From the Guidelines
Prostate-Specific Antigen (PSA) screening should begin at age 50 for average-risk men and at 45 for high-risk individuals, with screening intervals of every 1-2 years, and a PSA level below 4 ng/mL typically considered normal. The decision to start screening should be based on a shared decision-making process between the patient and healthcare provider, taking into account the patient's risk factors, general health, and life expectancy 1. For men with a family history of prostate cancer, screening should begin at age 45, and for those with multiple family members diagnosed with prostate cancer before age 65, screening should begin at age 40 1.
- The benefits and harms of screening should be discussed with the patient, including the potential for false-positive results, overdiagnosis, and overtreatment 1.
- The PSA test should not be used as a sole indicator for biopsy, and other risk factors, such as family history and ethnicity, should be taken into account 1.
- For men with a PSA level between 2.5 ng/mL and 4.0 ng/mL, an individualized risk assessment should be performed to determine the need for further evaluation or biopsy 1.
- Asymptomatic men with less than a 10-year life expectancy should not be offered prostate cancer screening 1.
- Treatment decisions should balance cancer control with quality of life considerations, as prostate cancer often progresses slowly, and some treatments carry significant side effects, including urinary incontinence, erectile dysfunction, and bowel problems 1.
Regular follow-up PSA testing is essential after treatment to monitor for recurrence, and treatment options depend on cancer stage, PSA level, and patient factors, including active surveillance, surgery, radiation therapy, hormone therapy, and chemotherapy 1.
From the FDA Drug Label
In clinical trials, dutasteride reduced serum PSA concentration by approximately 50% within 3 to 6 months of treatment. To interpret serial PSAs in men taking dutasteride, a new PSA baseline should be established at least 3 months after starting treatment and PSA monitored periodically thereafter Any confirmed increase from the lowest PSA value while on dutasteride may signal the presence of prostate cancer and should be evaluated, even if PSA levels are still within the normal range for men not taking a 5 alpha-reductase inhibitor. To interpret an isolated PSA value in a man treated with dutasteride for 3 months or more, the PSA value should be doubled for comparison with normal values in untreated men.
The guidelines for Prostate-Specific Antigen (PSA) checks in men taking dutasteride are:
- Establish a new PSA baseline at least 3 months after starting treatment
- Monitor PSA periodically thereafter
- Double the PSA value for comparison with normal values in untreated men if the treatment has been ongoing for 3 months or more
- Evaluate any confirmed increase from the lowest PSA value while on dutasteride, even if PSA levels are still within the normal range for men not taking a 5 alpha-reductase inhibitor 2.
The guidelines for Prostate-Specific Antigen (PSA) checks in men taking finasteride are:
- Establish a new PSA baseline at least six months after starting treatment
- Monitor PSA periodically thereafter
- Double the PSA value for comparison with normal ranges in untreated men if the treatment has been ongoing for six months or more
- Evaluate any confirmed increase from the lowest PSA value while on finasteride, even if PSA levels are still within the normal range for men not taking a 5α-reductase inhibitor 3.
When to start PSA checks is not directly addressed in the provided drug labels.
From the Research
Guidelines for Prostate-Specific Antigen (PSA) Checks
- The American guidelines recommend PSA screening to start no later than at age 55 for well-informed men in good health and a life expectancy of at least 10-15 years 4.
- Some studies suggest starting screening in early midlife for men with familial predisposition and men of African-American descent 4.
- Others suggest starting conversations at age 45 for all men 4.
Re-screening Intervals
- Re-screening intervals can be risk-stratified as guided by the man's age, general health, and PSA-value; longer intervals for those at lower risk and shorter intervals for those at higher risk 4.
- The use of reflex tests can help reduce overdiagnosis and unnecessary biopsies 4.
Active Surveillance for Prostate Cancer
- Active surveillance is a conservative management approach for patients with "low-risk" or "favorable-risk" disease, which avoids long-term adverse effects on the patient's quality of life 5.
- Active surveillance is characterized by a routine protocol of close monitoring with digital rectal examination, periodic biopsy, and serial PSA testing 5.
- The use of 5-alpha reductase inhibitors (5-ARIs) has been shown to reduce reclassification and cross-over to treatment in men on active surveillance for prostate cancer 6, 7.
Risk Stratification for Active Surveillance
- Patient factors associated with active surveillance outcomes include age, race, and family history 8.
- Biomarkers such as percentage of free prostate-specific antigen (PSA), Prostate Health Index (PHI), and PSA density (PSAD) can help predict the risk of progression during active surveillance 8.
- Serial measurements of PHI and PSAD, as well as repeat biopsy results, can predict later biopsy progression 8.