Is digital rectal examination (DRE) valuable for prostate cancer screening based on current evidence?

From the Guidelines

Digital rectal examination (DRE) is not recommended as a primary screening tool for prostate cancer due to its low sensitivity and specificity, and its role in screening is limited to being a complementary examination to prostate-specific antigen (PSA) testing. The evidence from recent studies, such as the 2013 guidance statement from the American College of Physicians 1, suggests that the benefits of prostate cancer screening do not outweigh the harms for most men, and the USPSTF recommends against screening using the PSA test. The American Cancer Society also emphasizes the importance of shared decision-making regarding testing, stating that PSA testing and DREs should be offered annually beginning at age 50 years to men with a life expectancy of at least 10 years 1.

Key Points

• The sensitivity and specificity of DRE screening are dependent on the examiner, and therefore, considerable variability can occur with this test.
• Many abnormalities detected by DRE are not cancerous, leading to unnecessary biopsies.
• The limited value of DRE stems from its inability to detect many significant cancers, particularly those in the anterior prostate.
• While DRE remains important for symptom evaluation and in conjunction with elevated PSA values, its role as a standalone screening tool has diminished as more sensitive and specific methods have emerged.
• The harms of prostate cancer screening are substantial and include false alarms, overdiagnosis, anxiety, and discomfort, as well as the risks associated with treatment, such as urinary, gastrointestinal, and sexual problems.

Recommendations

• Men considering prostate cancer screening should engage in shared decision-making with their clinicians, starting at age 50 for average-risk men and age 45 for high-risk men.
• If screening is pursued, a baseline PSA test with potential follow-up every 2-4 years is reasonable, with more frequent testing for higher PSA values.
• Clinicians should not screen for prostate cancer in men who do not express a clear preference for screening, and should help men judge the balance of benefits and harms and discuss whether the harms outweigh the potential reduction in prostate cancer mortality in their particular cases.

From the Research

Digital Rectal Examination (DRE) in Prostate Cancer Screening

• The value of DRE in prostate cancer screening has been debated, with some studies suggesting it is a valuable tool when used in combination with prostate-specific antigen (PSA) testing 2, 3, 4.
• A study from 1993 found that the combined use of DRE and PSA testing provides a more complete evaluation of the prostate gland for malignant involvement 2.
• Another study from 1994 reported that the combination of PSA and DRE seems to improve the stage of diagnosis of patients with prostate cancer 3.
• A multicenter clinical trial published in 2017 found that the use of PSA in conjunction with DRE enhances early prostate cancer detection, and that prostatic biopsy should be considered if either the PSA level is greater than 4 μg./l. or DRE is suspicious for cancer 4.
• A prospective cohort analysis study from 2023 investigated the diagnostic efficacy and adjunctive role of DRE in a population suspected of prostate cancer, and found that DRE may help physicians further judge the necessity of biopsy in patients with elevated PSA 5.
• However, a systematic review and meta-analysis published in 2024 found that DRE exhibits a notably low diagnostic value, and that the screening strategy combining DRE and PSA was not different from that of PSA alone in terms of cancer detection rate and positive predictive value 6.

Comparison of DRE and PSA

• Studies have compared the performance of DRE and PSA as screening tests for prostate cancer, with some finding that PSA is more effective than DRE in detecting prostate cancer 4, 6.
• A study from 2024 found that the pooled positive predictive value of DRE was similar to that of PSA, but the cancer detection rate of DRE was significantly lower than that of PSA 6.
• The same study found that the combination of DRE and PSA did not provide a significant benefit over PSA alone in terms of cancer detection rate and positive predictive value 6.

Clinical Implications

• The use of DRE in prostate cancer screening may be valuable when used in combination with PSA testing, particularly in patients with elevated PSA levels 2, 3, 4.
• However, the low diagnostic value of DRE as an independent test or as a supplementary measure to PSA suggests that it may not be necessary to conduct DRE routinely in asymptomatic men 6.
• Further studies are needed to determine the optimal role of DRE in prostate cancer screening, particularly in the context of modern screening strategies that incorporate PSA testing and other diagnostic tools 5, 6.