Digital rectal exams to screen for prostate cancer in family practice not recommended
There’s still no simple way to detect prostate cancer before it becomes a problem, family doctor says
Men don't need to receive routine digital rectal exams to screen for prostate cancer from their family doctors, a new review of the medical evidence suggests. But there are other times when the test is worth doing.
Prostate cancer is the most commonly diagnosed malignancy in men after nonmelanoma skin cancer. Deaths from prostate cancer tend to occur among those in older age groups, the Canadian Cancer Society said.
Traditionally, it was recommended that men over the age of 40 or 50 should be screened for prostate cancer by having a digital rectal exam every year.
But the evidence to support the effectiveness of such testing is poor, says a Canadian doctor who reviewed previous research on the topic involving more than 9,000 patients. The meta-analysis was published in Monday's issue of the Annals of Family Medicine.
"What I'm suggesting and what the study has shown is not that we abandon the digital rectal exam as a clinical skill, but we should not be screening men in primary care for prostate cancer by doing a digital rectal exam if they are asymptomatic," said study author Dr. Jason Profetto, a family and academic physician at McMaster University in Hamilton.
While there was no strong evidence to recommend the routine use of digital rectal exams in screening for prostate cancer, the test is helpful for rectal bleeding, enlarged prostate, rectal masses and other situations, Profetto said.
"I am not saying that the digital rectal exam is useless."
The truth is there's many cancers that we just don't have good screening protocol to detect them before the individual is symptomatic and the prostate seems to be part of this group- Dr. Jason Profetto
Profetto recalled that when he entered medical school in 2006, students were told to perform digital rectal exams whenever a man had an abdominal exam, regardless of the reason. That dogmatic practice runs contrary to the evidence-based approach that physicians are now encouraged to take, such as only doing a test to answer a specific question, such as why a patient is having symptoms, he said.
Some studies suggest that half of family doctors still do digital rectal exams, the researchers noted.
A survey of Canadian medical schools showed about half of graduating students had never performed a digital rectal exam, and only half of primary care physicians said they felt confident in their ability to detect prostate nodules.
Conflicting advice to doctors
The new review also suggested family doctors don't have the skill to determine whether what they feel through the bowel wall is prostate cancer.
The Canadian Urological Association recommends screening with both digital rectal exams and the prostate specific antigen (PSA) for all men of average risk aged 50 and older who are expected to live at least another 10 years. Other Canadian and U.S. guidelines recommend against it.
Profetto said in his family practice, he has a conversation with men to outline why digital rectal exams were traditionally done, why things have changed, and what the research has shown about its routine use for prostate cancer screening.
Some men will then ask him how health-care professionals detect prostate cancer before it becomes a problem.
"The answer is simple. We don't," Profetto said. "The truth is there's many cancers that we just don't have good screening protocol to detect them before the individual is symptomatic and the prostate seems to be part of this group."
When Profetto presented the findings to physicians twice last year, he received some pushback and he's expecting more. Part of the difficulty with much of the criticism is it's not based on evidence, he says. "As a result, the conversation is halted."
- An earlier version of this story mistakenly said that when family doctors perform a digital rectal exam, they are feeling for abnormalities in the rectum. In fact, doctors feel the rectum/bowel wall for a lump or nodule that may indicate prostate cancer.Apr 27, 2018 11:21 AM ET
With files from CBC's Amina Zafar