Is it time to abandon the digital rectal exam?
The dreaded finger exam to check for prostate cancer used to be a mainstay of check-ups for older men. With its value now in question, some doctors share the risks and benefits with their patients and let them decide. So, should they or shouldn’t they?
“The evidence suggests that in most cases, it is time to abandon the digital rectal exam,” says Ryan Terlecki, M.D., a Wake Forest Baptist urologist who leads the Wake Forest Men’s Health Clinic.
Dr. Terlecki has published research on the topic in Current Medical Research and Opinion.
The digital rectal exam, referred to by some urologists as a “clinical relic,” subjects a large number of men to invasive, potentially uncomfortable examinations for relatively little gain. In addition, some men may choose not to undergo testing for prostate cancer.
“Our findings have been welcomed by patients and doctors alike,” Terlecki says.
The issue Terlecki’s team explored was whether the digital rectal exam 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 doctors continue to perform digital rectal exams in attempts to identify men with aggressive prostate cancer who could die from the disease,” says 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 digital rectal 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” digital rectal exam. 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 digital rectal exam 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 digital rectal exam in detecting significant disease. The current analysis confirmed that PSA is superior to digital rectal exam as an independent screen for prostate cancer.
“When PSA testing is used, the digital rectal exam rarely assists in diagnosing significant disease,” according to Terlecki. “In cases where PSA testing is used, the digital rectal exam should be abandoned in common clinical practice.”
There is still a place for digital rectal exam 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 digital rectal exam is also abnormal. He also stressed that this research had to do with screening for the disease in absence of a prior diagnosis. This is separate from men with a history of prostate cancer requiring surveillance.