Is a Digital Rectal Exam (DRE) still recommended?

From the Guidelines

A digital rectal examination (DRE) is still recommended as part of routine screening for prostate cancer in men, particularly when combined with prostate-specific antigen (PSA) testing. For men aged 50 and older, annual or biennial screening that includes DRE can help detect prostate abnormalities that might not be identified through PSA testing alone. The procedure involves a healthcare provider inserting a gloved, lubricated finger into the rectum to feel the prostate gland for any irregularities in size, shape, or texture. DRE is especially valuable because it can detect abnormalities in the posterior and lateral aspects of the prostate that may be missed by other screening methods. The examination takes only a few minutes, causes minimal discomfort, and requires no special preparation. While DRE is not perfect and may miss some cancers, it remains an important clinical tool because it provides immediate information about the prostate's physical characteristics and can help identify conditions beyond cancer, including benign prostatic hyperplasia and prostatitis. Men should discuss with their healthcare provider whether and when to begin prostate cancer screening based on their individual risk factors, as recommended by the American Cancer Society 1.

Some key points to consider:

• The American Cancer Society recommends that men aged 50 and older with a life expectancy of at least 10 years should be offered annual DRE and PSA testing 1.
• DRE can detect abnormalities in the prostate that may be missed by PSA testing alone, particularly in the posterior and lateral aspects of the prostate.
• The examination is quick, causes minimal discomfort, and requires no special preparation.
• Men should discuss their individual risk factors with their healthcare provider to determine the best screening approach.
• The benefits and risks of PSA testing should be discussed with the patient, as recommended by the American Urological Association 1.

Overall, DRE remains an important tool in the early detection of prostate cancer and other prostate-related conditions, and men should discuss their individual risk factors and screening options with their healthcare provider.

From the Research

Digital Rectal Exam (DRE) Recommendations

• The recommendation for a Digital Rectal Exam (DRE) is still a topic of debate among medical professionals, with some studies suggesting its continued use 2, 3, 4 and others proposing its abandonment 5, 6.
• A study from 2007 found that a substantial proportion of prostate cancers detected by DRE at PSA levels less than 4 ng/mL have features associated with clinically aggressive tumors, suggesting that omitting DRE from screening protocols might compromise treatment outcomes 2.
• Another study from 2012 discovered that detection of high-grade prostate cancer while still clinically localized on DRE can improve survival in men with a normal prostate-specific antigen (PSA) level 3.
• However, a 2016 study analyzing data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Screening Trial found that DRE screening in the setting of normal PSA captured an additional 2% of men with clinically significant prostate cancer, suggesting that routine DRE screening may subject a large number of men to invasive examinations for relatively minimal gain 5.
• A 2020 study evaluating the utility of DRE in a population with prostate cancer treated with active surveillance found that a suspicious DRE at confirmatory biopsy, particularly if the DRE at diagnosis was negative, was a predictor of clinically significant prostate cancer 4.
• In contrast, a 2005 study assessing the role of DRE in the clinical diagnosis of prostate cancer and in predicting the pathological stage found no correlation between the DRE and biopsy findings, and concluded that the DRE did not contribute to managing patients with prostate cancer 6.

Key Findings

• DRE can detect prostate cancers with aggressive features, even at low PSA levels 2.
• DRE can improve survival in men with high-grade prostate cancer and normal PSA levels 3.
• The incremental gain of DRE screening in the setting of normal PSA is relatively small 5.
• DRE can predict the presence of clinically significant prostate cancer in men on active surveillance 4.
• DRE may not be essential for patients with a PSA level of 2.5-10 ng/mL 6.

Study Limitations

• The studies had various limitations, including retrospective design, lack of magnetic resonance imaging, and inconsistent biopsies following positive screening tests 5, 4.
• The generalizability of the findings may be limited by the study populations and settings 2, 3, 6.