What is the most appropriate next step for a 42-year-old man with a normal digital rectal examination and a father diagnosed with prostate cancer at age 76?

Reassurance is the Most Appropriate Next Step

For this 42-year-old man with a normal digital rectal examination and a father diagnosed with prostate cancer at age 76, reassurance is the best next step (Option C).

Rationale Based on Risk Assessment

Family History Does Not Significantly Elevate Risk

• The father's diagnosis at age 76 does not constitute a high-risk family history. Prostate cancer diagnosed after age 70 is considered late-onset disease and does not substantially increase familial risk compared to diagnosis at younger ages 1, 2.
• Family history becomes a strong risk factor primarily when first-degree relatives are diagnosed at younger ages (typically <65 years) or when multiple family members are affected 2.
• The patient's age of 42 is well below the typical screening age, as the median age at diagnosis is 67 years 1.

Current Screening Guidelines Do Not Support Testing at This Age

• PSA screening should only be performed if life expectancy exceeds 10 years AND a prostate cancer diagnosis would modify management 3.
• According to the AUA Best Practice Policy, both digital rectal examination and serum PSA measurement should be offered annually in men over 50 with an estimated life expectancy of more than 10 years 4.
• Early diagnosis (screening) of asymptomatic men with PSA testing and digital rectal examination has not been proven to prolong survival 4.

Normal Physical Examination Findings

• The digital rectal examination revealed a soft, normal-shaped and normal-sized prostate, which provides additional reassurance 3.
• If DRE reveals suspicious findings, one would proceed directly to transrectal ultrasound-guided prostate biopsy regardless of PSA level, but this patient has normal findings 3.

Why Other Options Are Not Appropriate

Annual DRE (Option A) is Premature

• Annual screening is not indicated until age 50 in average-risk men 4.
• Even with family history, this patient's risk profile does not warrant annual surveillance at age 42.

PSA Testing After 2 Weeks (Option B) is Not Indicated

• There is no clinical indication for PSA testing in this asymptomatic 42-year-old man with normal examination 4, 3.
• The 2-week delay mentioned in the option might suggest waiting after infection or inflammation, but there is no evidence of either condition in this case 5.
• Shared decision-making about PSA testing should occur, but routine testing at age 42 is not recommended 3.

Appropriate Counseling Points

When reassuring this patient, address the following:

• His father's late-onset prostate cancer (age 76) does not place him at significantly elevated risk requiring early screening 2.
• He should begin discussions about prostate cancer screening around age 45-50, depending on updated guidelines and his preferences 3.
• He should return if he develops urinary symptoms or other concerning signs 3.
• Maintaining a healthy lifestyle, including regular physical activity, may reduce disease progression risk if cancer were to develop 2.

Common Pitfalls to Avoid

• Do not order PSA testing simply because a patient requests it due to anxiety about family history. Use this as an opportunity for education about actual risk factors and appropriate screening ages 3.
• Do not confuse any family history with high-risk family history. The age at diagnosis and number of affected relatives matter significantly 2.
• Avoid creating unnecessary anxiety through premature or excessive testing in low-risk individuals 4.