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MA: Low-quality evidence finds DRE screening for prostate cancer inaccurate
Clinical Question
How reliable are digital rectal examinations for prostate cancer screening in primary care settings?
Bottom line
The existing data evaluating digital rectal examinations (DREs) for prostate cancer screening in primary care settings are limited to poor-quality studies. Nonetheless, these data suggest that DRE is inaccurate and provides no additional diagnostic information. 2a-
Reference
Study design: Meta-analysis (other)
Funding: Unknown/not stated
Setting: Various (meta-analysis)
Synopsis
These authors searched multiple databases and trial registries to identify studies of DREs performed in primary care settings for the purposes of screening for prostate cancer. The included studies all used prostate biopsy to determine the diagnosis of prostate cancer. The authors attempted to identify unpublished studies by manually searching reference lists. The inclusion of studies, data extraction, and assessment of risk of bias in the studies were performed independently by pairs of researchers, with discrepancies settled by consensus (or a third member if consensus could not not reached). Ultimately, the authors included seven studies with 9241 patients who had undergone screening DRE and prostate biopsies. All of the studies were of high risk of bias, and only patients with abnormal DRE results were referred for biopsy. This latter issue, called verification bias, results in inflated estimates of sensitivity and underestimates the specificity. In many other forms of cancer, one of the methods for guarding against verification bias is to repeat assessments one year later and assume that if no cancer is detected after one year that the patient does not have cancer. Since most prostate cancers are indolent and never come to diagnosis, this approach would not be particularly helpful. The authors' pooled estimates of sensitivity and specificity were 0.51 (95% CI 0.36 - 0.67) and 0.59 (0.41 - 0.67), respectively. This translates to a positive likelihood ratio of 1.2 (0.6 - 2.0) and a negative likelihood ratio of 0.8 (1.6 - 0.5). Recall that tests with likelihood ratios of 1 add no additional diagnostic information. The authors also found lots of heterogeneity in the data.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
The summary of this study implies that digital rectal exam should not be done for screening for prostate cancer. Although it is not a particularly sensitive nor specific test, this is a dangerous message. Prostate cancers that are detected by digital rectal exam tend to be more aggressive advanced cancers which need diagnosis. Digital rectal exam is imperative for prostate cancer screening in addition to PSA testing.
"Active surveillance" as a management option for Gleason Grade Group 1 prostate cancer does include regular and repeated DRE's as a component. Should that inclusion be reviewed?
This paper is inaccurate and misleading as is the Joule bottom line. DRE is a worthwhile exam for anorectal pathology and should not be deferred as commonly as it is. The only reasons for not doing a DRE are if the patient does not have an anus or the examiner does not have a finger. This paper was posted earlier on MEDSCAPE and met with an appropriate widespread negative response as it concluded the exam's lack of sensitivity at excluding occult prostate ca made it an unworthy exam which is a conclusion inaccurately based on a lack of clinical knowledge of the wide gamut of common and significant anorectal pathology.
DRE is used in my practice to check for nodular disease in symptomatic BPH patients with normal PSA
Sure most physicians will continue to offer DRE.
You had an earlier POEM that reported PSA lacks specificity in detecting prostate ca. I have always felt that DRE is inadequate - we are only examining the surface of 65% of the prostate as the ant portion is not accessible. So, right now, we do not have any valid screening tools. In my experience, it seems that men ages 50-60 are more likely to succumb to the disease so it is important to have diagnosis for this population. I wonder if anyone know if there are researches on new imaging tool or assay in the early experimental stage?
There’s an old saying in medicine in our part of the world about DRE- if you don’t put your finger in it, you’ll put your foot in it. One has to ask the question what portion of patients would submit to obnoxious, painful prostate biopsy screening on the basis of randomization alone
Good poem
You already published a report saying that PSA should not be used as it was the source of too many needless interventions with their attending complications, and now you are telling us we should not perform DREs as they are so inaccurate and uninformative. Are we only going to be able to diagnose prostate cancer once it has metastasized and is causing pain or will everyone be condemned to having periodic trans rectal ultrasounds?
Usefulness of PSA had been questioned for screening for prostate cancer. Now my suspicion of DRE's limited usefulness is confirmed. I think I will continue to do both until a better screening test comes along.
Excellent