When should a Prostate-Specific Antigen (PSA) test be ordered?

From the Guidelines

A PSA test should be ordered for men aged 55-69 after a thorough discussion of the potential benefits and harms of prostate cancer screening, as recommended by the American College of Physicians 1. The test may be considered earlier (around age 40-45) for men with high-risk factors including African American race or a family history of prostate cancer, particularly in first-degree relatives. Some key points to consider when deciding to order a PSA test include:

• The potential benefits of early cancer detection, including reduced mortality from prostate cancer
• The known harms of prostate cancer screening, including false-positive results, overdiagnosis, and overtreatment of slow-growing cancers
• The importance of individualized decision-making, taking into account the patient's risk factors, overall health, and preferences
• The need for thorough discussion and shared decision-making between the clinician and patient before ordering a PSA test PSA testing is also appropriate when monitoring patients with a history of prostate cancer, evaluating symptoms of prostate disease (such as difficulty urinating, frequent urination, or pelvic pain), or assessing response to treatments for prostate conditions. The test measures a protein produced by the prostate gland that can be elevated in prostate cancer, but also in benign conditions like prostate enlargement, inflammation, or infection. This non-specificity means that elevated PSA levels require further evaluation, typically through additional tests or prostate biopsy. The decision to order a PSA test should be individualized, weighing the potential benefit of early cancer detection against the risks of overdiagnosis and overtreatment of slow-growing cancers that might never cause symptoms, as supported by the US Preventive Services Task Force recommendation statement 2.

From the Research

Prostate-Specific Antigen (PSA) Test Ordering

• The decision to order a PSA test should be based on various factors, including the patient's age, family history, and overall health status 3.
• For men aged 55-69 years, the PSA test may be considered as part of a discussion about the pros and cons of screening, and only those who express a definite preference for screening should undergo testing 3.
• The use of 5-alpha-reductase inhibitors (5-ARIs) can affect PSA levels, and any increase in PSA from nadir should be considered suspicious for malignancy 4.
• However, 5-ARI use has been associated with a delayed diagnosis and worse cancer-specific outcomes in men with prostate cancer, highlighting the need for clear guidelines and optimal care for men using these medications 5.
• In men on active surveillance for prostate cancer, long-term use of 5-ARIs has been shown to be safe and effective in reducing the risk of pathologic, grade, and volume progression 6.
• The following factors should be considered when deciding when to order a PSA test: + Age: PSA screening is generally recommended for men aged 55-69 years 3. + Family history: Men with a family history of prostate cancer may benefit from earlier or more frequent screening 7. + Overall health status: Men with a limited life expectancy or significant comorbidities may not benefit from screening 3. + 5-ARI use: Men using 5-ARIs should be aware of the potential effects on PSA levels and the need for regular monitoring 4, 5.