By Rodney Herbert

The digital rectal exam (DRE) involves a doctor inserting a gloved, lubricated finger into the rectum to feel the back surface of the prostate gland. This simple physical exam can detect hard lumps or irregularities on the prostate that might indicate cancer. Historically, the DRE was a cornerstone of prostate cancer screening, often combined with the PSA blood test. However, in the past decade its role has become increasingly debated​ journals.sagepub.com and sciencedaily.com. Modern techniques (better PSA-based strategies, advanced imaging like MRI, and new biomarkers) have led many experts to question whether the DRE provides enough benefit to justify its routine use in screening men without symptoms​. MRI scans, by contrast, can visualize the entire prostate gland.

How Effective Is the DRE at Finding Prostate Cancer?

Clinical studies over the last ten years have measured the DRE’s accuracy and generally found it to be limited. In medical terms, the exam has fair specificity (it can correctly identify many healthy men) but low sensitivity (it misses a lot of cancers). In plain language, a normal DRE doesn’t guarantee the absence of cancer, and an “abnormal” DRE is far from a sure sign of cancer.

  • Sensitivity (True Positive Rate): Older literature often cited that DRE could detect about 70–90% of prostate cancers​ pmc.ncbi.nlm.nih.gov

    But more recent research paints a less optimistic picture. For example, in the large Prostate Cancer Prevention Trial, DRE’s ability to catch cancer was described as “very low,” with one analysis noting a sensitivity of only ~29% in a screening context​ journals.sagepub.com
    In other words, DRE missed roughly 70% of cancers that were present. A 2021 editorial summarized that DRE has “poor sensitivity” for early prostate cancer, meaning many tumors (especially small or deep-seated ones) would be overlooked​ journals.sagepub.com
    A meta-analysis focused on family doctors performing DRE in routine practice found a pooled sensitivity of about 51% – essentially, the exam caught only about half of the cancers in those studies​ pmc.ncbi.nlm.nih.gov.

  • Specificity (True Negative Rate): Many studies show DRE has fairly high specificity, often reported around 85–95%​ pmc.ncbi.nlm.nih.gov

    .High specificity means most men with no cancer will correctly have a “normal” DRE. However, specificity can vary depending on who performs the exam. Unlike a lab test, the DRE is subjective – different examiners might interpret the same prostate exam differently. One study demonstrated that the proportion of “suspicious” DRE findings ranged widely (from 4% to 28%) between examiners, highlighting inconsistent technique or judgment​

    journals.sagepub.com

    .Experience helps: When expert urologists do the exam, they tend to agree on findings much more than less experienced clinicians​

    journals.sagepub.com

     Still, even a careful doctor can only feel part of the gland, so a man could have prostate cancer that is simply out of reach of the finger exam (for example, tumors in the front part of the prostate cannot be felt​ pmc.ncbi.nlm.nih.gov).

  • Positive Predictive Value (PPV): This measures how often an “abnormal” DRE actually means cancer is present. Unfortunately, the DRE’s PPV is quite low in screening settings. Most abnormal DRE results turn out not to be cancer. Widely cited statistics put the PPV of a suspicious DRE at only about 25–35% (roughly a 1 in 3 chance that cancer is truly present)​ pmc.ncbi.nlm.nih.gov

    . Some studies have found even lower rates. In one analysis of a large U.S. screening trial, only about 21% of men with a positive DRE actually had cancer confirmed on a biopsy​ journals.sagepub.com . Put another way, nearly 4 out of 5 men with an abnormal exam were false alarms. Another study found a PPV of ~17–18% for DRE in primary care screening – meaning over 80% of those flagged by DRE were cancer-free​ sciencedirect.com. One notable trial (PLCO) reported that among thousands of men who had normal PSA blood tests but an abnormal DRE, only ~2% were found to have significant prostate cancer​ sciencedaily.com. Those are very long odds – the DRE would wrongly worry the other 98% of men in that group. Such numbers underscore that an abnormal DRE is not very definitive.

  • Negative Predictive Value (NPV): This measures how often a normal exam means there’s no cancer. The DRE’s NPV is higher than its PPV, but still not perfect. In the primary care meta-analysis above, the pooled NPV was about 64%​ pmc.ncbi.nlm.nih.gov

    That suggests around one-third of men with “nothing suspicious” felt on DRE did actually have cancer that was missed. To be fair, many of those missed cancers were early-stage or low-risk. But the takeaway is that a normal DRE cannot rule out prostate cancer – especially not the small, early cancers that we ideally want to catch.

