Part 1: Up yours. The case for DREs.

To DRE or Not To Dre: That is the question.

(Can you answer the anonymous questionnaire on your thoughts on DREs? Go here: https://forms.gle/QVXTXmuTrHjTppKq8)

Introduction

By Howard Wolinsky

I moderated a peer support group recently where a participant asked about the necessity of digital rectal exams.

He said his preeminent urologist, Christian Pavolovich, MD, Program Director, Prostate Cancer Active Surveillance Program, James Buchanan Brady Urological Institute, at Johns Hopkins, relies on digital rectal exams (DREs) to look for the lumps and bumps that can signal prostate cancer. (I’ll get to Dr. Pavlovich in a minute.)

DREs are a matter of debate not only among physicians but patients.

(DREs also are the butt of many jokes. Check out “urologist” Danny DeVito giving a digital rectal exam, to “patient” Michael Douglas: https://9gag.com/gag/aerE79B)

Some guys resist digital exams. Others demand them because they feel it’s just another check mark in seeing the urologist on their Active Surveillance program.

And in some cases, a DRE saves a life, but some docs think that an MRI might be enough to cover the, uh, waterfront, or their butts.

Some guys complain that DREs are painful. Maybe they have extra nerves?

Other men simply are physically or mentally uncomfortable with DREs. I once heard a man talking to his pals in a locker room at a gym near my house. The guy said he was glad to have undergone a prostatectomy so that he could be free from DREs.

Seemed like an extreme position. But I kept my mouth shut.

Some men say the exam is painful.

Meanwhile, some straight men consider DREs as bordering on a homosexual act. Seriously. I’ve heard this.

Personally, I think DREs are no big deal. I had DREs for more than 20 years during routine primary care visits and urology visits for AS.

I remember when I was 50-something my female family doctor did my first DRE. You never forget your first. She observed: “It [your prostate is small. But just wait.” Glad she had confidence in me.

Part of the argument against DREs is that they don’t yield much information, and also, some patients avoid seeing the urologist because they don’t want to get anywhere near a DRE

I fell off the DRE wagon in 2020 during the early days of the COVID-19 pandemic, and I only saw my urologist in telehealth visits for three years.

I saw my urologist once recently in person, and the question of a DRE never came up.

(My urologist, Dr. Brian Helfand gloved up for a pre-COVID-DRE—Howard Wolinsky.)

I suppose the day will come when you’ll be able to do a remote DRE using haptic feedback.

I was a member of a panel from Movember, the leading international men’s health organization, that a year ago called for an end to the “finger waves,” or DREs.

The panel said: “The use of DRE ranked lowest for both determining eligibility for and continuation on AS, due to its poor positive predictive value and impact on the patient. In fact, the use of DRE to initiate either additional tests (such as biopsy or MRI) or a treatment choice scored lowest among all tests, including PSA density, which is not commonly included in any of the guidelines.” 

Meanwhile, guidelines from the American Academy of Family Physicians do not recommend family physicians perform DREs in routine screening for prostate exams.

However, the 2022 early detection guidelines from the American Urological Association recommend PSAs be performed not more frequently than every six months and for “updating a symptom assessment and physical examination with DRE every one to two years.”

The late Gerald Chodak, MD, a personal friend and pioneer in the concepts that led to Active Surveillance in the 1990s, once told me he had the solution for getting more men and more women tested to detect early prostate and breast cancer.

He envisioned couple-based training of men to do breast exams and women to do prostate exams. I called this “tits for ‘tates.” The idea didn’t catch on. (These days, to be inclusive, we’d train gay couples to prostate exams as well.)

Here are Dr. Pavlovich’s thoughts on DREs in response to my email to him. (Bert Vorstman, MD, the uro-heretic, and journalist Ron Piana, co-author of the classic “The Great Prostate Hoax,” has agreed to present the opposing position in this newsletter soon.)

Why Hopkins’ Dr. Pavolich favors DREs

By Dr. Christian Pavlovich

Hello Howard,

I follow your bulletin closely and remain impressed with the service you are rendering to the AS population.

Thank you for the email and for the good question.

