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 (DRE),” said Ryan Terlecki, M.D., 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
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
“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
“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.
Until 2012, men over 50 (age 40 for African-Americans) were urged
to have both DRE and PSA tests annually. That was before the United States
Preventive Services Task Forces recommended against routine PSA testing because
it could lead to over-treatment of slow-growing, non-harmful tumors. The panel
did not address DRE, which was the primary method of detecting prostate cancer
prior to the blood test.
As a result of the task force’s recommendation, there has been
confusion and controversy about whether men should be screened for prostate
cancer. Some organizations recommend against any screening and others recommend
PSA screening, but only if men are counseled about the potential benefits and
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.