The primary screening modality recommended for the early detection of prostate cancer is a PSA blood test. Clinicians should not use DRE as the sole screening method in otherwise asymptomatic patients. This statement does not apply to symptomatic patients where a DRE could be considered a diagnostic exam. There is insufficient evidence to support adding DRE to PSA-based prostate cancer screening. The PPV of DRE as a screening method to detect prostate cancer is low. In the PROBASE trial, DRE was not effective for early detection; the PPV of a suspicious DRE at 50 years of age was 0.87% (as compared to 4.9% among patients aged 55 to 59 years in PLCO); of the 57 participants with suspicious DRE, 37 were biopsied and only 2 had prostate cancer (both GG1).41 A recent meta-analysis demonstrated that adding DRE to PSA screening did not significantly improve the PPV compared to PSA screening alone for detection of prostate cancer.88 The study reported a pooled PPV of 0.21 (95% CI: 0.13 to 0.33) for DRE, which was similar to the PPV of PSA (0.22; 95% CI: 0.15 to 0.30; p=0.9), and no difference in PPV with the combination of DRE and PSA (PPV: 0.19; 95% CI: 0.13 to 0.26; p=0.5).88 For various reasons, clinicians may choose to complement PSA screening with DRE based on SDM; however, the evidence base for this practice is weak. In a U.S.-based cohort study, the risk for finding cancer among people with PSA < 4 ng/mL and abnormal DRE was only 3% but the addition of DRE was found to improve detection of higher-grade disease.89 There are practical considerations for performing DRE in clinical practice, and it may not be acceptable to all patients as compared to a blood draw. Survey data suggest nearly a quarter of patients may forego prostate cancer screening when it includes up-front DRE with PSA testing.90 In contrast to a screening application, use of DRE subsequent to the screening encounter may be of value. It has been shown that the greatest utility of DRE in randomized trials is demonstrated in the workup of patients with an elevated PSA. For this reason, among patients with PSA ≥ 2 ng/mL, clinicians should strongly consider supplementary DRE to establish risk of clinically significant prostate cancer. In patients undergoing prostate biopsy for an elevated PSA during screening, abnormal DRE improves the PPV for any prostate cancer and GG2+ detection.23, 91, 92 In ERSPC Rotterdam, the PPV of a suspicious DRE in conjunction with an elevated PSA level ≥ 3 ng/mL to detect prostate cancer was 48% compared to 22% in patients with a normal DRE. However, the impact of abnormal DRE on PPV became attenuated in the subsequent screening rounds.91 In PLCO, the absolute difference in the risk of clinically significant prostate cancer at 10 years between patients with suspicious versus non-suspicious DRE was small for patients with PSA < 2 ng/mL (1.5% versus 0.7%), whereas the difference was modestly relevant for patients with PSAs 2 to 3 ng/mL (6.5% versus 3.5%) and clinically relevant for patients with PSA ≥ 3 ng/mL (23.0% versus 13.7%), all statistically significant increases.93