From the Guidelines
A digital rectal examination (DRE) is not recommended as a screening method for colorectal cancer due to its very low sensitivity for advanced adenomas and cancer. The American Cancer Society guidelines, as updated in 2018 1, do not support the use of single-panel guaiac fecal occult blood test (gFOBT) in the medical office using a stool sample collected during a DRE for CRC screening. This is because the sensitivity of DRE for detecting colorectal cancer is limited, and it is not a reliable method for screening asymptomatic individuals.
Key Points to Consider
- The sensitivity of DRE for detecting advanced adenomas and cancer is very low, making it an inadequate screening method for colorectal cancer 1.
- The American Cancer Society recommends other screening methods, such as colonoscopy, fecal immunochemical testing, and flexible sigmoidoscopy, which have higher sensitivity and specificity for detecting colorectal cancer 1.
- A DRE may be performed as part of a comprehensive physical examination, but it should not be relied upon as the sole method for colorectal cancer screening.
- Patients should be informed about the limitations of DRE and the importance of using other screening methods to detect colorectal cancer early.
Recommendations for Colorectal Cancer Screening
- Adults at average risk for colorectal cancer should begin annual screening at age 50 years, with options including colonoscopy, fecal immunochemical testing, and flexible sigmoidoscopy 1.
- African Americans should initiate routine screening at age 45 years.
- Screening should be discontinued at age 75 years for persons who have prior negative screening or those with less than 10 years of life expectancy.
From the Research
Indications for Digital Rectal Examination (DRE) in Colorectal Cancer
- DRE can be indicated for colorectal cancer in certain situations, such as when a patient presents with red-flag symptoms like rectal bleeding, as seen in a case study of a 38-year-old male with early-onset rectal malignancy 2.
- The diagnostic value of DRE in primary care for palpable rectal tumor has been evaluated, showing a sensitivity of 0.762, specificity of 0.917, positive predictive value of 0.296, and negative predictive value of 0.988 3.
- However, the effectiveness of a single digital fecal occult blood test (FOBT) as a screening method for colorectal neoplasia is poor, with a sensitivity of 4.9% compared to 23.9% for the 6-sample at-home FOBT 4.
Limitations and Disparities in DRE Utilization
- DRE has become less routinely performed following its removal from cancer screening guidelines, resulting in low rates of utilization, with only 8.5% of outpatient encounters documenting a DRE between 2015 and 2020 5.
- Disparities in DRE utilization exist across sociodemographic factors, with non-Hispanic Black patients and Hispanic patients having lower rates of DRE documentation compared to non-Black patients and Non-Hispanic White patients, respectively 5.
- Men are more likely to have a documented DRE procedure than women, both overall and in encounters with primary care and surgical specialties 5.
Comparison with Other Screening Modalities
- The two most common colorectal cancer screening modalities are colonoscopy and the stool-based occult blood test, with the guaiac-based FOBT and the immunochemical FOBT being the two types of stool-based occult blood tests 6.
- The effectiveness of different screening modalities, including stool DNA and colonoscopy, has been compared in the literature, highlighting the importance of choosing the most appropriate screening method for individual patients 6.