Doc: Physical prostate exam not always in a physical

Dear Dr. Roach: I am a 66-year-old male and now have a young, new doctor and at my recent physical, he did not give me a prostate exam. While the exam isn’t something I looked forward to, I’ve always thought that a prostate exam was very important for someone my age. Should I be concerned?

T.A.

Dear T.A.: The prostate exam remains controversial. Even though the prostate exam is no longer recommended by many authorities, I still think you may be right to be concerned.

Prostate cancer is a common condition affecting men in their 60s (it’s very uncommon below age 50), and becomes even more common in the 70s and older. Prostate cancer is a whole spectrum of illness, ranging from very aggressive cancers that spread rapidly, both locally and to the bones, to very indolent cancers that will never cause problems. In general, younger men are more likely to have the rare, aggressive cancers, and older men are more likely to have more indolent cancers. Unfortunately, that doesn’t always hold.

Age 66 is a time when prostate cancer is not uncommon, so it is worthwhile discussing screening for cancer, with a PSA blood test (the prostate physical exam probably adds little to the blood test).

I would have hoped your new doctor would have discussed the benefits and risks of screening, including a discussion on why the manual exam isn’t recommended anymore. You should have heard that the PSA test may find cancer, but much of the time, the cancer has a low risk for progressing, and is watched carefully rather than treated immediately. This is because treatment of low-risk cancer causes more harm than good. It’s natural to want to remove any cancer, but it is neither necessary nor helpful. The goal of prostate cancer screening is to find the unusual case of a high-risk prostate cancer, which is treated aggressively. Although the evidence is mixed, I believe that lives can be saved with screening, and if men receive proper counseling about NOT treating low-risk cancer, unnecessary procedures can be minimized.

Dear Dr. Roach: Every time a doctor takes my blood pressure, he tucks my arm under his to keep it at heart level, unless I am sitting down and can stretch out my arm at a desk or table to keep it at heart level. Yet every medical technician who takes it lets the arm dangle down my side.

How would the position of the arm affect the reading? And what is the correct position?

E.S.H.

Dear E.S.H.: The doctor is using the correct position, since we are interested in the pressure inside the heart. If the cuff is lower than the heart (such as when the arm is dangling), the reading will be artificially high, whereas if it is above the heart the reading would be artificially low. It’s just an effect of gravity, and the magnitude is small — roughly 0.7 mm Hg (the units of blood pressure) for every cm above or below the heart. That might be the difference between needing medicine or not, so it’s best to perform the technique correctly.

Email questions to ToYourGoodHealth@med.cornell.edu.