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Independents' Day

Digital rectal examination for prostate cancer by GPs 'unnecessary', finds study

GPs should urgently refer patients with prostate cancer symptoms regardless of their digital rectal examination results, a new study has suggested.

Researchers from Hull York Medical School found that many men diagnosed with prostate cancer do not have an abnormal DRE result, so concluded that performing the examination in primary care is 'unnecessary' and may even delay diagnosis by deterring some men with symptoms from seeking medical help.

The systematic review, published in BMC Family Practice, found that patients with symptoms who have a normal result upon the physical check still have a 15.8% risk of cancer, well above the 3% risk threshold suggested by NICE for an urgent referral.

GP leaders called for more research to support the ‘interesting’ findings, before any changes to current recommendations for digital rectal examinations.

The research team set out to determine the accuracy of rectal examinations for prostate cancer diagnosis, in patients presenting to their GP with symptoms.

The review included four studies from 2015 which passed the quality assessment scale. A total of 3,225 patients were included, with the age of patients ranging from 40 to 89 years.

The research team, led by the dean of Hull York Medical School Professor Una Macleod, a practicing GP, looked at the sensitivity and specificity of the examination, as well as the cost-effectiveness and adverse effects.

They found that while DRE performed in general practice is accurate, 'many patients diagnosed with prostate cancer do not have an abnormal DRE'.

The paper said: 'Symptomatic patients who present to primary care and have a normal prostate examination still have a risk of cancer of 15.8%, which above the 3% risk threshold suggested by NICE...

‘DRE performed in primary care is an unnecessary investigation, adding little to the decision to refer, which should be made on the basis of symptoms alone.'

It added: 'This review questions the benefit of performing a DRE in primary care in the first instance, suggesting that a patient’s risk of prostate cancer based on symptoms alone would warrant urgent referral even if the DRE feels normal.'

The researchers also suggested that 'DRE may deter some men from seeking medical help for symptoms suggestive of prostate cancer...performing DRE in primary may in fact be delaying the diagnosis of prostate cancer'.

The University of Hertfordshire's Professor Mike Kirby, a former GP with a special interest in men's health, said: ‘A normal DRE of course does not exclude prostate cancer, but failing to do one misses the opportunity to diagnose locally advanced disease, and prioritise the referral, but also pick up other pathologies such as prostatitis, BPH, rectal tumours.’

RCGP chair Professor Helen Stokes-Lampard said: ‘This review certainly presents some interesting ideas…Improving rates of early diagnosis of prostate cancer is hugely important, but more research is needed before there is a change to the current recommendations about when to carry out a digital rectal examination.’

She added that it is ‘essential’ that for any updates to clinical guidelines, which are used by GPs to inform their diagnosis and treatment plans, that a ‘variety of the most current medical research and evidence’ is considered.

The findings come after Prime Minister Theresa May announced a £75m investment to support new research into early diagnosis and treatment of prostate cancer. 

This will fund more than 60 studies in prostate cancer over the next five years to test treatments, such as more precise radiotherapy, high-intensity focused ultrasound and cryotherapy, coupled with exercise and dietary advice. 

Readers' comments (30)

  • Fits so well with the iPhone doctor agenda.

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  • Dear All,
    Not really, think about the anatomy, DRE can only ever access the backside of the sphere of the prostate, you're never going to be able to examine the entire gland and even then you don't have ultrasonic transducers in your finger tips. Its always been a pointless and unnecessary examination. I've not done one for 20 years. i'm just surprised its taken so long to work out.
    Regards
    Paul C

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  • No shit Sherlock. :D

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  • Totally agree and they are going to be examined in great detail in secondary care so I rarely do them. However, the other day a colleague who does felt a nodule in a man with symptoms but a low PSA and they found a cancer. The exception that proves the rule?

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  • Not sure I agree. All clinical signs have sensitivity and specificity nil being 100%. The trick is to put them together and reach a conclusion. Prostate volume useful in deciding on therapy as well .

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  • David Banner

    Prof Miles is spot on, not performing DRE could miss alternative diagnoses, so don’t risk a GMC “failed to examine” prosecution.

    Also, to echo what is stated above, I recently found a nodule on a patient with a PSA of 3, turned out to be cancer after 2WW referral. PSA is simply not fit for excluding cancer, so are they seriously suggesting that every chap with vaguely prostatic symptoms be referred on a 2WW cancer rule with neither PSA nor DRE???

    We were all told a zillion times in Med School that “if you don’t put your finger in it you’ll put your foot in it”. Think I’ll stick to DRE thanks.

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  • Dear All,
    indeed the adage was taught at medical school, 30 years ago, and was derived from decades of prior medical practice going back to the venerable cutting for the stone.
    moving forward to the 21st century with ubiquitous USS and MRI scanning don't you think its time you moved from adage and anecdote based medicine to some of that evidence based stuff?
    Regards
    Paul C

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  • AlanAlmond

    So the take home message is that symptoms trump everything. If someone is highly symptomatic that’s grounds for a referral regardless of DRE and PSA. It does have implications on referral rates. I agree to suggest DRE is a pointless examination is missing it’s other uses, as detailed above. I’d love to find a reason not to perform this examination but I don’t this this reasearch paper is that reason.

