Like most men, I'll never forget my first time.
I was 50-ish. On command, I dropped my drawers and bent over the examining table. I heard the snap of the gloves and I felt some resistance as an index finger was inserted in my taut rectum for the dreaded digital rectal exam (DRE). I squirmed a little.
Next thing I knew, my family doctor was exploring my until-then-ignored, invisible-to-me prostate gland, looking for unusual bumps and textures. The rest is a blur.
The verdict? "It's small but just wait," the doctor told me authoritatively.
As it happens, she was wrong. My prostate never got large. But "small" doesn't mean I escaped carefree. About seven years later, my prostate-specific antigen scan, not something to which I paid much attention, suddenly rose to nearly 4 ng/mL and a biopsy was performed, the first of several over the years since 2010. I had a near-microscopic cancer in a single core -- 1 mm long, with a low-risk Gleason 6. Seen once, never seen again.
I go to the urologist twice a year. We chat about PSA results and then it's time for another DRE. I once wrote a story about researchers working with female primates who were trained to present for gynecologic tests. I feel something like that undergoing my biennial DREs.
DREs were a key to diagnosing prostate cancer maybe back 30, 40 years ago before the era of PSAs and magnetic resonance exams.
Patients today whose cancer first is diagnosed based on a DRE apparently are rare, and they have more advanced cancers large enough to be felt on the exam.
These days, prostate cancer typically, but not always, is found early before things get to that point with biopsies and magnetic resonance imaging scans.
I have found DREs mildly and momentarily uncomfortable but a definitely uncomfortable subject, one tinged with grade-school sniggers and embarrassed red faces. I remember a sketch with two famed doctors, one a urologist and the other a medical oncologist, at a patient-oriented meeting last year in which gloves were snapped on and fingers waggled. Everyone laughed.
The new Netflix TV series, features Hollywood veteran Michael Douglas as an acting teacher, Sandy Kominsky, dealing with the vulnerabilities and infirmities of aging, including low-risk prostate cancer. Wise-ass urologist Dr. Wexler (Danny DeVito) gives Kominsky a DRE. Wexler snaps his gloves and says to Kominsky: "You complete me." Again, a good laugh.
Most doctors take the attitude of why not perform the DRE? It won't hurt and might help.
But some doctors think the days for digital rectal exams ought to end.
In a hard-hitting critique of prostate care entitled Florida urologist Bert Vorstman, MD, attacked the DRE for being as accurate as a coin toss. "Performing this feeble test every few months during so-called surveillance makes no scientific sense; can be very uncomfortable; is especially unreliable for detecting the potentially deadly 15% or so of high-grade cancers early and, the examination is often abused by dishonest urologists to push patients towards more profitable evaluations because of 'feeling something'; sensing a 'nodule' or, feeling 'unevenness' (asymmetry, which is normal)."
UpToDate.com, which offers peer-reviewed analyses, says its panel suggests "not performing digital rectal examination for prostate cancer screening either alone or in combination with prostate-specific antigen screening. Although DRE has long been used to diagnose prostate cancer, no controlled studies have shown a reduction in the morbidity or mortality of prostate cancer when detected by DRE at any age."
The reviewers also gave bad marks to urologists: "Urologists have been found to have relatively low interrater agreement for detecting prostate abnormalities."
also took on the topic of DREs. We met about 10 years ago at Northwestern University's Medill School of Journalism in Chicago, where I was a new faculty member. I attended a lecture he gave about his work exposing malpractice in medical journalism. He is a long-time critic of the way health journalism is conducted with promises of breakthroughs and ignoring the cost of care. We see eye to eye.
I introduced myself afterward. He impressed me in part because without prompting he knew who I was and praised my then 20-year-old book, . No wonder he's my hero.
But there are other reasons: Schwitzer is disturbed about the lack of skepticism in news reports containing unverifiable quotes from patients claiming screening tests had saved their lives.
