The continuing importance of the digital rectal exam

Many men dislike digital rectal examinations (DREs) — for all sorts of reasons. However, a new study has again pointed out the value of the DRE in helping to establish clinical risk and the potential aggressiveness of a specific prostate cancer diagnosis in each individual patient.

The full text of this new paper by Borkenhagen et al., just published in the Journal of the National Comprehensive Cancer Network, is available on line. Basically, it documents the clear fact that the differences between the subsets of clinical stage T2 disease can be very important (and very low-cost) factors in establishing risk for an individual patient — both on their own and then in combination with other data. Interested patients and other individuals can therefore read this full text for themselves.

In particular, Borkenhagen et al. note the importance of the DRE is establishing the appropriate treatment for men with higher risk forms of prostate cancer.

Prostate Cancer International would also observe that the DRE can also be very important in establishing risk for prostate cancer in some men who have no other clear evidence of risk whatsoever (i.e., a “normal” PSA level).

Male squeamishness about being given a DRE is understandable. However, we would observe that this test is as nothing to what women need to put up with in being given their annual gynecological examinations, and a DRE holds the potential to save the lives of some men by ensuring early treatment for higher-risk forms of prostate cancer that may not be evident on the basis of a PSA test.

7 Responses

  1. Yet not a word about the benefits of multiparametric MRI.

  2. Thank you, Sitemaster, for pointing out the importance of DREs for ‘men who have no other clear evidence of risk whatsoever (i.e., a “normal” PSA level).’

    Just this past week we supported another gentleman with Gleason 10 prostate cancer showing lymphatic involvement (N1) who produces negligible PSA — approx 1.0 ng/ml reading at time of his RP. Fortunately he was symptomatic at diagnosis with a GP who did not believe in either DREs or PSA testing — not that it would have shown remarkable.

    Like other men with low PSA production that we have navigated, his issue now is how best to monitor for risk of recurrence.

  3. I thought that it might be useful to re-post my March 2019 post:
    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. The previous year, my PSA was 1.8.

    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. In fact, the urologist tried to dissuade me from the biopsy as neither he nor his PA could feel anything abnormal. 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 pT2c. 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!

  4. Dear Murray:

    This study had nothing to do with MRIs. It was about the value of DREs, which cost near to nothing, and could suggest that a man who has a “normal” PSA level might actually be at significant risk for prostate cancer (which would probably then lead to him getting an MRI which no one would otherwise have thought was needed). See the other comments posted that describe specific patients meeting these criteria. No one would have even thought about giving these patients an MRI unless they had had a positive DRE.

  5. Dear Sitemaster,

    Yes, you are correct, this study has nothing to do with MRI, and this is my very point. If a man has any concern for prostate cancer he should seek out a multi-parametric MRI. The widely accepted data on DREs is that they miss three out of four cancers, and almost always identify an advancing cancer; not early stage. I know, this was the case for me. Further to the shortcomings of this article, it does not address the actual best-practice procedure; which is having the man lay on a table and alternately draw a knee towards his chin. I learned this and about mpMRI in Europe in 2014; my cancer had been missed for several years in USA despite PSA and DRE screening. Regards, Murray

  6. Dear Murray:

    First, there is no one “best practice” with regard to how to do a DRE. Some of the world’s very best urologists from the time when there was no PSA test and no MRIs or anything else had different opinions about how best to carry out a DRE. The one you describe is one of them. It takes skill and experience to carry out a thorough DRE and the positioning of the patient actually depends to some extent on exactly what part of the prostate you are trying to feel, as well as on the individual anatomy of the individual patient.

    Second, MRIs can also miss a whole bunch of early cancers, and the only thing that this article is saying is that DREs remain an important factor in prostate cancer testing and management. This article is not in any way intended to review best practices in the overall management of risk for either initial diagnosis of prostate cancer or its recurrence after first-line treatment. There are now a whole bunch of other tests that have relevance to specific subsets of patients in the initial diagnosis and the management of prostate cancer. MRIs and DREs are just two of those tests that are appropriate for specific patients with specific clinical signals. I can think of at least a dozen other possible tests that may be relevant and appropriate to the initial diagnosis and prognosis of differing types of patient.

  7. I support our Sitemaster’s comments and also observe that @Murray Wadsworth misses the point of this article and post.

    No one is debating the value of multiparametric MRIs. If these were not made available to Mr. Wadsworth in the US, it is highly likely he was not attending NCCN or NCI Centers of Excellence. Back in 2014 many of these centers had this technology available.
    The way I see this post and article, it points out the DRE is a good starting point. It can be used as a supplementary tool to help early identification of prostate cancer indicating the need for an mpMRI especially in the absence of an elevated PSA.

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