In simpler terms, if 100 men who do have prostate cancer get a DRE, the exam might only detect about 30–50 of those cancers (low sensitivity). If 100 men without cancer get the exam, about 85–95 will correctly be told everything feels fine (high specificity). And if a doctor tells you your DRE was “abnormal,” there’s only about a 1 in 4 chance that it’s actually due to cancer – more often, it’s a false alarm (low positive predictive value). This imperfect performance is a big reason why the utility of DRE as a standalone screening test is being questioned.

DRE vs. Other Screening Methods (PSA Blood Tests and MRI Scans)

PSA testing has largely overtaken DRE as the first-line screening tool for prostate cancer. PSA is a blood test that measures prostate-specific antigen, a protein that tends to be elevated in men with prostate tumors (though it can rise for other reasons too). Over the past decade, studies have consistently shown that PSA is more sensitive than DRE for detecting prostate cancer​ uspreventiveservicestaskforce.org. For example, in the PLCO trial mentioned earlier, PSA blood tests detected more than twice as many clinically significant cancers as DRE exams did (680 vs. 317 cancers)​ sciencedaily.com. In practical terms, this means relying on the blood test finds substantially more cancers than the finger exam. As one researcher put it, “When PSA testing is used, the DRE rarely assists in diagnosing significant disease”​ sciencedaily.com. This has been confirmed in multiple studies: PSA outperforms DRE in identifying high-grade, treatable cancers​ sciencedaily.com.

That said, the DRE can occasionally pick up a cancer that PSA misses. About 1–2% of prostate cancers are “PSA-negative,” meaning they don’t raise the PSA level despite being potentially serious​ pmc.ncbi.nlm.nih.gov. In those rare cases, an attentive doctor might feel an abnormal lump on DRE even though the PSA test is normal, which could lead to a cancer diagnosis that would have otherwise been missed​ pmc.ncbi.nlm.nih.gov. For instance, one UK source notes that roughly “2 in 100 men with a normal PSA may have an aggressive cancer”, and a DRE could catch some of these​ pmc.ncbi.nlm.nih.gov. Because of this, clinical guidelines still say that an obviously abnormal DRE is sufficient reason to refer a man to further testing (like a biopsy), even if his PSA isn’t high​ pmc.ncbi.nlm.nih.gov. In men who already have symptoms suggestive of prostate cancer (such as urinary difficulties), an abnormal DRE has an even higher predictive value and should prompt swift follow-up​ pmc.ncbi.nlm.nih.gov. So while DRE adds little for routine asymptomatic screening, it can be important in certain individual cases or if a man has prostate-related complaints.

Beyond PSA, the biggest game-changer in prostate cancer detection in the past 10 years has been multiparametric MRI. An MRI scan of the prostate can reveal suspicious areas and is especially useful before doing a biopsy. MRI has far greater ability to visualize tumors anywhere in the prostate gland, including the front or deep portions that a DRE cannot reach​ pmc.ncbi.nlm.nih.gov. Studies have shown that using MRI in the diagnostic process improves cancer detection and helps focus biopsies on the right areas. For example, one study found that combining MRI with PSA and DRE raised the diagnostic accuracy to 83%, compared to 70% with PSA + DRE alone​ pmc.ncbi.nlm.nih.gov. Large trials like PROMIS (2017) demonstrated that MRI can identify men who do not have aggressive cancer with high reliability, sparing those men unnecessary biopsies​ journals.sagepub.com. In short, MRI is better at ruling out clinically significant cancer than DRE, and it can find significant tumors that a finger exam would never detect.

Given the power of modern imaging, some experts have suggested that “if MRI services are available, the need to perform a DRE routinely should be questioned”​ pmc.ncbi.nlm.nih.gov. The logic is that an MRI-first approach (often combined with PSA) can guide who truly needs a biopsy or further intervention, making the old routine of feeling the prostate less relevant. In practice, the DRE today is often skipped if a man is undergoing advanced screening with PSA and MRI. It might still have a role if MRI isn’t accessible or if a quick office exam is needed to decide on next steps, but its importance is diminished in the face of newer technology.

What Do Medical Guidelines Say About DRE for Screening?

