What is the most appropriate next step for a 45-year-old man with a family history of prostate cancer, whose father was diagnosed at age 74, and who has a normal digital rectal examination (DRE) finding with a soft and normal-sized prostate?

Reassurance is the Most Appropriate Next Step

For this 45-year-old man with a normal DRE and a family history of prostate cancer diagnosed at age 74 (not before age 65), reassurance is the most appropriate immediate management, followed by initiating shared decision-making about PSA screening. 1

Why Reassurance is Appropriate

Family History Does Not Meet High-Risk Criteria

• This patient's family history does NOT qualify him as high-risk because his father was diagnosed at age 74, not before age 65 as required by guideline definitions. 1

• High-risk criteria requiring earlier screening (age 45) include: African American race, OR a first-degree relative diagnosed before age 65 years. 1

• Men with average risk (which includes this patient) should begin screening discussions at age 50, not 45. 1

Normal DRE Findings Are Reassuring

• The DRE findings described (soft prostate, normal size, palpable median sulcus) are completely normal and do not warrant immediate further investigation. 1, 2

• DRE alone should not be used as a stand-alone screening test and has no proven mortality benefit when used in isolation. 2

• An abnormal DRE would be an indication for PSA testing regardless of age, but this patient has normal findings. 1

Recommended Management Algorithm

Immediate Action (Today's Visit)

1. Provide reassurance that his normal DRE is encouraging and his family history does not place him in a high-risk category requiring immediate screening. 1

2. Educate the patient that screening discussions should begin at age 50 for average-risk men (which includes him), not at age 45. 1

Plan for Age 50

• At age 50, initiate shared decision-making about PSA screening, discussing both benefits (approximately 1.3 fewer prostate cancer deaths per 1,000 men screened over 13 years) and harms (false-positives, overdiagnosis, treatment complications). 1, 3

• If the patient chooses screening after informed discussion, offer baseline PSA with or without DRE at age 50. 1

• For men with PSA <2.5 ng/mL, screening intervals can be extended to every 2 years. 1

Why Other Options Are Incorrect

Annual DRE (Option A) - Not Recommended

• No randomized controlled trials have demonstrated that regular DRE screening reduces prostate cancer mortality. 2

• DRE should not be used as a stand-alone screening test and is not recommended for men under age 50 at average risk. 1, 2

Transrectal Ultrasound (Option B) - Not Indicated

• Transrectal ultrasound is not a screening tool and is only performed as part of prostate biopsy procedures when PSA is elevated or DRE is abnormal. 4

• This patient has neither indication for biopsy. 1, 4

Assess PSA in 2 Weeks (Option D) - Premature

• PSA screening should not begin until age 50 in average-risk men, and this patient is only 45. 1

• Immediate PSA testing would be appropriate only if he were African American, had a first-degree relative diagnosed before age 65, or had multiple family members diagnosed before age 65. 1

Common Pitfalls to Avoid

• Do not misinterpret any family history as "high-risk" - the age of diagnosis in the relative matters significantly. A father diagnosed at 74 does not meet criteria for earlier screening. 1

• Do not perform PSA testing without shared decision-making - all guidelines emphasize informed consent before any screening. 1, 3

• Do not use DRE as a stand-alone screening test - it has no proven mortality benefit and should only be used in conjunction with PSA if screening is chosen. 1, 2