An elderly gentleman from rural India came to a secondary care hospital, referred by a general practitioner for a blood transfusion due to very low blood counts. He had already received two bags of blood at another center over the past two weeks. His son, a cook at a resort near the hospital, accompanied him.
The son explained that his father had been feeling unwell for the past two months and had been found to have very low hemoglobin levels during recent blood tests. He had brought his father to this center in hopes of receiving regular blood transfusions.
The doctor was alarmed. Such low blood counts suggested an underlying problem. Regular blood transfusions were not a solution; the cause needed to be identified. The doctor asked for further details about the patient’s symptoms to investigate whether he was actively losing blood or whether the issue stemmed from the bone marrow producing blood.
The patient reported feeling breathless even with minimal activity, and his symptoms had worsened over the past two months. He also had swelling in his legs and face. There was no bleeding when passing stools or vomiting, and no injuries causing blood loss.
Upon examining the patient, the doctor noted his extreme paleness, indicating very low hemoglobin. There was noticeable puffiness in his face and swelling in both legs. When the doctor asked about urinary symptoms, the patient mentioned frequent urination and occasional blood in his urine over the past two months.
The doctor then suggested a rectal examination, but the patient appeared apprehensive. “Doctor, why do you want to do a rectal examination when his problem is low hemoglobin? None of the previous doctors asked for it!” exclaimed the patient’s son.
The doctor explained that a rectal examination is a crucial part of a comprehensive physical exam, as it can reveal issues like growths in the rectum or hemorrhoids. A digital rectal examination is when a doctor inserts his finger into a patient's rectum and feels around the walls. The prostate, a gland located around the urinary bladder, can be felt through the wall of the patient’s rectum and examined in this way.
Upon obtaining the patient’s consent, the doctor performed the rectal exam and discovered a hard, nodular growth in the prostate gland, possibly prostate cancer.
At first, the doctor wondered why prostate cancer would cause low blood counts, as it’s not typically associated with anemia. However, there was an insidious link. Prostate cancer often remains asymptomatic for a long time, sometimes spreading to other organs before the patient experiences any symptoms. One common site for cancer spread is the vertebrae (the spine), where the bone marrow produces blood. Cancer spreading to this area can suppress bone marrow, leading to low blood counts.
The doctor explained the possibility that the patient’s low blood count could be due to prostate cancer and ordered further tests, including a PSA (prostate-specific antigen) blood test and a bone scan. The PSA level was alarmingly high at 1200 ng/mL (normal is <5 ng/mL), and the bone scan confirmed that the cancer had spread to the vertebrae.
Rising incidence of prostate cancer
Prostate cancer is the second most common cancer and the sixth leading cause of cancer-related death among men worldwide. Its occurrence has been steadily rising in India as well, with major cities like Bangalore, Chennai, Delhi, and Mumbai reporting it as one of the top ten cancers in the most recent cancer registries from 2008-2011. Even in rural areas, the incidence of prostate cancer has increased in recent years, though it is often misdiagnosed or under-reported.
Approximately 6 in 10 cases of prostate cancer are diagnosed in men over the age of 65, and it is rare in men under 40. Symptoms of prostate cancer may include increased frequency of urination, blood in the urine, sensation of incomplete bladder emptying, recurrent urinary infections, poor urinary stream, and a strong urge to urinate. These symptoms overlap with benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate, which is common in older men. Therefore, it’s crucial to get evaluated if these symptoms arise.
Besides age, a higher risk of developing this cancer is associated with a family history of prostate cancer, obesity, and smoking.
The importance of Digital Rectal Examination and PSA testing
Digital rectal examination (DRE) plays a vital role in the early detection of prostate cancer. This simple test doesn’t require a urologist and can be performed by any trained healthcare provider, even in small rural or primary healthcare settings. DRE is also valuable in diagnosing conditions like rectal cancer, hemorrhoids, polyps, and pelvic infections.
In conjunction with DRE, the PSA blood test (prostate-specific antigen) is essential for screening and monitoring prostate health. PSA is not exclusive to prostate cancer and can be elevated in cases of benign prostatic enlargement, urinary retention, prostate infections, trauma, older age, or following physical manipulation of the prostate. Therefore, consulting with a healthcare professional for an accurate interpretation of PSA results is essential.
Shame and digital rectal examination:
DRE, or digital rectal examination, is the least performed examination by medical professionals. Although it is unpleasant and makes the patient uncomfortable, explaining its importance, providing reassurance, and providing adequate privacy will make almost all patients consent to it.
The apprehension is often from medical professionals who either lack experience and training in performing DRE or lack infrastructure like examination cubicles, examination gloves, or lubricating gel.
During the MBBS training and internship, students and young doctors are discouraged from doing rectal examinations. Similarly, it is routine for the other departments, including surgical superspecialties like plastic, cardiothoracic, neurosurgery, etc., to refer patients to surgical OPDs just for DRE.
The rural counterparts who lack surgeons presume and treat any rectal bleeding or mass as hemorrhoid despite knowing very well that it could be cancer of the rectum, anal canal, cervix infiltrating into the rectum.
Similarly, despite the patient reporting apparent symptoms of prostate disorder, a rectal examination is deferred or referred out, leading to delays in diagnosis. Most guidelines make DRE mandatory for all men above the age of 45 years during any routine check-up. However, this is never practiced in reality, including in general surgical outpatient clinics.
Raising awareness for early detection
As treatment complexity increases with the increasing stages of cancer, it is essential to identify the subtle symptoms this cancer is associated with. Getting periodically screened once older than 40 years, especially in men with risk factors of smoking, obesity, and a family history of prostate cancer, is essential. General physicians should examine such patients with suspicious symptoms, keeping the probability of prostate cancer in mind.
It is important to teach and impart the skill of digital rectal examination to healthcare providers and mandate that they routinely practice it on patients who require it.
We need to include conversations about health and cancers regularly to remove the stigma and fear associated with the diagnosis. With advancing treatment options, it is possible to even live with cancer, just like diabetes and hypertension. The only prerequisite is that cancer should be diagnosed early - and early detection must not be gatekept due to the shame of performing a simple procedure - whether it be from the side of the patient or the provider.
Edited by Parth Sharma and Christianez Ratna Kiruba
Image by Gayatri