Professional organizations in the last decade have increasingly de-emphasized or removed DRE as a routine screening recommendation. Here’s a summary of positions from major groups (2015–2025):

  • USPSTF (U.S. Preventive Services Task Force): This influential panel does not recommend the DRE for prostate cancer screening. The USPSTF found a “lack of evidence” that routine DRE screening benefits patients, and they note that the big clinical trials of prostate screening did not even include DRE as a component(they focused on PSA blood tests)​ uspreventiveservicestaskforce.org

    .In its guidance for doctors, USPSTF explicitly states that DRE should not be used as a standalone screening test​ uspreventiveservicestaskforce.org. Instead, the focus is on an individualized decision about PSA testing for men aged 55–69, and no routine screening at all for older men​ uspreventiveservicestaskforce.org. The bottom line: according to the USPSTF, there is insufficient benefit to doing DREs on healthy men with no symptoms, so they are not recommended for general screening​

    uspreventiveservicestaskforce.org

     

     

  • AUA (American Urological Association): The AUA’s latest guidelines (updated 2023) also center on PSA-based screening. The guidelines say to use PSA as the first test and only consider DRE as an optional, secondary tool​ auanet.org

     The AUA gives the DRE a “Conditional Recommendation” with low-level evidence (Grade C) for use alongside PSA​

    auanet.org

    This means a doctor may perform a DRE in addition to the PSA test to help assess risk, but it’s not a strongly endorsed practice. The language implies that DRE is not mandatory – many men can be screened with PSA alone. AUA acknowledges the DRE’s “questionable accuracy” as a primary screening method​ pmc.ncbi.nlm.nih.gov. So, while urologists haven’t completely abandoned it, they view DRE as optional at best in the screening context, to be used at the physician’s discretion or the patient’s preference.

  • NCCN (National Comprehensive Cancer Network): NCCN guidelines clearly show that DRE has a limited role. They advocate DRE only for men who have an elevated PSA result​ pmc.ncbi.nlm.nih.gov

     In other words, don’t bother doing a DRE unless the PSA is already high or concerning. If the PSA is elevated, a DRE might provide additional information (for instance, finding a palpable nodule might suggest a higher likelihood of an aggressive tumor). However, if the PSA is normal, NCCN does not advise screening DREs because the chance of finding something meaningful is extremely low. This aligns with evidence we discussed (PSA does the heavy lifting; DRE rarely adds new information in PSA-screened populations). So, NCCN’s stance for the past several years has been to reserve the DRE for follow-up of abnormal PSA or for clinically suspected cases, rather than use it as a blanket screening test.

     

  • EAU (European Association of Urology): European guidelines have also scaled back on DRE. The 2020 EAU guideline said DRE “should only be performed on patients with suspected prostate cancer.”​ pmc.ncbi.nlm.nih.gov

    That means no routine DRE for every man – only do it if there is already a suspicion based on symptoms, high PSA, or other clues. Essentially, EAU treats DRE as part of the diagnostic work-up once there’s a reason to suspect cancer, not as a screening tool for everyone. This is in line with practice trends in many European countries, where organized PSA screening is not widespread and MRI is quickly adopted when cancer is suspected. (It’s worth noting that the UK’s National Health Service also does not have a national DRE screening program; rather, GPs use PSA and refer to specialists for MRI/biopsy if needed).

  • Other organizations: The American Cancer Society (ACS) does not specifically recommend routine DRE for prostate screening either; their guidance since mid-2010s has been that men should have a discussion about PSA testing with their doctor, and DRE may be offered as part of an exam but is not mandated. The NCCN and AUAguidelines both still mention that if screening is done, it could include a DRE, but as we saw, they place low importance on it. Meanwhile, some specialists during the COVID-19 pandemic even suggested suspending DREs to avoid close contact – which further pushed the trend of omitting the exam unless absolutely necessary​ pmc.ncbi.nlm.nih.gov

    . Across the board, no major medical organization in the past decade has promoted routine DRE screening for asymptomatic men – at best, they tolerate it as an option, and at worst, they explicitly advise against it.

     

Is the DRE Still Used in Practice? (Trends and Real-World Insights)

Given the above, one might expect the DRE to have disappeared from doctors’ offices, but practice patterns vary. Over the last ten years, there has been a significant decline in DRE use for screening, especially by general practitioners. After the USPSTF’s 2012 advice against routine PSA screening, many primary care physicians scaled back both PSA tests and DREs. Studies of U.S. primary care data showed a sharp drop in DRE screening rates in the 2010s – one report noted about a 64% decrease in the use of DRE and a 39% decrease in PSA testing over a several-year period​ sciencedirect.com  In men aged 55–69 (the group where screening is most debated), doctors were much less likely to perform DREs by the late 2010s than they were before 2010​ sciencedirect.com. This suggests that fewer and fewer men are getting DREs as part of routine check-ups.

