Arielle Levin Becker
June 23, 2010
As a boy, Ophni Davis dreamed of becoming a doctor. Instead, he became a barber. But he still considers it his job to look after people's welfare.
So if a man who looks about the right age comes into his Blue Hills Avenue salon in Hartford, Connecticut, Davis will make a pitch for him to get screened for prostate cancer.
Frequently, in return, he gets a look that says "you're crazy."
He knows what they're thinking: the dreaded digital rectal examination, which, along with a blood test, constitutes a prostate cancer screening.
"No, no, no, man, it's not that kind," he tells them. Then he lets them know: You can get screened with just a blood test.
"It does make a big difference in getting people to do it," Davis said.
Digital rectal exams have been around for more than a century as a way to detect prostate cancer. These days, doctors also use them as part of screening for colorectal cancer and to detect infections or other conditions. They come with little risk or cost.
But increasingly, some doctors are questioning whether the benefits they offer in detecting prostate cancer are enough to outweigh the number of men they scare off.
That view gained support earlier this month when the American Cancer Society released new guidelines for prostate cancer screenings and advised that the prostate-specific antigen, or PSA, blood test could be done with or without the rectal examination. The cancer society cited concerns that the rectal exam may discourage men from getting screened and uncertainty about the value such exams add to cancer screening, although it did identify circumstances when the exam might be useful.
Not everyone believes ditching the rectal exam is a good idea. But the cancer society's recommendation affirmed what Dr. Andrew Salner, director of the Helen & Harry Gray Cancer Center at Hartford Hospital, has been seeing.
In the past, doctors involved in the community outreach programs the hospital runs believed that a complete screening required both the blood test and the digital rectal exam. Through the outreach program, perhaps 100 men a year got screened.
More recently, doctors in the program have come to view the rectal exam as much less important than the blood test. They made the rectal exam optional, under the idea that it was better to get more people in high-risk groups screened than to worry about a test that adds limited value, Salner said.
The year after the change, more than 700 men got tested.
The Screening Debate
The cancer society's guideline on the rectal exam was part of a larger set of recommendations for prostate cancer screening, released amid a debate about the value of screening.
The logic behind screening is fairly straightforward: By testing patients before they have symptoms, you can potentially find cancer in its early stages, treat it, and keep the patient from dying of cancer.
But when it comes to prostate cancer, experts disagree about the extent to which that happens.
There is little doubt PSA testing catches more cases. Since the test became widespread in the U.S. in the 1990s, the incidence of prostate cancer rose dramatically.
But while deaths from prostate cancer have fallen in that time, it has not come at a degree that matches the rise in cases.
"We know the test has found many, many, many, many more cancers," said Dr. Peter Albertsen, chief of the division of urology at the University of Connecticut Health Center and a professor of surgery at UConn. "Where the controversy comes in, however, is that the subsequent decline in mortality — in other words, how many men die from this disease — is relatively modest."
Experts believe the disparity in part reflects the fact that while screening can identify aggressive cancers, it also finds those that would never have progressed or progressed so slowly they never would have killed a man. That means some men receive treatment — which can lead to urinary, sexual or bowel problems — for cancers that might not have caused problems if not detected.
A randomized study released last year, conducted in Europe, found that to avoid one prostate cancer death, 1,410 men would have to be screened and 48 men would need to be treated.
"If you're that one guy, you think this is wonderful, and every man who undergoes surgery assumes they are that one guy," Albertsen said. "The problem is the public health folks are saying, 'Wait a minute, you can't all be that one guy because 47 of you are not that one guy.'"
Tests are not sophisticated enough to tell who might fall into which category, he said.
There is no question that screening and treatment has had an impact, Albertsen said; the question is how much.
In its guidelines, the cancer society emphasized the importance of telling patients about the benefits and drawbacks of screening and reaching an informed decision about whether to proceed.
