Why has it taken so long for someone to denounce the digital rectal exam (DRE) as a screening tool? Despite expert opinion against the DRE, many primary care doctors still do a DRE as part of routine annual checkups. The DRE has also been considered an essential monitoring practice for prostate cancer (PCa) patients on Active Surveillance (AS).

MRI vs DRE in Active Surveillance

Regarding use of the DRE as part of AS, in early 2023 a panel of experts issued a statement that during AS, “best [current] practice includes the use of high-quality magnetic resonance imaging” which can allow discontinuing DREs.^[i] Since men on AS have already been diagnosed with PCa, multiparametric MRI (mpMRI) is essential for monitoring their disease. There is no question that such imaging is far more accurate, rendering DRE pointless for surveillance.

DRE for Prostate Cancer Screening?

This raises the question, does DRE have value for broad screening? Proponents argue that it’s fast and virtually free as part of annual physicals. As healthcare expenditures go, it doesn’t get cheaper than that! However, the evidence stacks up against DRE as a routine screening tool.

In October 2023, a large panel of German experts in urology, radiology and oncology published their evaluation of DRE’s diagnostic performance in a large scale screening trial (over 46,000 men screened by PSA and DRE. For purposes of their statistical analysis, “(1) DRE was analyzed as a one-time, stand-alone screening offer at age 45 in 6537 men in one arm of the trial and (2) PCa detection by DRE was evaluated at the time of PSA-screen-driven biopsies (N = 578).”^[ii]

They concluded, “The performance of stand-alone DRE to screen for PCa is poor. DRE should not be recommended as a PCa screening test in young men. Furthermore, DRE does not improve the detection of PSA-screen-detected PCa.” Thus, the rule of thumb is, dump the DRE for routine screening and for AS monitoring.

Are there exceptions to the rule?

Dr. Mark Scholz, a respected medical oncologist, issues a word of caution against dropping the DRE altogether. While admitting it’s a poor screening tool, he points out that there are some dangerous PCa variants that do NOT produce a rise in PSA, but depending on their location in the gland, a DRE may pick up what he calls consequential prostate cancers. Numbers show a very small incidence of this. In 2016, a team of authors published an analysis of 38,340 men who had annual PSA tests plus DREs. Out of that group, 5064 had normal PSAs but abnormal (suspicious) DREs—but only 99 of them (2%) were diagnosed with clinically significant PCa.^[iii] One of the authors, Dr. Ryan Terlecki, was quoted in a Science News press release, “In cases where PSA testing is used, the DRE should be abandoned in common clinical practice.” He did, however, allow for a case in which a patient with an abnormal PSA is reluctant to have a biopsy, but will agree to a DRE; should there be a palpable lump, he may then agree to proceed to a needle biopsy.

Let’s face it. MRI is far more accurate than DRE, and it makes DRE superfluous. This is not a sudden revelation. Five years ago, a multicenter Canadian team had already reached the conclusion to ditch the DRE. After reviewing previously published literature, they wrote, “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.” One can only imagine the millions of men who will breathe a sign of relief when they show up for their annual physical—knowing there will be no lubricated, gloved finger interrogating their rectal wall to feel if there’s a lump behind it.

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

[i] Moore CM, King LE, Withington J, Amin MB et al. Best Current Practice and Research Priorities in Active Surveillance for Prostate Cancer-A Report of a Movember International Consensus Meeting. Eur Urol Oncol. 2023 Apr;6(2):160-182.
[ii] Krilaviciute A, Becker N, Lakes J, Radtke JP et al. Digital Rectal Examination Is Not a Useful Screening Test for Prostate Cancer. Eur Urol Oncol. 2023 Oct 6:S2588-9311(23)00203-1.
[iii] Cui T, Kovell RC, Terlecki RP. Is it time to abandon the digital rectal examination? Lessons from the PLCO Cancer Screening Trial and peer-reviewed literature. Curr Med Res Opin. 2016 Oct;32(10):1663-1669.