Is The DRE on Its Way Out

The first time you hear that your doctor is going to give you a digital rectum exam (DRE), you think, “Well, that's cool, sounds pretty high tech... I wonder if it works by wi-fi or bluetooth?” And then when you realize that “digital” refers to “digit, as in his finger,” you begin to wonder if the whole thing is really necessary...

As it turns out, it may not be.

“The evidence suggests that in most cases, it is time to abandon the digital rectal exam,” said Ryan Terlecki, MD, a Wake Forest Baptist urologist who recently published an article on the topic in Current Medical Research and Opinion. “Our findings will likely be welcomed by patients and doctors alike.”

Terlecki said the DRE, referred to by some urologists as a “clinical relic,” subjects a large number of men to invasive, potentially uncomfortable examinations for relatively minimal gain. In addition, it may deter some men from undergoing any test for prostate cancer.

The issue Terlecki’s team explored was whether the DRE is needed when another more accurate test that measures prostate-specific antigen (PSA) in the blood is available. PSA is a protein that is often elevated in men with prostate cancer.

“Many practitioners continue to perform DRE in attempts to identify men with aggressive prostate cancer who could die from the disease,” said Terlecki. “In the era of PSA testing, we wanted to explore whether it’s time to abandon the digital exam.”

To reach their conclusion, Terlecki’s research team reviewed both medical literature and the results of a nationwide screening trial in which 38,340 men received annual DRE exams and PSA tests for three years. They were then followed for up to 13 years.

Of interest to Terlecki’s team were the 5,064 men who had a normal PSA test but an “abnormal” DRE. Only 2 percent of these men had what is known as clinically relevant prostate cancer, which means it may need to be monitored or treated.

“The DRE does capture an additional small population of men with significant prostate cancer, but it also unnecessarily subjects a large number of men to the test,” he said.

In previous studies, PSA had been shown to outperform DRE in detecting significant disease. The current analysis confirmed that PSA is superior to DRE as an independent screen for prostate cancer. PSA testing detected 680 cases of significant cancer, compared to 317 cases for DRE.

“When PSA testing is used, the DRE rarely assists in diagnosing significant disease,” said Terlecki. “In cases where PSA testing is used, the DRE should be abandoned in common clinical practice.”

There is still a place for DRE testing for certain patients, Terlecki said. For example, a patient with abnormal PSA who is “on the fence” about having a biopsy, may feel more comfortable proceeding with the procedure if a DRE is also abnormal, he said.