When it comes to the digital rectal exam (DRE) for a prostate cancer screening men come in two types. And by digital we don't mean of course as in smartphone, app, or technology. But rather as in inserting a finger (the digit) into the rectum to palpate for disease. One type of man will unabashedly agree or request a digital rectum exam, while the other will steadfastly refuse to have one. And there seems to be no in-between.
The other day three men presented, one representing one type, and two representing the other. None were having symptoms related to the prostate -- frequent urination, painful or bloody urination, difficulty starting or stopping urination, and slow stream. One man had a family history, his father being a prostate cancer survivor. The other two were part of Blue Cross Blue Shield's annual Healthy You Exam, which is a nice benefit at no charge to the patient.
Instead all three men opted to have the PSA (prostate-specific antigen test) test only. The PSA is a blood test that detects a substance made by the prostate cells. The higher and faster the level rises the more likely cancer is present. When the PSA test was first approved, a collective sigh (of relief) could be heard across the fruited plain from both men and doctors who thought the dreaded DRE would no longer be necessary for prostate screening. The PSA would pick up all prostate cancers.
But as time went on experience taught that one in ten men who had normal PSAs were returning with prostate cancers, cancers that could've been felt on a DRE.
By the same token, we know from experience that not every digital rectal exam can detect every prostate cancer. There are about one in ten men who have normal rectal exams, where a prostate cancer cannot be felt, that have prostate cancer.
And so the standard of care for prostate cancer screening came to be that for optimizing prostate cancer screening, a man should have both, the PSA and the digital rectal exam, so that the probability of detecting a cancer is optimized and the possibility of missing one is minimized.
If you're of the opinion that ten percent is not much of a difference and is worth forgoing the ole DRE, yet incurring the risk of not discovering an existing cancer, then you may not have a problem -- maybe. (Ask the casino if they're willing to give you a ten percent edge at the card table) If, on the other hand, you're not like this guy and decide to have both the PSA and DRE, then you've maximized your chance of ruling out a prostate cancer.
There's now a genetic test that's performed using urine instead of blood. But it too, at best, is 90% accurate, missing 10% of cancers, which means a DRE is recommended to maximize one's chance in detecting the presence of a cancer.
While the rectal exam is integral in the screening of prostate cancer in men, it has its advantages and is also important in detecting problems in women. Some years ago a seventy-two year old woman presented, attended by her daughter, complaining of two months of persistent vaginal odor, vague pelvic discomfort, and low back pain, all of which developed insidiously. A vaginal and pelvic exam was unremarkable; but a DRE revealed a small bump on the backside of the rectum. She was referred and a biopsy revealed rectal cancer which had not spread, and she underwent life-saving surgery.
One might think a man justified in skipping the DRE since most would agree that it's unpleasant in having something inserted in the rectum that doesn't belong. But the exam, as most everyone knows who's had one, especially one that reveals pathology, is that it is an important one.
The unpleasantness of the DRE has caused the occasional fellow to make some disparaging remark about it. My staff once changed vendors and ordered pink latex gloves. The first time I donned on a pair, I raised an eyebrow. I remember a jokester once who, as he bent over to have his DRE, made a politically incorrect remark that, at the time, was unavoidably humorous.
So ladies, if your man's mission is prostate cancer screening and he's either shy or of the type that's a fraidy cat, tell him to get 'er done -- both the DRE and PSA -- because, assuming he's been behaving himself, you may want to hold on to him much longer than you otherwise would, regardless of whether he's worth more dead than alive. Tell him the ten percent difference is in him maybe living another year or two, or living long enough to see his grandchildren grow old and pay taxes. I figure if he won't listen to professional medical advice perhaps he may listen to the person with whom he's sleeping.
Actually, a rectal exam really isn't that bad. I'm due this month for my annual prostate check. And while I do not look forward to getting it done, I can guarantee you I'm looking forward to getting it over!
Live clean! Stay healthy!