Prostate cancer screening in primary care: A dilemma, a Hobson’s choice, or a Morton’s fork?

Prostate cancer screening

What am I talking about? Well of course, I am talking about choices in prostate cancer screening programs in primary care.

Recommendations about prostate cancer screening in general are inconsistent. The Canadian Urological Association, with specialists in urology in mind, recommends screening with both digital rectal examination and PSA test; the Canadian Task Force on Preventive Health Care recommends against the use of PSA test in men aged 55 years or older without a prior diagnosis of cancer. Digital rectal examination is commonly performed to screen for prostatic cancer but there has been limited data to support its use in primary care. In a recent study published in the Annals of Family Medicine, Leen Naji and a group of researchers from the Department of Family Medicine, McMaster University, used complex statistical methods to study more than 9000 patients’ screening process with digital rectal exam by primary care physicians.[1] All patients analyzed underwent both digital rectal examination and biopsy. The findings were disappointing. “Given the considerable lack of evidence supporting its efficacy,” Naji’s group recommends against routine performance of digital rectal exam by primary care physicians to screen for prostate cancer in the primary care setting. Inaccurate findings lead to unnecessary and potentially harmful further investigations.

In my medical school training and internship close to 60 years ago the importance of digital rectal exam was drilled into my brain: if you do not put your finger in, you will put your foot in it. But in those days there was no specific emphasis on any screening program—and while there was much focus on detecting rectal carcinoma and other problems related to the rectal environment, I cannot recall receiving specific training in digital exam for feeling the various physical manifestations of early prostate cancer

So we do face a dilemma: should primary care physicians stop offering digital rectal examination for prostate cancer screening? Are we also facing a Hobson’s choice? According to the Naji study it might be a PSA test or nothing for screening for prostate cancer in primary care. And we may be stuck with the Morton’ fork: in the primary care situation neither rectal examinations nor PSA tests are quite satisfactory.

I am not familiar with modern clinical teaching techniques relating to digital rectal examinations, but surely mannequin teaching models simulating the great variety of shapes and textures of the prostate gland suggesting prostatic cancer are available somewhere by now—and if not, surely they could be developed for palpation practice purposes, to qualify the primary care physician to offer additional reliability to the screening of their patients.

1. Naji L. Digital rectal examination for prostate cancer screening in primary care: A systematic review and meta-analysis. Ann Fam Med

This posting has not been peer reviewed by the BCMJ Editorial Board.

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