Digital rectal exam in prostate cancer screening: a critical review of the ERSPC Rotterdam study

Abstract

The history of prostate cancer screening has evolved from relying on the Digital Rectal Exam to the introduction of PSA test. Initially, DRE was the cornerstone for diagnosing aggressive PCa, but the advent of PSA testing allowed for proactive detection. Distinctions between screening for the general population and early detection for individuals are vital. The French Onco-Urology Recommendations cite the European Randomized Study of Screening for Prostate Cancer (ERSPC), highlighting a 21% reduction in mortality using total PSA for screening, endorsing DRE in combination with PSA for early detection. However, a comprehensive analysis of the ERSPC study raises questions about DRE's role in screening. Studies indicate weak correlations between DRE and PCa diagnosis, especially with low PSA values. DRE's reproducibility is also a concern. As the ERSPC study progressed, DRE's significance diminished, and PSA became the primary screening tool. Other trials omitted DRE from their protocols, emphasizing PSA’s dominance. While some studies advocate for DRE in specific contexts, its overall utility in screening is questionable. It can be uncomfortable, has low sensitivity and specificity, and may lead to unnecessary biopsies. Controversies persist regarding its role in follow-up tests after the initial screening. In summary, the analysis of various publications suggests that DRE has limited value in subsequent PCa screening procedures, particularly in regions where screening has evolved beyond its initial use. PSA's dominance underscores the diminishing role of DRE in modern PCa screening practices.