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  • I think the point is that digital rectal exams have poor sensitivity as a test for prostrate cancer and normal clearly doesn’t rule it out. However I suspect the specificity is good. I’ve picked up prostate cancer on a DRE twice now with a normal PSA and referred as 2ww. If I’d not done it and referred as standard for symptoms only there would have been a delay.

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  • I'm with Osler - "Listen to the patient - he's telling you the diagnosis."
    Except that the USS / MRI speaks more loudly, of course.
    And the GMC trumps absolutely everything. So maybe I'll keep the KY handy after all.
    And the Daily Wail has no clue about false positives and false negatives. A false negative is a bad doctor who needs to be struck off, strung up and banged up.

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  • Quite happy to keep the finger out. So any man with symptoms refer fast track?
    Why not just give GP direct access to mri if its that good?

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  • If we dont do a rectal exam, and miss it we are in trouble, until the NHS ups it game with urology,MRI access, radiologist numbers and capcity issues we have to keep covering our selves until we can leave this mess.Not soon enough as I am too young,but at least Im in the 1995 pension.

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  • A multiple choice question containing the phrase "always been a pointless and unnecessary examination" has a high probability of being false. This study is referring to symptomatic patients.

    NICE recommends referring men if their prostate feels malignant on digital rectal examination. Not all these men have symptoms.

    I hope anyone who reads the headline reads the paper itself in order to understand the context more clearly.

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  • What are these symptoms (other than metastatic symptoms)? Was there not a recent paper that LUTS are poor predictor of prostate cancer?

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  • The problem is the increasing number of men asking for a check up who are asymptomatic.
    The significant false negative rate for PSA is a problem. By combining digital examination with PSA you can increase the sensitivity. You do need to explain that small cancers can still be missed . Recent change in LUTS May need referral.

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  • Aren't the BHP symptoms pretty similar to CA prostate unless presented in the late stage? Sorry, don't get it!

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  • Maverick

    Read "Overdiagnosed. Making people sick in the pursuit of health" by Dr H Gilbert Welch.

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  • What is the secondary care specialist going to do PSA +- DRE .
    If GPs haven’t got the skill to determine normality upon DRE they should refer and go to another CCG locality meeting.

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  • Maverick

    Then read "Follies and fallacies in medicine" followed by "The death of humane medicine" both by Petr Skrabanek. Get some perspective....

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  • Maverick

    Then read "This is going to hurt" by Dr Adam Kay followed by "Bad Pharma. How medicine is broken and how we can fix it" by Ben Goldacre. Makes you think...

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  • Have I missed out on something somewhere along the line?
    Apart from symptoms of the late stages, like bone pain, cachexia, cough, what are symptoms of (usefully) treatable prostate cancer that are not symptoms of prostatism or prostatitis? Should we 2ww every man with lower issues, or should we assess them?
    Simplest information works best: first we are told not to do PSA it is not good screening tool, now we are told not to do DRE, it is not good screening tool. So what are the 'experts' going to tell the men who want screening for Cancer?

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  • I think we should still perform a DRE to rule out differentials such as a rectal tumour so we refer to the correct subspecialty.

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  • Have had a few cases myself with vague symptoms, normal psa, abnormal examination and cancer picked up. What is the alternative to using DRE? At the end of the day we need a better test than psa in the mean time I will continue DRE...

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  • "The father has syphilis and the mother TB. Child 1 is blind, child 2 dead, child 3 has TB and child 4 is mute. The moter is pregant again. Is termination appropriate?"

    "Yes!Of course"

    "Then you have just murdered Beethoven"

    From Follies and Fallacies
    The Beethoven fallacy

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  • Let common sense prevail

    I agree with Paul Cundy. I gave up DRE years ago as I could not see the logic of performing a test which would not affect my management. The value of this study might be to keep the GMC dogs off experienced and competent GPs who use their brains when they consult.

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  • Chaps, use your experience and common sense. You do not need to be told how DRE, as routine is useless and poor.
    Use my algorithm :

    55+ with PSA 5= 2WW no DRE
    45 ish with marginal PSA and +- symptoms = DRE and proceed
    Moaning rest, what ever symptoms = DRE

    Problem solved.

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  • The thing I question is what does it mean by "prostate cancer" when i was in medical school the urologist says by the time men gets to their 80s about 80% of them will have some form of "prostate cancer" most will die with it rather than off it. A fair number of prostate cancer seen in clinic will end up with watch and wait. Also my understanding is a normal PSA does not exclude prostate cancer as I have seen a few patient with normal PSA but an abnormal feeling prostate. So the idea of an examination is unnecessarily seems a little far fetch

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  • I'm sorry are they saying that ALL men with lower urinary tract symptoms should be referred on a 2ww because their chance of having prostate cancer is over 3% ?

    How does that work?

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  • Finally one piece of research that I AGREE with.
    Hurrah !!

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  • Bob Hodges

    … Nowadays everybody wanna talk like they got something to say
    But nothing comes out when they move their lips
    Just a bunch of gibberish
    And m*********s act like they forgot about DRE…

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