Originally published 4/2/2020
Four years after we posted the blog below, physicians are still scratching their heads over whether or not the digital rectal exam (DRE) has a useful place as a screening tool for prostate cancer (PCa). Frankly, it seems inconceivable that anyone is still asking, given the substantial body of evidence that the screening pathway was been revolutionized by the addition of MRI. However, many traditionalists are still donning rubber gloves, lubricating fingers, and probing what the British call “the back door.”
The latest published study (2024) comes from an impressive multinational team of 16 researchers, out of numerous countries in Asia, Europe, the Middle East, and the U.S. They reviewed previous literature covering over 85,000 cases of PCa detection. They conclude: “Our comprehensive review and meta-analysis indicates that both as an independent test and as a supplementary measure to PSA for PCa detection, DRE exhibits a notably low diagnostic value. The collective findings from the included studies suggest that, in the absence of clinical symptoms and signs, DRE could be potentially omitted from PCa screening and early detection strategies.”[1]
Hopefully, this will put the matter to rest. Ditch the DRE.
I wonder how many men put off getting a physical because of the digital rectal exam (DRE)? While the DRE has comic value in movie and TV scenes (the doctor snaps on a rubber glove while the man on the table looks like he’d rather walk on hot coals), a question circulating among urologists and primary care doctors is whether it still has screening value. Screening means using a readily available, relatively inexpensive method to detect a suspicious abnormality, for example, breast mastectomy screens for breast cancer and colonoscopy for colon cancer.
Screening for prostate cancer
The two most widely used methods to screen for prostate cancer (PCa) are the PSA (prostate specific antigen) blood test and the DRE. The DRE has been around for a long time. Until the PSA blood test was developed and put to broad use in the early ‘90s, the DRE was the only way to screen PCa. It is simple and cheap. By inserting a gloved, lubricated finger in the rectum, a doctor can palpate (feel) the closest surface of the prostate gland on the other side of the rectal wall. A normal gland feels firm and has no irregularities. However, if the doctor feels a hard spot or bump, it could mean PCa. The problem is, as a screening tool it’s very limited. Since it is impossible to move the finger around the whole gland, the information is incomplete; therefore, in the conventional standard of care, there will also be a PSA test, imaging, and probably a biopsy. An August, 2019 online opinion poll asked if the DRE had relevance as a PCa management tool. Of the 1089 respondents, 78% voted yes, 16% voted no, and 6% weren’t sure.[2] Since that was an informal survey, let’s turn to formal published literature on the subject.
Review of published opinion
Here is a chronology of pro and con opinions over several decades:
- 1964 – “No physical examination of the male, especially after the fourth decade, is complete without a digital rectal examination.”[3]
- 1999 – “Neither a positive nor a negative [DRE] test result is sufficient to enable conclusions without further confirmation.”[4]
- 2006 – “…DRE results are most informative when evaluated in conjunction with other clinical and demographic information.”[5]
- 2011 – “The American Cancer Society’s updated screening guidelines for prostate cancer (CaP) render digital rectal examination (DRE) optional.”[6]
- 2014 – It’s a key part of the assessment for PCa because, “It can independently identify patients at risk of prostate cancer, with a substantial proportion of these having clinically significant disease requiring treatment.”[7]
More recently, we find a growing number of opinions emerged that the DRE is losing its status:
- 2018 – “Given the considerable lack of evidence supporting its efficacy, we recommend against routine performance of DRE to screen for prostate cancer in the primary care setting.”[8]
- 2018 – “…this review questions the benefit of performing a DRE in primary care.”[9]
- 2019 – “Is digital rectal examination still useful in prostate cancer diagnosis? NO!”[10]
The detection and diagnostic value of mpMRI
The DRE, especially in conjunction with PSA testing, has had its place in the detection of PCa. Despite its inadequacy due to the limited anatomy it could access, it did detect some cancers—though rarely—in men whose PSA was considered normal. It is to be expected that there are still hangers-on who maintain the value of a DRE, but urologist Bert Vorstman, MD pulls no punches about tossing it out:
Performing this feeble test every few months during so-called surveillance makes no scientific sense; can be very uncomfortable; is especially unreliable for detecting the potentially deadly 15% or so of high-grade cancers early and, the examination is often abused by dishonest urologists to push patients towards more profitable evaluations because of ‘feeling something’; sensing a ‘nodule’ or, feeling ‘unevenness’ (asymmetry, which is normal).[11]
Dr. Vorstman may be happy that the DRE Is increasingly being eclipsed by advanced imaging. A growing body of published research makes a forceful case to keep the PSA, but follow a suspicious result with multiparametric MRI (mpMRI) of the prostate. There is no comparison between DRE’s low accuracy vs. the high definition tissue characteristics revealed by mpMRI. It’s clear to me that, thanks to our ability to capture a portrait of prostate tumors anywhere in the gland, the DRE has all but lost its relevance.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
References
[1] Matsukawa A, Yanagisawa T, Bekku K, Kardoust Parizi M, et al. Comparing the Performance of Digital Rectal Examination and Prostate-specific Antigen as a Screening Test for Prostate Cancer: A Systematic Review and Meta analysis. Eur Urol Oncol. 2024 Jan 4:S2588-9311(23)00292-4.
[2] https://www.urologytimes.com/poll/poll-dre-still-relevant-tool-management-prostate-cancer
[3] Garvin, CH. Carcinoma of the Prostate: The Value of Digital Rectal Examination in Diagnosis. J Natl Med Assoc. 1965 Jan; 57(1): 13–15.
[4] Hoogendam A, Buntinx F, de Vet HC. The diagnostic value of digital rectal examination in primary care screening for prostate cancer: a meta-analysis. Fam Pract. 1999 Dec;16(6):621-6.
[5] Issa MM, Zasada W, Ward K, Hall JA et al. The value of digital rectal examination as a predictor of prostate cancer diagnosis among United States Veterans referred for prostate biopsy. Cancer Detect Prev. 2006;30(3):269-75.
[6] Chu DI, DeNunzio C, Gerber L, Thomas II J-A et al. Predictive value of digital rectal examination for prostate cancer detection is modified by obesity. Prost Canc and Prost Diseases. 2011;14:346-53.
[7] Walsh AL, Considine SW, Thomas AZ, Lynch TH, Manecksha RP. Digital rectal examination in primary care is important for early detection of prostate cancer: a retrospective cohort analysis study. Br J Gen Pract. 2014 Dec;64(629):e783-7.
[8] Naji L, Randhawa H, Sohani Z, Dennis B et al. Digital Rectal Examination for Prostate Cancer Screening in Primary Care: A Systematic Review and Meta-Analysis. Ann Fam Med. 2018 Mar;16(2):149-154.
[9] Jones, D., Friend, C., Dreher, A. et al. The diagnostic test accuracy of rectal examination for prostate cancer diagnosis in symptomatic patients: a systematic review. BMC Fam Pract 19, 79 (2018).
[10] Totaro A. Is digital rectal examination still useful in prostate cancer diagnosis? NO! Urologia. 2019 Feb;86(1):32-33.
[11] Vorstman, B. “Prostate Cancer Treatment – Deception and Lies.” Feb. 21, 2019. https://medium.com/@bvorstman/prostate-cancer-treatment-deception-and-lies-30e23f17b749.
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
