Digital rectal exams for prostate cancer can be a little uncomfortable, but they're vital for early cancer detection as part of regular screening. Dr. Ross Krasnow explains why a digital rectal exam is important and what to expect.
TRANSCRIPT
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thanks for joining us today. We're talking to Dr. Ross Krasnow, a urologist who specializes in urologic oncology at MedStar Washington Hospital Center. Welcome, Dr. Krasnow.
Dr. Krasnow: It's great to be here. Thanks for having me.
Host: Today we're talking about the digital rectal examination used to check for abnormalities of the lower rectum, particularly prostate cancer. Doctor Krasnow, what can a man expect when he gets a digital rectal examination?
Dr. Krasnow: So, I think that most people, when I tell them they need a digital rectal examination, get pretty nervous about it. And they also don't always understand why they need it. So, the first thing I do is try to explain, "Why are we doing it? Why do I need to put my finger in your rectum?" And typically, I'll…I'll grab a mannequin and I'll show them where the prostate is. And we do the digital rectal exam because the prostate sits right next to the rectum, right in front of it actually, and the best way to access the prostate through an examination is through the rectum. You can't feel it on the outside of the body.
Host: When might a man get this test - at what age should they start and how often?
Dr. Krasnow: So, there is a lot of controversy surrounding prostate cancer screening. But for the most part, men who choose to undergo prostate cancer screening, which should occur around the age of fifty, should have both a PSA test along with a digital rectal exam. There is some controversy as to whether the digital rectal exam adds anything to the blood test called the PSA that we use to screen for prostate cancer, but I think it's an important part of screening.
Host: So, in both of those tests, what exactly are you looking for?
Dr. Krasnow: So, when we talk about screening for prostate cancer there are really two components. One is a blood based test called the PSA. PSA is a substance that's secreted into the ejaculate by the prostate, but a small amount of it leaks into the bloodstream. When a prostate has prostate cancer in it, more of that substance can leak into the bloodstream, and that number becomes elevated and can be a signal of prostate cancer. That's why we use that as a screening test. The digital rectal exam is pretty crude, really. We're just feeling for any nodules, lumps on the prostate and any evidence of a prostate cancer extending into nearby organs like the rectum.
Host: So, you mentioned around age fifty - are there any other recommendations for men, perhaps men that are at higher risk for prostate cancer because of family history of the disease?
Dr. Krasnow: Absolutely. So, there are different guidelines as to when prostate cancer screening should start. The American Cancer Association recommends screening for prostate cancer starting at age 50. And in men with a family history of prostate cancer, specifically in men with a first relative who had prostate cancer - that would be a brother or a father with prostate cancer, screening should start earlier. Also, men of African American descent should start screening earlier because not only are those men at an increased risk of prostate cancer, specifically they're…they are at an increased risk of lethal prostate cancer. I believe that African Americans with a history of prostate cancer are supposed to be screened at age forty-five and men with a first relative who had prostate cancer should be screened at age forty.
Host: So, with the advent of PSA tests and those becoming more and more popular, what do you recommend for patients? Do you still continue to recommend different tests depending on their specific risk, their family history and so forth? Should all men have both the digital rectal exam and the PSA?
Dr. Krasnow: So, the problem with the digital rectal exam is that it's not a really good test for prostate cancer at the end of the day. In men who have an abnormal digital rectal exam, only about three maybe four percent of those patients will actually have prostate cancer. In men who have an abnormal PSA, it's about six to seven percent of those men will have prostate cancer. Really, I view a digital rectal exam as an adjunct to PSA testing to learn more about the size of the prostate and the anatomy of the prostate to understand the interpretation of either their PSA or…or biopsy.
Host: What are a couple of the…the most common concerns that men will ask you about this test, or the most common fears?
Dr. Krasnow: I think for the most part, most men are concerned about it being painful. I think men also wonder if it's even necessary. So, when I talk to them about it, I try to reassure them that it's certainly awkward but it's not painful, and I also tell them the rationale for why I'm doing it. Often when I see men for prostate cancer screening, very rarely am I only seeing them for prostate cancer screening. More often than not, men who are coming to me regarding prostate cancer screening are in their 50s, 60s and 70s, and they have associated urinary symptoms. They are getting up to go to the bathroom at night, they feel like they are not emptying their bladder completely, so when I am talking to these men, I'm not just focused on prostate cancer and prostate cancer screening. I'm focused on other aspects of a man's health - sexual function and urination - and so the digital rectal exam helps me treat those aspects of their life as well.
Host: Do you feel like there's still work to be done to educate men about the importance of prostate cancer screening and what do you think the future of that looks like in DC?
Dr. Krasnow: So, Washington, DC is very interesting in terms of prostate cancer. It has some of the highest incidents of prostate cancer compared to the rest of the United States. And the risk of prostate cancer mortality is higher in the DC area than in the rest of the United States. So…so certainly prostate cancer screening seems to be important in this area. That being said, there has been a lot of controversy regarding the efficacy of prostate cancer screening. So, recently the US preventative task force upgraded their recommendation for prostate cancer screening from a grade D recommendation to a grade C recommendation. The grade D recommendation essentially recommended against prostate cancer screening but newer and more robust data has shown that prostate cancer screening can be effective in lowering prostate cancer mortality. So, the grade C recommendation means that the patient and the clinician should have a discussion regarding prostate cancer screening and after weighing the risks and benefits of the screening, they can be offered PSA testing. Urologists are to blame for over-diagnosis and over-treatment of low-risk prostate cancer that would otherwise not affect a man in their lifetime, leading to toxicity – treatment-related toxicity, such as urinary problems and sexual problems. I think that now we're doing a much better job of screening more intelligently. Selecting who is at risk for prostate cancer and screening just men in the right age category or the right risk category that would benefit from screening, and often, even if we make a diagnosis of prostate cancer, we may not treat it if that cancer is low-volume and low-grade cancer, and this is a paradigm shift compared to what we used to do, which was treat everyone indiscriminately.
Host: Thanks for joining us today, Dr. Krasnow.
Dr. Krasnow: Thank you so much for having me.
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