"The abundance of data now available regarding prostate cancer early detection supports neither a clear mandate to screen nor a proscription against screening," the American Cancer Society Prostate Cancer Advisory Committee wrote in the new guidelines.
Doubts About Exam
But the group did raise doubts about the benefits of the digital rectal exam, citing a lack of evidence about its benefits and concerns that it keeps men from getting screened.
There have only been three case control studies that examined digital rectal exams alone, without the PSA, and only one found a statistically significant benefit, according to the cancer society. The sensitivity of the exam depends on the individual performing it, the group wrote.
Even under optimal circumstances, the cancer society committee wrote, "the added value of performing a periodic DRE is likely to be quite low."
Still, the group noted that the digital rectal exam can detect some high-grade cancers in men whose PSA test results would not raise concern. It also suggested that the exam may be helpful in some circumstances, such as in evaluating men whose PSA test results fall into a range where a biopsy may or may not be warranted.
The exam is not particularly comfortable, and for some men, particularly men of color, it may be seen as culturally inappropriate, said Salner, who was a member of the committee that wrote the guidelines.
"It has implications of them being kind of violated in some ways," Salner said. "Particularly if another man is doing it."
Which makes it particularly tricky to reach the men at the greatest risk from prostate cancer, Salner said. African-American men have higher rates of both getting prostate cancer and dying from it.
"That's the very population that we really need to try and screen," he said.
In more than five years of talking about prostate cancer with clients at his shop, Shallimar Barber and Beauty Salon, Davis has found the men to be receptive. Some tell him about relatives who had prostate cancer. One mentioned a 37-year-old nephew who died form it.
Davis took a course at Hartford Hospital and participated in a program aimed at getting barbers to talk to men about the disease. He holds annual screening events at his salon in conjunction with Hartford Hospital and St. Francis Hospital and Medical Center.
Some men say they fear what the exam might find and what treatment might cost if it does find cancer. But the biggest concern, he said, is what he calls the "invasiveness" of the test.
"That scares a lot of us black men," he said.
There are patients for whom the rectal exam makes sense, Salner said, such as those who have urinary tract symptoms.
But for patients without symptoms, Salner predicts the medical standard will evolve to embrace PSA testing alone.
A Complementary Test
Not everyone agrees.
The American Urological Association recommends that men who wish to be screened for prostate cancer receive both the PSA test and the digital rectal exam.
And Dr. Jeffrey Steinberg, chairman of surgery at St. Francis and medical director of the Curtis D. Robinson Men's Health Institute, said the digital rectal exam has value that should not be discounted.
A patient could have a PSA test in the normal range, but a digital rectal exam could turn up a nodule that might indicate cancer, he said. The PSA is not a perfect test, Steinberg said, and the digital rectal exam offers a complement to it. It also helps doctors detect other conditions, like a benign enlarged prostate.
"The rectal exam is a valuable adjunct when we're seeing patients either for initial testing or if they're referred to a specialist," he said.
Still, Steinberg knows the test is not a crowd pleaser.
The newly launched men's health institute offered screenings last weekend at The First Cathedral in Bloomfield. Some men there wanted just the blood test, without the rectal exam.
When that happens, Steinberg said, men should be told about the importance of the rectal exam and that the PSA is only half of the recommended test.
"You have to respect patient's fears and you have to give them reassurances that literally the digital rectal examination lasts five seconds," Steinberg said. When he administers it, he has men count to five, to prove that, contrary to what they may think, it only takes a few seconds.
"It's five seconds of discomfort for an exam that could potentially detect cancer or other abnormalities," he said.
At The First Cathedral, about 150 people came, and the majority took advantage of the PSA testing and the rectal exam.
But for those who won't agree to the digital rectal exam, Steinberg still administers the blood test. It's not all or nothing, he said.
"If they still refuse and they know the possibility that you're missing significant pathology, if they're willing to have the PSA test, at least you're having some testing with that man," Steinberg said.
Copyright © 2014, The Hartford Courant