As background, I took over as AS program director at Hopkins in 2020 for Dr. Bal Carter’s ground-breaking cohort that started in 1995. I also participated recently in GAP3 as a Steering Committee member, though I have not been associated with many of their prior publications, nor with the joint paper you were co-author on regarding the omission of DRE. (See above.) I did read it however, and have studied the literature somewhat.

(Dr. Christian Pavlovich.)

I will say the following to be succinct in terms of my opinion on DRE in AS:

1. The AS program (at Hopkins) has for over 20 years had annual DRE as a part of it, especially since prostate MRI was not ready for primetime until more recently. So, it’s an institutional habit in part. AS has changed over time here and we no longer biopsy every year as was done in the early years before the urologic community accepted AS.

2. At Hopkins, AS is currently being offered by multiple clinicians—it is a standard of care. Although most men are formally in our AS program (which I administer) not all are.

   So follow-up regimens can differ, and even within the program they are risk-based and not strict in terms of biopsy timing, etc. I personally perform a DRE annually on my patients, as do some of my colleagues.

   All men who are MRI-eligible get MRI every 2-3 years or so, and micro-ultrasound is offered as an alternative for others. I am participating in (AS pioneer)Dr. Laurie Klotz’s OPTIMUM trial regarding that technology (vs. MRI) and, believe it or not, I was the first person ever to perform micro-ultrasound on a human

3. DRE has a role in prostate cancer screening, and can have one in AS (Herrera-Caceres JO et al. Utility of digital rectal examination in a population with prostate cancer treated with active surveillance – see the Toronto experience: Can Urol Assoc J. 2020 Sep;14(9):E453-E457. doi: 10.5489/cuaj.6341.) Also, it is important to note the clinical stage of a man entering AS - I would not feel comfortable with say a cT2b patient with GG2 disease entering long-term AS, especially if he has a long-life expectancy.

4. Given that AS men are seen annually I think DRE is no-cost and low impact part of the visit. I concede that it is not painless nor pleasant but it is short. Also, it provides more information than no DRE, limited information but again, more than no DRE. I notate last year’s DRE and compare with current DRE and on very rare occasion have noted a change. I concede that of all parameters (grade, PSA/density, MRI, biopsy parameters, other biomarkers) DRE is probably the least sensitive for change in cancer status but it can be highly specific.

5. Some men on AS actually expect to undergo the DRE – this expectation can be changed over time with education and citation of the literature. Others detest it and would happily drop it. In the face of a negative MRI and prior negative DREs it is certainly reasonable to miss a DRE now and again, but I’d still suggest doing one every 2-5 years on AS at a minimum. I am pretty sure we don’t have level 1 evidence either way and again, the cost of a DRE is nil unless it’s the only reason you are bringing a patient in in-person. We use the annual visit for a review of all relevant parameters and to go over progression predictions using our in-house ActiveCare Model (Coley RY et al. Prediction of the Pathologic Gleason Score to Inform a Personalized Management Program for Prostate Cancer. Eur Urol. 2017 Jul;72(1):135-141. doi: 10.1016/j.eururo.2016.08.005) which I am updating to include MRI information (but not DRE since again, it’s probably the least helpful of all informational parameters to predict grade reclassification/progression while on AS in my opinion).

   Question: Who shares short shorts?

   Answer: Active Surveillance Patients International (ASPI) does.

   An hour-long webinar may be too much for some guys to watch. Attention spans can be short. And nature can call often for those with enlarged prostates.

   So Bill Manning, the new executive director of ASPI, for the fist time has carved up a webinar into bite-sized video shorts. Check them out here: https://www.youtube.com/@aspi2020/shorts .

   As a frequent moderator, I feel I have been left on the cutting-room floor.

   More shots are coming

   PCa—not just for old men: Join ASPI webinar on May 25—and bring your sons and grandsons

By Howard Wolinsky

Prostate cancer typically is diagnosed in men in their late 60s. It’s considered a disease of aging, an old man’s disease.

But my friend Gabe Canales tells a different story.

He was diagnosed when he was 35. At an upcoming webinar for Active Surveillance Patients International (ASPI), Canales will share his prostate cancer experience and how it can help you and your sons and grandsons. Why not invite the young men to join our oldsters?

The webinar will be at noon Eastern Saturday, May 25. Register Here: https://tinyurl.com/3sexhrrp

(Gabe Canales, of Blue Cure, https://bluecure.org/)