14 Mar Are Routine Digital Rectal Exams Helpful In Detecting Asymptomatic Prostate Cancer?

MedicalResearch.com Interview with:

Dr. Jason Profetto

Dr. Jason Profetto, MD, CCFP
Family and Academic Medicine
Chair, Clinical Skills
Undergraduate Medical Education
McMaster University

MedicalResearch.com: What is the background for this study?

 Response: The main reason that prompted me to investigate the issue of digital rectal exams in primary care for prostate screening was that it appeared to be rather dogmatic practice (continually practiced by many despite updated data suggesting a lack of benefit).  I was very curious to see if there was any data that suggested the digital rectal exams was indeed a useful indicator in primary practice (ie. Family Medicine) in detecting prostate cancer in asymptomatic men.  Intuitively, I didn’t believe the DRE was accurate mainly because in medical school it’s generally under-represented in clinical skills teaching and poorly taught and assessed (not just in Ontario, but also Canada).  As a result, it seemed bizarre to me that this specific clinical skills was being used as a routine measure in family medicine to screen for prostate cancer.  Also, for me this was a big issue as many men in my practice were used to having yearly “rectal exams” done and I thought it was time to really take a closer look at the research to see whether or not we can support this practice.

MedicalResearch.com: What are the main findings?

Response: The main findings suggest that the digital rectal exam is not helpful/accurate in detecting prostate cancer in asymptomatic men in family practice or primary care.

MedicalResearch.com: What should readers take away from your report?

 Response: The main take away from the report is that the routine, yearly “rectal exam” that has been done for decades really isn’t nearly has helpful in the detection of prostate cancer screening in asymptomatic men as once thought.  In fact, there is no evidence to substantiate it’s use in this context.   

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: Yes, I’ve received significant push back from both patients and physicians suggesting that our conclusions are short-sighted and generally “wrong”.  I find that patients who have been diagnosed with prostate cancer via a digital rectal exam are most concerned with my findings (which I do appreciate).  Similarly, physicians who believe they can accurately detect prostate cancer in asymptomatic men or physicians who have indeed caught cancer before using a digital rectal exams have pushed back the most and offered rebuttals to our conclusions.  Many will cite anecdotes of when they caught prostate cancer by doing a simple DRE as their main source of evidence.  While I sympathize with this cognitive process, it still is indeed a logical fallacy to suggest this is evidence to the positive.

The truth is that there is no evidence to support the routine use of the DRE in detection of prostate cancer in asymptomatic men.  THIS is what the research looked at.  The digital rectal exams is still arguably a useful clinical skill in many contexts, specifically rectal cancer, rectal bleeding, hemorrhoidal pathology, BPH and several other anorectal issues.

Also, we must concede that true “evidence-based medicine” is contingent on what the physician thinks, the patient feels/wishes, and what the data suggests.  Therefore even a guideline will have it’s rules and exceptions without anything specific written in stone.  Medicine is a dynamic field and clinical acumen is something that is taught/learned over years and decades.

Next step?

1) To determine if the digital rectal exams adds any benefit in addition to the PSA in prostate cancer screening (Many will argue it doesn’t, some suggest it does).

2) To determine how to better teach the DRE in medical school and how to deliver more accurate assessments of medical students whom are expected to graduate with this skill.

3) To assess the accuracy of the DRE in other diagnostic processes.

MedicalResearch.com: Is there anything else you would like to add?

Check out my new book!

In The Trenches; the Daily Grind of Family and Academic Medicine

http://www.icbookstore.ca/inthetrenches

Citations:

Leen Naji, Harkanwal Randhawa, Zahra Sohani, Brittany Dennis, Deanna Lautenbach, Owen Kavanagh, Monica Bawor, Laura Banfield, and Jason Profetto

Digital Rectal Examination for Prostate Cancer Screening in Primary Care: A Systematic Review and Meta-Analysis
Ann Fam Med March/April 2018 16:149-154; doi:10.1370/afm.2205 

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Last Updated on March 14, 2018 by Marie Benz MD FAAD