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Most studies on use of PSA for screening were based on using the test as the primary modality, not as a follow-up to an abnormal rectal exam. For example, however, the USPSTF guidelines specifically say that their recommendations do not apply to use of the test as an aid to evaluating patients with an abnormal rectal exam.
The issue of testing in persons with a strong family history is also not usually addressed specifically in guidelines. The same issues would likely apply, however, with not being able to distinguish aggressive cancers from those that are not aggressive.
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