Underutilization of digital rectal examination when screening for prostate cancer

Background: Screening for prostate cancer is controversial. American Cancer Society and American Urology Association recommend screening with both digital rectal examination (DRE) and prostate-specific antigen (PSA) testing. Often, PSA testing is not combined with DRE when screening for prostate cancer. Methods: We collected a list of veteran outpatients who had PSA testing performed between june 1, 1998, and September 30, 1998, from our computerized database. We reviewed their records for documentation of age, race, urinary symptoms, family history of prostate cancer, DRE, and professional training and sex of the health care provider. Results: Of the 588 records reviewed, DRE was not performed in 311 patients (52.9%). Digital rectal examination was not performed in 276 (53.2%) of 519 patients who had a PSA level less than 4.0 ng/mL; in 202 (58.7%) of 344 patients by male providers and in 109 (44.9%) of 243 patients by female providers (P < .001); and in 231 (61.1%) of 378 patients by doctors of medicine (MDs), 24 (40%) of 60 patients by physician assistants (PAs), and in 56 (37.3%) of 150 patients by nurse practitioners (NPs) (MDs vs PAs, P < .001; MDs vs NPs, P < .001; and NPs vs PAs, P = .42). Conclusions: Digital rectal examination is underutilized when screening for prostate cancer. This leads to nondetection of some prostate cancers. Although the DRE rate was poor among all health care providers, female providers and physician extenders outperformed male providers and physicians, respectively.