Interestingly, older surveys from the early 2010s indicated a majority of primary care doctors still combined PSA and DRE out of habit​ pmc.ncbi.nlm.nih.gov. For instance, one Canadian survey found 81% of family physicians used both tests when screening​ pmc.ncbi.nlm.nih.gov. But that was before recent evidence and guidelines fully permeated. Now, anecdotal reports and smaller studies indicate many doctors have quietly dropped the DRE. Some clinicians joke that the DRE is becoming a “lost art” in younger doctors who see it as low-yield. A 2020 article noted “most urologists and even general practitioners continue to perform DREs” out of tradition, but this is gradually changing as new data emerges​ renalandurologynews.com. In certain specialties (like some gastroenterologists who might check the prostate during colonoscopy), DRE use has also trended downward, with estimates that about 60% of physicians omit DRE when screening for prostate cancer during other exams​ journals.lww.com.

Rural and underserved settings: In areas with fewer medical resources, one might think DRE remains common (since it’s a low-tech, no-cost exam). It’s true that in some low-resource countries or remote regions, PSA testing or MRI may not be readily available, so a DRE might be one of the few screening options. However, even in those settings, the DRE’s limitations are recognized. Doctors are advised not to rely on DRE alone but to use it in combination with PSA if possible, because by itself the exam’s specificity is too low to act upon​ pubmed.ncbi.nlm.nih.gov. Moreover, patient reluctance to undergo DRE is not limited to wealthy, urban populations – it is common across different cultures and locales. For example, a study in Greece found high rates of men refusing DRE screening due to embarrassment, in both rural and urban communities​ rrh.org.au. The authors noted this “negative feeling and embarrassment” is a worldwide barrier that exists at all education levels and in various regions​ rrh.org.au. In underserved populations, there may also be less awareness about prostate health; some men may only associate screening with the dreaded “finger exam,” which can discourage them from coming in at all pressroom.cancer.org. Public education efforts now emphasize that a prostate cancer screening can be just a simple blood test (PSA) – you don’t necessarily “need a finger exam” to get checked​ prostatecanceruk.org. This message is important to reach men who might avoid screening out of fear or misunderstanding.

Impact of COVID-19: During the COVID-19 pandemic (2020–2021), many routine screenings were delayed or modified. There was discussion in urology circles about whether it was finally time to do away with the routine DRE, since minimizing close contact was a priority. One paper in 2021 (cheekily titled “Is there still a role for DRE in the COVID-19 era?”) argued that doctors could safely forego the DRE in most cases and rely on PSA/MRI, without risking patient care. The pandemic essentially accelerated an existing trend of moving away from the exam, except where absolutely necessary.

Expert opinions: In recent years, some urologists have been blunt: “It is time to abandon the DRE.” Dr. Ryan Terlecki and colleagues at Wake Forest made headlines in 2016 by calling the DRE a “clinical relic” that offers “relatively minimal gain” while subjecting many men to an uncomfortable procedure​sciencedaily.com. They pointed out that thousands of men were being examined to catch a very small number of cancers, and that this trade-off no longer made sense in the PSA era​ sciencedaily.com. Similarly, a 2024 editorial in the Scottish Medical Journal argued that DRE’s limitations (low cancer detection rate, subjectivity, and patient aversion) mean it’s increasingly hard to justify its routine use​ journals.sagepub.com. The authors emphasized how modern diagnostics are “rendering DRE obsolete” and highlighted that even when DRE does find cancer, it’s usually not adding much beyond what PSA and MRI would find​ journals.sagepub.com.

On the other hand, a minority of practitioners still defend the DRE in certain contexts. They note that DRE has discovered some high-risk cancers in men with low PSAs, and that skipping the exam entirely could conceivably miss those rare cases. There’s also the point that DRE isn’t just about cancer – during the exam, a doctor might discover other issues (like an extremely enlarged prostate or a tender prostate suggestive of prostatitis, an infection) and help the patient address those. In practice, many doctors will perform a DRE if a man has urinary symptoms or a very strong family history of prostate cancer, as part of a thorough evaluation. But for the average asymptomatic man, the trend is clearly toward omitting the DRE.

Patient Perspectives and Acceptability

From the patient’s standpoint, the DRE has always been, at best, an awkward moment in the check-up, and at worst, a source of serious anxiety or even avoidance of care. Many men dread the DRE, and this has real public health implications. Recent surveys and studies underline how significant this issue is:

  • A 2023 survey by Prostate Cancer UK of over 2,000 men found that 60% were concerned about having a rectal exam​ pmc.ncbi.nlm.nih.gov

    . Even more striking, 37% said they might avoid speaking to a doctor about prostate concerns specifically because of the DRE​

    pmc.ncbi.nlm.nih.gov

     In other words, the fear or embarrassment associated with “the finger test” is enough to keep a large subset of men away from the doctor’s office entirely. This is alarming because it means some men would rather not get screened at all than undergo a DRE, potentially missing an early cancer diagnosis.

