Should Digital Rectal Exam Still Be Used For Prostate Cancer Screening?

Ryan P. Terlecki, MD, FACS Director, Men's Health Clinic Director, Fellowship in Urologic Reconstruction, Prosthetic Urology, and Infertility Director, Medical Student Education Associate Professor of Urology Wake Forest Baptist HealthMedicalResearch.com Interview with:
Ryan P. Terlecki, MD, FACS
Director, Men’s Health Clinic
Director, Fellowship in Urologic Reconstruction, Prosthetic Urology, and Infertility
Director, Medical Student Education
Associate Professor of Urology
Wake Forest Baptist Health

Medical Research: What is the background for this study? What are the main findings?

Response: In recent years, the value of generalized screening for prostate cancer (PCa) in adult men has been questioned, with several national associations recommending against the practice in men without recognized risk factors. Screening, when performed, often consists of a blood test for prostate specific antigen (PSA) and a digital rectal exam (DRE). Once PSA was developed as a screening tool, we witnessed a stage migration such that observing a locally advanced cancer that would be initially found via DRE became a rarer event. In practice, we have noticed that some men will actually avoid a clinic visit because of the DRE. Additionally, the digital rectal exam has limitations and is often poorly reproducible among providers. We chose to review a large body of data to shed some light on the utility of the digital rectal exam exam. We analyzed data from the Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) Screening trial, to determine the ability of the digital rectal exam to result in a diagnosis of clinically significant PCa in the setting of a normal PSA. We found that if PSA is normal and digital rectal exam is considered abnormal, the chance of detecting a clinically significant cancer is similar to a situation of normal DRE and normal PSA. Also, 1,372 men would need to undergo a digital rectal exam to identify a single case of clinically significant prostate cancer not detected by PSA.

Medical Research: What should clinicians and patients take away from your report?

Response: We did find that if both PSA and DRE was abnormal, there was a higher chance of clinically significant PCa. Thus, if a patient has abnormal PSA and is ‘on the fence’ about having a biopsy, also having an abnormal DRE may lend more support to proceeding with the procedure.

The guideline from the American Urological Association (AUA) states that the literature supporting the efficacy of DRE as a screening test to reduce deaths from prostate cancer is too limited to draw conclusions. The panel responsible for creating the guideline stated that they could find no evidence to support the continued use of DRE as a first line screening test. This element of the guideline seems to be further supported by the findings of our analysis.

Medical Research: What recommendations do you have for future research as a result of this study?

Response: It should be determined if the digital rectal exam should disappear from routine urologic management in patients without a prior history of prostate cancer. If the AUA has already asserted that using the DRE as a first line screening tool is not supported by evidence, research should be directed at the use of DRE in the setting of benign disease. In regard to benign prostatic hyperplasia (BPH), decision-making is guided by patient symptoms (reflected in the AUA symptom score) and not by the DRE, which often poorly estimates the nature of the prostate and does not provide reliable information regarding the inner portion of the prostate, which is most relevant to urination.

Citation:

American Urological Society abstract May 2015:

Does digital rectal examination provide additional value in the era of PSA screening?: Lessons from the PLCO study

Cui, Tao (Winston Salem, NC); Cui, Tao; Kovell, Robert C; Kovell, Robert C; Brooks, David C; Brooks, David C; Terlecki, Ryan P; Terlecki, Ryan P

MedicalResearch.com Interview with: Ryan P. Terlecki, MD, FACS (2015). Should Digital Rectal Exam Still Be Used For Prostate Cancer Screening?