A pioneer in shared decision-making, Schwitzer, who continues his on an ad hoc basis, said he had been pondering DREs for a long time. "If we have reason to raise questions about the trade-off involved in prostate-specific antigen screening, then we should place DRE under the same scope as well," he said.
Two public health campaigns on DRE caught his attention in 2018 and led him to write on the topic.
Last fall, the advocacy group sponsored a very humorous video featuring Mike Rowe. He'd hosted the Discovery Channel show "Dirty Jobs," which explored all manner of unpleasant jobs, such as turkey inseminator and concrete stamper.
In , he underwent a DRE at the finger of his personal physician, Jordan Schlain, MD. Rowe, outfitted in a short bathrobe and laying on his side on an examining table, milks the situation for laughs, mentioning the "amazing burrito" he had eaten the night before. Then, he gets into a play-by-play: "He is going to insert his actual finger into my actual rectum to examine my actual prostate. There he goes! He's in! He's all the way in."
Schlain delivers the good news to Rowe about his prostate: "feels fine, normal size, no nodules." The physician, who himself hams it up in the video, takes some parting shots, saying there are only reasons not to do a DRE: the physician is missing a finger or the patient is missing a rectum. Rim shot, please.
Schlain, like my urologist, Brian Helfand, concedes that doctors aren't crazy about digital exams, but they go with the territory.
ProstateCancerCanada last May showing a focus group of four men in hospital gowns opened in the back bent over in a line. They are undergoing apparently repeated DREs with gloves supposedly fashioned after figures in history, music and fantasy, including Abraham Lincoln, Napoleon Bonaparte and Genghis Khan. Also, Babe Ruth recalling his home run shot, Billy the Kid, Dr. Frankenstein's Monster, and Bigfoot. Winston Churchill was a favorite. Huh? Maybe Dr. Frankenstein himself would have have been the most qualified glove model.
"We're testing to see if their fingers are famous enough to get you checked. Because it just might save your life," the narrator says.
I thought this ad was not well thought out, not informative and not a motivator to undergo an exam some find of dubious value. It was a joke for joke's sake and not a very good one. PSA tests are presented as a backup to a DRE. Some critics see PSA as a scam; others see it as essential. I suspect no one sees DREs as being equal to a PSA test. Did the writers consult with Danny DeVito's Dr. Wexler? I felt like giving ProstateCancerCanada the finger.
Humor of course is in the eye of the beholder. But more importantly, do spots like this persuade men to undergo an exam they would prefer to avoid? If they do, will the testing really help?
Schwitzer found these spots "funny, but shallow, incomplete, and unhelpful." He said HealthNewsReview focuses on "helping people improve their critical thinking by primarily analyzing media messages of all sorts -- news, advertising, marketing public relations, talks, and journals."
But Schwitzer said doctors and patients need to keep in mind the need for shared decision making, even for a DRE. Doctors need to explain the purpose of the exam and PSAs and what they might reveal. It turns out physicians don't always do that, which can be confusing and upsetting to the men, who may get an unexpected order for a biopsy or MRI to confirm the presence of prostate cancer.
In recent months, I have heard about two instances where men were not informed about what was going on with prostate testing. One involved an elderly Canadian man who was stunned to get an order to have a biopsy. He had no idea he'd even been screened for prostate cancer with a PSA.
Second, I was surprised when Schwitzer told a personal story.
He said: "My own primary-care physician slipped in an order for a PSA on me amidst a broader blood profile he had ordered from the lab. I was furious when I learned that," he said. "In another encounter, as he was preparing to slip on a glove, I questioned him about evidence supporting a DRE. He never slipped on the glove again. That's the kind of discussion more men (and women, with their separate screening issues) need to feel empowered to have with their docs."
I think Schwitzer is right again about discussing any tests with patients before performing them. Seems like common sense. What do you doctors and patients think? Is the DRE making things safer for prostate cancer patients?