  • That fear is often higher in communities that already have elevated prostate cancer risk. For instance, Black men have a higher incidence of prostate cancer and a higher mortality rate from it – yet surveys indicate Black men also report greater cultural stigma around the DRE exam​ pmc.ncbi.nlm.nih.gov

    This combination of high risk and reluctance to be examined is a challenge for healthcare providers trying to encourage early detection. Efforts are being made to reassure patients and, again, to emphasize that a blood test (PSA) can be a good first step if they’re uncomfortable with a DRE.

  • Beyond embarrassment, there are deeper psychological factors. Some men find the DRE “traumatic.” A recent study reported that 61.9% of men described their DRE experience as traumatic or unpleasant​ journals.sagepub.com

    It’s not just modesty – for certain individuals (for example, survivors of sexual abuse or those with PTSD), a DRE can trigger intense distress​

    pmc.ncbi.nlm.nih.gov

    Knowing this, doctors are increasingly sensitive about not forcing the exam on patients who are hesitant. In modern practice, patient consent and comfort are prioritized, and many clinicians will explicitly ask if the patient is okay with a rectal exam and explain its limited value before proceeding. Shared decision-making is key here: if a man is very apprehensive, the physician might opt to skip the DRE and perhaps monitor PSA more closely instead.

  • Another insight is that many men have misconceptions about prostate cancer screening. A sizable portion of men over 45 in the U.S. still believe that a rectal exam is the only way or the main way to get screened​. This misconception can deter them from any screening at all. Public education campaigns are now trying to clarify that a simple blood test (PSA) is available, and the DRE is not an absolute requirement. As one catchy awareness slogan put it, “You don’t need a finger up the bum to diagnose prostate cancer”​ prostatecanceruk.org

    The hope is that by reducing the emphasis on DRE, more men will be willing to undergo some form of screening (like PSA), rather than avoiding screening altogether out of fear.

Is the DRE Still Useful or Necessary Today?

In summary, the digital rectal exam has a dramatically reduced role in prostate cancer screening today compared to a decade or two ago. The bulk of evidence from 2015–2025 indicates that the DRE by itself is not a particularly effective test for finding prostate cancer in asymptomatic men. It misses a large number of cancers, and the majority of “positive” DRE findings turn out to be false alarms​ journals.sagepub.com. Meanwhile, the PSA blood test and modern imaging (MRI) are better at detecting significant cancers and have become the mainstays of early detection​ sciencedaily.com. As a result, most expert guidelines no longer endorse routine DRE screening​ uspreventiveservicestaskforce.org

That said, “not routinely necessary” doesn’t mean “never useful.” The DRE can still provide valuable information in certain scenarios – for example, if a man has a very high PSA or worrisome symptoms, feeling a hard nodule on exam would strongly point toward cancer and urgency in treatment. DRE also remains part of the physical exam for men who already have prostate cancer (it helps in clinical staging, to judge if the tumor seems confined or has spread beyond the prostate). In men with low PSA but high risk factors, some doctors may still do a DRE hoping to find an aggressive cancer that PSA missed​pmc.ncbi.nlm.nih.gov, though this yields few discoveries. Essentially, the DRE has shifted from a front-line screening test to a supplementary or confirmatory exam in specific cases.

Perhaps just as importantly, the patient acceptability issue cannot be overstated. An exam that causes significant numbers of men to avoid screening is counterproductive to public health. In this light, many doctors and patients alike welcome the trend of relying on less invasive screening methods (like PSA, which is just a blood draw). As one urologist said, “the evidence suggests that in most cases, it is time to abandon the DRE”​ sciencedaily.com. Eliminating an unnecessary DRE spares men discomfort and anxiety, without meaningfully compromising cancer detection in the era of PSA and MRI​.

Bottom line: For prostate cancer screening in 2025, the DRE is no longer a routine must-do. It’s a tool that might be used selectively – for example, if a PSA test is elevated or if no other options are available – but it is not required for most men. Regular PSA testing (with informed discussion) and timely follow-up with imaging or biopsy for abnormal results have become the preferred strategy for early detection. Men concerned about prostate cancer should know that screening does not necessarily have to involve a rectal exam, and they should discuss with their healthcare provider the approach that they are most comfortable with. In the clinical community, the consensus of the past decade is that while the DRE helped in the past, its routine use in prostate cancer screening has largely run its course – we have safer, more effective ways to find aggressive prostate cancers early, and we can spare most men the indignity of the old-fashioned “finger test.”

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