Digital rectal examination as a standalone trigger for urgent prostate cancer investigation

INTRODUCTION: The contemporary value of digital rectal examination (DRE) as a standalone trigger for urgent prostate cancer investigation remains a subject of intense debate. Increasing scepticism regarding its diagnostic sensitivity, coupled with patient reluctance, has led to declining uptake of DRE in primary care. This study evaluates the outcomes of patients referred solely based on an abnormal DRE to determine its role in identifying clinically significant disease that might otherwise be overlooked by prostate-specific antigen (PSA) screening. METHODS: A retrospective analysis was conducted on 2,700 patients referred via the rapid prostate cancer pathway over a 33-month period. A specific cohort of 288 patients referred primarily because of an abnormal DRE finding - with PSA levels within the age-specific reference range - was identified. RESULTS: The mean patient age was 69 years and median PSA was 2.7ng/mL. Following secondary care assessment, 56.6% (163 of 288) of patients underwent biparametric magnetic resonance imaging. Of these, 35.5% had suspicious findings (Prostate Imaging-Reporting and Data System score ≥3). Ultimately, 14.2% (41 of 288) of patients underwent transperineal biopsy. Clinically significant prostate cancer was diagnosed in 16 patients (cancer detection rate: 5.6%); all 16 underwent radical treatment. CONCLUSIONS: DRE should not be superseded by PSA testing alone. Rather, it should be offered as part of a comprehensive primary care assessment, with its use determined through shared decision making that balances clinical benefit against patient acceptability. An abnormal DRE, regardless of the PSA level, necessitates urgent referral to a rapid access urology pathway.