Most Appropriate Next Step: Assess PSA Now
For this 45-year-old man with a family history of prostate cancer (father diagnosed at age 74) and normal DRE findings, the most appropriate next step is to assess PSA now (Option D is closest, though "in 2 weeks" is unnecessary—PSA can be checked immediately). His age and family history place him in a risk category that warrants baseline PSA testing with shared decision-making about screening.
Why PSA Testing is Indicated Now
Age-Based Screening Recommendations
Multiple guidelines recommend initiating PSA screening discussions at age 45 for men with a first-degree relative diagnosed with prostate cancer before age 65 1, 2, 3.
The National Comprehensive Cancer Network (NCCN) recommends baseline PSA testing at age 45 for all men with at least 10 years life expectancy 1, 2, 3.
The American Urological Association (AUA) recommends obtaining a baseline PSA at age 40 to establish future risk stratification, as baseline PSA above the median is a stronger predictor of future prostate cancer risk than family history or race alone 2, 3.
Family History Risk Stratification
This patient's father was diagnosed at age 74, which is relatively late-onset and represents lower familial risk compared to diagnosis before age 65 1, 2.
However, even with one first-degree relative diagnosed at any age, screening discussions should begin at age 45 1, 2, 3.
Men with multiple first-degree relatives diagnosed before age 65 should begin screening at age 40, but this patient doesn't meet that higher-risk threshold 1, 2, 3.
Evidence Supporting Baseline PSA at This Age
A baseline PSA level before age 50 predicts subsequent prostate cancer up to 30 years later with robust accuracy (AUC 0.72-0.75) 2, 3.
Baseline PSA levels in men aged 45-49 strongly predict future prostate cancer death, with 44% of deaths occurring in men in the highest tenth of PSA distribution 2, 3.
Early PSA measurement provides a more specific test in younger men because prostatic enlargement is less likely to confound interpretation 2, 3.
Why Other Options Are Inappropriate
Annual DRE Alone (Option A) is Inadequate
No randomized controlled trials have demonstrated that regular DRE screening reduces mortality from prostate cancer 4.
The PSA test is more sensitive than DRE, and no screening trials have evaluated the utility of DRE alone 4.
Even men with positive family history should receive PSA-based screening with shared decision-making, not routine DRE alone 4.
Transrectal Ultrasound (Option B) is Premature
Transrectal ultrasound is not a first-line screening tool and is typically reserved for guiding prostate biopsy when PSA or DRE findings are abnormal 1.
Multi-parametric MRI is now recommended before prostate biopsy in contemporary practice, not transrectal ultrasound as an initial screening step 1.
Reassurance (Option C) Misses Screening Opportunity
Reassurance alone ignores guideline recommendations for risk-stratified screening in men aged 45 with family history 1, 2, 3.
The patient is actively seeking screening, demonstrating engagement in his health—this is the ideal time for shared decision-making and baseline PSA testing 1, 5.
His normal DRE does not exclude the need for PSA testing, as approximately 25% of men with family history, normal DRE, and PSA ≤4.0 ng/mL may still have prostate cancer 6.
Practical Implementation Algorithm
Step 1: Shared Decision-Making Discussion
Explain that PSA screening prevents approximately 1.3 deaths per 1,000 men screened over 13 years 2, 5.
Discuss potential harms including false-positive results (requiring additional testing), overdiagnosis risk, biopsy complications, and treatment-related erectile dysfunction and urinary incontinence 1, 5.
Emphasize that screening should never occur without an informed decision-making process 3, 5.
Step 2: Obtain Baseline PSA
Order PSA testing now (no need to wait 2 weeks as suggested in Option D) 2, 3.
Ensure the patient avoids ejaculation and vigorous exercise (particularly cycling) for 48 hours before testing to optimize PSA accuracy 3.
Document that shared decision-making occurred and the patient chose to proceed with screening 1, 5.
Step 3: Interpret Results and Plan Follow-Up
PSA ≥2.5 ng/mL: Screen annually with consideration for further evaluation including possible biopsy 2, 3.
Men with PSA >1 ng/mL at age 40-49 are at increased risk of prostate cancer metastasis or death 1.
Common Pitfalls to Avoid
Don't delay PSA testing unnecessarily—the "2 weeks" timeframe in Option D has no clinical basis; PSA can be checked at the current visit 2, 3.
Don't rely on DRE alone for screening—normal DRE findings do not eliminate the need for PSA testing in this risk category 4, 6.
Don't proceed with PSA testing without informed consent—this violates guideline recommendations and may lead to unwanted downstream consequences 2, 3, 5.
Don't use fixed annual screening intervals for all men—risk-stratify based on baseline PSA results to avoid unnecessary testing and false-positives 2, 3.
Don't continue screening beyond age 70 in most men—discontinue routine PSA screening at age 70 except in very healthy men with minimal comorbidity, prior elevated PSA values, and life expectancy >10-15 years 1, 2, 3, 5.