger into my aorta.

  12. Dear Mr. Miller:

    Every patient is different. The vast majority of men don’t have all the problems you have. You are probably not a good candidate for a DRE. There are other tests that can be used to determine your risk for prostate cancer. If I was wearing your shoes I wouldn’t want to have a DRE either!

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: