From the Guidelines
Prostate examination is recommended for men starting at age 50, or earlier (age 45) for those with risk factors such as African American heritage or family history of prostate cancer, with a shared decision-making approach considering the potential benefits and harms of screening. The standard approach involves a digital rectal examination (DRE) performed by a healthcare provider, where a lubricated, gloved finger is inserted into the rectum to feel the prostate gland through the rectal wall 1. The examination typically takes less than a minute and while it may cause mild discomfort or pressure, it shouldn't be painful. Before the exam, you should inform your doctor about any medications you're taking, particularly blood thinners, and mention any previous prostate issues. No special preparation is required, though some men prefer to empty their bladder beforehand for comfort.
Key Considerations
- The DRE is often performed alongside a PSA (prostate-specific antigen) blood test for more comprehensive screening 1.
- The examination is important because it can detect abnormalities such as enlargement, inflammation, or potentially cancerous nodules that might not be identified through blood tests alone, allowing for early intervention when treatment is most effective.
- Clinicians should inform men between the age of 50 and 69 years about the limited potential benefits and substantial harms of screening for prostate cancer, and base the decision to screen on the risk for prostate cancer, a discussion of the benefits and harms of screening, the patient's general health and life expectancy, and patient preferences 1.
- Asymptomatic men older than 75 years or those who have a life expectancy less than 10 years should not be offered prostate cancer screening due to the substantial harms associated with prostate cancer screening and treatment relative to questionable benefits 1.
Screening Approach
- Screening is recommended with PSA with or without DRE for men who choose to be screened for prostate cancer after considering the possible benefits and risks 1.
- Screening should be conducted yearly for men whose PSA level is 2.5 ng/mL or greater, and for men whose PSA is less than 2.5 ng/mL, screening intervals can be extended to every 2 years 1.
- A PSA level of 4.0 ng/mL or greater historically has been used to recommend referral for further evaluation or biopsy, which remains a reasonable approach for men at average risk for prostate cancer 1.
From the Research
Prostate Examination Approaches
The recommended approach for a prostate examination is a topic of ongoing debate.
- Digital rectal examination (DRE) is a traditional method used to detect prostate cancer, but its effectiveness as a screening tool has been questioned 2, 3.
- Prostate-specific antigen (PSA) testing is another common method used to detect prostate cancer, and it has been shown to be more effective than DRE in detecting cancer 4, 3.
- Some studies suggest that combining DRE and PSA testing may not be more effective than using PSA testing alone 2, 5.
Diagnostic Value of DRE
The diagnostic value of DRE has been found to be low in several studies.
- A systematic review and meta-analysis found that the positive predictive value of DRE was 0.21, which is similar to the positive predictive value of PSA testing 2.
- Another study found that the cancer detection rate of DRE was significantly lower than that of PSA testing, and that combining DRE and PSA testing did not improve the detection rate 4.
- A study published in 2023 found that DRE was not a useful screening test for prostate cancer, with a detection rate of 0.05% compared to 0.21% for PSA testing 3.
Clinical Implications
The findings of these studies have important clinical implications.
- They suggest that DRE may not be a necessary component of prostate cancer screening, especially in men with a low risk of prostate cancer 5, 3.
- However, other studies suggest that DRE may still have a role in detecting prostate cancer, especially in men with a high risk of prostate cancer or those who have not undergone PSA testing 6.
- Ultimately, the decision to use DRE as a screening tool should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 4, 6.