ON GIVING THE FINGER
- Oct 9
- 4 min read
Updated: Nov 3
I was just listening to some drunken, middle-aged Irishfolk. As happens four pints in, they started talking about their recent doctor visits. With two males involved, the conversation inevitably turned to the digital rectal exam. One declared he'd never had the procedure done and had no interest in having one. The other two barked and howled, exclaiming he was foolish or that, perhaps, there was something wrong with his head.
I couldn't believe all the confident vigor of the push-back. Why? Well, there was never any evidence, none at all, supporting digital rectal exams for early detection of prostate cancer. That's not my personal perspective or some sudden reversal of our understanding. No one ever conducted the study to investigate doctors' abilities to detect cancer this way or even the minimum of assessing patient outcomes. More than that, recent surveys have shown primary care physicians reporting being neither well-trained nor, as a result, confident in their abilities to detect prostate nodules with their finger. And in the absence of personal confidence or any sound medical reason for doing so, those doctors who give it a go, regardless, also tend to report that they themselves feel there's no value in it. Amazing, right? Talk about giving you the finger! What's worse, all this has been known for decades now. Medical journals have been publishing research papers, meta-analyses, and systematic reviews continuously over the last 25 years with emphatic results concluding there is no sense to anyone giving digital rectal exams.
Typical findings for the value prostate exams generally have looked something like that found in this 2013 Cochrane Review:
Prostate cancer is one of the most prevalent forms of cancer in men worldwide. Screening for prostate cancer implies that diagnostic tests be performed in the absence of any symptoms or indications of disease. These tests include the digital rectal examination (DRE), the prostate-specific antigen (PSA) blood test and transrectal ultrasound (TRUS) guided biopsy. Screening aims to identify cancers at an early and treatable stage, therefore increasing the chances of successful treatment while also improving a patient's future quality of life.
This review identified five relevant studies, comprised of 341,342 participants in total. Two of the studies were assessed to be of low risk of bias, whilst the remaining three had more substantive methodological weaknesses. Meta-analysis of all five included studies demonstrated no statistically significant reduction in prostate cancer-specific mortality ... Meta-analysis of the two low risk of bias studies indicated no significant reduction in prostate cancer-specific mortality ... Harms included overdiagnosis and harms associated with overtreatment, including false-positive results for the PSA test, infection, bleeding, and pain associated with subsequent biopsy.
On the value of one particular exam, the finger-in-the-bum method of cancer detection, most reviews appear to agree with this 2018 Annals of Family Medicine review:
A survey across Canadian medical schools revealed considerable differences in teaching methods and found that approximately one-half of graduating students had never performed a DRE (Digital Rectal Exams) during their clerkship training. Furthermore, only one-half of surveyed primary care physicians reported feeling confident in their ability to detect prostate nodules using DRE ... Surprisingly, a majority of Canadian primary care physicians routinely use DRE ... Although the majority of physicians in this sample offered screening, only 38% believed it provided a survival benefit. On the basis of the lack of evidence supporting its use, we do not recommend routinely using DRE as a screening tool for prostate cancer in primary care, unless it is proven effective in future studies. Additionally, although we did not study possible harms of DRE, its invasiveness and potential to lead to unnecessary biopsy, overdiagnosis, and overtreatment argue against its routine use. The World Health Organization has stipulated that screening tests should have scientific evidence to demonstrate their effectiveness and that the overall benefits of screening should outweigh harms. As it stands, DRE does not meet these criteria.
So what of that? All this has been widely reported in medical journals and primary care publications, science media as well as in popular magazines and the in the news for at least two decades. But what does your family doctor do? They still conduct rectal exams by a method with the proven efficacy of tobacco smoke enemas or phrenology. Bold.
#TrustTheScience
SOME EVIDENCE:
1990 - Screening for carcinoma of the prostate by digital rectal examination in a randomly selected population
1994 - Accuracy of Digital Rectal Examination and Transrectal Ultrasonography in Localizing Prostate Cancer
1998 - Screening digital rectal examination and prostate cancer mortality: a case-control study
1998 - Evaluation of the Digital Rectal Examination as a Screening Test for Prostate Cancer
2002 - Screening for Prostate Cancer: An Update of the Evidence for the U.S. Preventive Services Task Force
2009 - Prostate Cancer Screening Attitudes and Continuing Education Needs of Primary Care Physicians
2010 - Screening for prostate cancer: systematic review and metaanalysis of randomised controlled trials
2011 - Bad medicine: digital rectal examination
2016 - Is it time to abandon the digital rectal examination? Lessons from the PLCO Cancer Screening Trial and peer-reviewed literature
2018 - Digital Rectal Examination for Prostate Cancer Screening in Primary Care: A Systematic Review and Meta-Analysis
2018 - The diagnostic test accuracy of rectal examination for prostate cancer diagnosis in symptomatic patients: a systematic review
2020 - Assessment of the value of the different variants of abnormal digital rectal examination finding in predicting carcinoma of the prostate: a preliminary report of a two-center study
2023 - Digital Rectal Examination Is Not a Useful Screening Test for Prostate Cancer
2024 - Is the digital rectal exam any good as a prostate cancer screening test?
2024 - Digital rectal exam in prostate cancer screening: a critical review of the ERSPC Rotterdam study
2025 - The British Association of Urological Surgeons aligns with Prostate Cancer UK in declaring that men do not need a 'finger up the bum’ to test for prostate cancer https://www.baus.org.uk/professionals/baus_business/news/289/rectal_exam_a_poor_test_for_prostate_cancer_surgeons_and_charity_agree
