What are the guidelines for Prostate-Specific Antigen (PSA) screening?

From the Guidelines

Prostate-Specific Antigen (PSA) screening should be offered to men aged 55-69 years after a thorough discussion of potential benefits and harms, as this age group benefits most from screening. Men should make an informed decision based on their personal values and risk factors. For average-risk men who choose screening, testing should occur every 1-2 years. African American men and those with a family history of prostate cancer should consider beginning screening earlier, around age 40-45, due to their higher risk. Men with a life expectancy less than 10 years or those over 70 generally should not be screened as the harms often outweigh benefits. The PSA test measures a protein produced by prostate cells, with levels above 4.0 ng/mL typically warranting further evaluation, though some cancers can occur at lower levels.

Key Considerations

• The decision to screen for prostate cancer should be made after a thorough discussion of the potential benefits and harms, taking into account the individual's personal values and risk factors 1.
• The American Cancer Society recommends that men with at least a 10-year life expectancy should have an opportunity to make an informed decision about whether to be screened for prostate cancer with serum prostate-specific antigen (PSA), with or without digital rectal examination (DRE) 1.
• Men at higher risk, including African American men and men with a family member diagnosed with prostate cancer before age 65, should receive information about screening beginning at age 45, while those at appreciably higher risk should receive this information beginning at age 40 1.
• For men who choose to be screened, the screening interval can be extended to every 2 years for those with PSA levels less than 2.5 ng/mL, and screening should be conducted yearly for men with PSA levels of 2.5 ng/mL or higher 1.

Screening Recommendations

• The US Preventive Services Task Force recommends providing information about the potential benefits and harms of screening for men aged 55-69 years 1.
• The American College of Physicians recommends that clinicians inform men between the ages of 50 and 69 about the limited potential benefits and substantial harms of screening for prostate cancer 1.
• The European Association of Urology recommends against PSA testing without prior counseling on potential risks and benefits and offers an individualized, risk-adapted strategy for early detection to well-informed men with good performance status and life expectancy of at least 10-15 years 1.

Risk Assessment and Screening Interval

• A PSA level of 4.0 ng/mL or higher has historically been used to recommend referral for further evaluation or biopsy, which remains a reasonable approach for men at average risk for prostate cancer 1.
• For men with PSA levels between 2.5 and 4.0 ng/mL, healthcare providers should consider an individualized risk assessment that incorporates other risk factors for prostate cancer, particularly for high-grade cancer 1.

From the Research

Guidelines for Prostate-Specific Antigen (PSA) Screening

• The US Preventive Services Task Force (USPSTF) recommends that men aged 55 to 69 years discuss the benefits and harms of PSA-based screening with their clinician, as the net benefit of screening is small for some men 2.
• For men aged 55 to 69 years, screening programs may prevent approximately 1.3 deaths from prostate cancer over approximately 13 years per 1000 men screened, and approximately 3 cases of metastatic prostate cancer per 1000 men screened 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.
• Most guidelines recommend screening every 2 to 4 years in men 55 to 69 years of age at average risk 3.
• After a positive prostate-specific antigen test result, the test should be repeated, and if the prostate-specific antigen level is still elevated, next steps include multiparametric magnetic resonance imaging, assessment of urine or blood biomarkers, and referral to urology 3.

Shared Decision-Making and PSA Screening

• Shared decision-making is strongly recommended by all national guidelines before initiating screening 3.
• A study found that receipt of shared decision-making increased in men aged ≥50 years from 30.5% in 2015 to 36.7% in the second half of 2018, with the most prominent increase in men aged 55 to 69 years 4.
• However, there was no significant increase in PSA-based prostate cancer screening between 2015 and 2018 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.
• Oncologic outcomes for active surveillance cohorts have shown the long-term safety of this approach, with a cancer-specific mortality rate of 3% at 10 to 15 years 5.

Changes in PSA Testing Rates

• A study found that rates of PSA testing increased after the USPSTF's draft statement in 2017, reversing trends seen after earlier guidance against PSA testing for all patients 6.
• The mean rate of PSA testing increased from 32.5 to 36.5 tests per 100 person-years between 2016 and 2019, a relative increase of 12.5% 6.