From the Guidelines
The current guidelines for PSA testing recommend shared decision-making between men and their healthcare providers, with screening considered for men aged 55-69 after discussing potential benefits and harms, as stated in the most recent guideline from 2019 1.
Key Points
- For men aged 55-69, PSA screening may be considered after discussing potential benefits and harms, with the benefit being primarily reduced risk of dying from prostate cancer, and harms including false positives, overdiagnosis, and complications from unnecessary treatment.
- Most guidelines suggest testing every 1-2 years for men who choose screening, with a PSA level above 4.0 ng/mL traditionally considered abnormal, though this threshold may vary based on age, race, and other factors.
- Digital rectal examination may complement PSA testing but is not recommended as a standalone screening tool.
- Men should understand that an elevated PSA doesn't necessarily indicate cancer, as conditions like prostatitis, benign prostatic hyperplasia, and recent ejaculation can also raise PSA levels.
- For men under 55 with risk factors (family history or African American descent), earlier screening discussions are appropriate, while for men 70 and older or with less than 10-15 year life expectancy, routine PSA screening is generally not recommended as the harms typically outweigh benefits.
Screening Recommendations
- The American College of Physicians (ACP) recommends that clinicians inform men between the age of 50 and 69 years about the limited potential benefits and substantial harms of screening for prostate cancer, and base the decision to screen on the risk for prostate cancer, a discussion of the benefits and harms of screening, the patient's general health and life expectancy, and patient preferences 1.
- The ACP also recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in patients who do not express a clear preference for screening, and that clinicians should not screen for prostate cancer in average-risk men under the age of 50 years, men over the age of 69 years, or men with a life expectancy of less than 10 to 15 years.
Risk Factors
- Risk factors for prostate cancer include African American race and a first-degree relative diagnosed with prostate cancer, especially before age 65 years, with patients with such risks receiving information about the uncertainties, risks, and potential benefits associated with prostate cancer screening beginning at age 45 years 1.
- Men at appreciably higher risk (multiple family members diagnosed with prostate cancer before age 65 years) should receive this information beginning at age 40 years.
From the Research
Current Guidelines for PSA Testing
- The US Preventive Services Task Force (USPSTF) recommends that men aged 55 to 69 years discuss the potential benefits and harms of PSA-based screening for prostate cancer with their clinician, as the net benefit of screening is small for some men 2.
- The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older, as the potential benefits do not outweigh the expected harms 2.
- For men aged 55 to 69 years, the decision to undergo periodic PSA-based screening should be individualized, taking into account factors such as family history, race/ethnicity, comorbid medical conditions, and patient values 2.
Active Surveillance
- Active surveillance is a conservative management approach for men with low-risk or favorable-risk prostate cancer, which avoids long-term adverse effects on quality of life 3.
- Active surveillance involves close monitoring with digital rectal examination, periodic biopsy, and serial PSA testing, with the goal of early recognition of higher-risk disease 3.
- Multiparametric magnetic resonance imaging (MRI) has become an accepted monitoring tool in patients enrolled in active surveillance programs, with an estimated negative predictive value of 95% for the detection of prostate cancer 4.
Role of Digital Rectal Exam and MRI
- A digital rectal exam (DRE) may provide occasional benefit in detecting higher-risk disease, but its value is limited, with a sensitivity of 21.8% and specificity of 91.3% for clinically significant prostate cancer 5.
- MRI-guided active surveillance may reduce the need for routine, protocol-based biopsies, and biopsies could be used only when there are changes on MRI or a rising prostate-specific antigen (PSA) not explained by an increase in prostate size 6.