Should we offer Prostate-Specific Antigen (PSA) testing to an asymptomatic patient?

From the Guidelines

The decision to offer PSA testing to an asymptomatic patient should be based on shared decision-making after discussing the potential benefits and harms. For men aged 55-69, PSA screening may reduce prostate cancer mortality but comes with significant risks of overdiagnosis and overtreatment 1. Before ordering a PSA test, healthcare providers should have a thorough discussion with patients about the test's limitations, including false positives, unnecessary biopsies, and potential treatment complications like urinary incontinence and erectile dysfunction. The discussion should consider the patient's age, family history, race (as Black men have higher risk), and overall health status. Some key points to consider in the discussion include:

• The potential benefits of PSA screening, including the reduction of prostate cancer mortality
• The potential harms of PSA screening, including overdiagnosis, overtreatment, and treatment complications
• The patient's individual risk factors, including age, family history, and race
• The patient's overall health status and life expectancy PSA testing is generally not recommended for men under 40, over 70, or with less than 10-year life expectancy 1. If screening is chosen, it typically involves PSA blood testing every 1-2 years with a threshold of 4.0 ng/mL often used to trigger further evaluation, though this value should be interpreted in context of the patient's risk factors 1. The value of PSA screening lies in early detection of clinically significant prostate cancer, but this benefit must be weighed against the psychological and physical harms of the screening cascade. Ultimately, the decision to offer PSA testing should be based on a thorough discussion of the potential benefits and harms, and should take into account the individual patient's preferences and values.

Some of the key evidence-based guidelines for PSA screening include:

• The American Cancer Society recommends that asymptomatic men who have at least a 10-year life expectancy have an opportunity to make an informed decision with their healthcare provider about whether to be screened for prostate cancer 1
• The American Urological Association recommends that men aged 55-69 undergo PSA screening every 2-4 years, and that men with a life expectancy of less than 10-15 years should not be screened 1
• The US Preventive Services Task Force recommends that men aged 55-69 undergo PSA screening every 2-4 years, and that men with a life expectancy of less than 10-15 years should not be screened 1

It's worth noting that the evidence for PSA screening is not universally accepted, and different organizations have different recommendations. However, most guidelines agree that shared decision-making is essential, and that patients should be fully informed of the potential benefits and harms of PSA screening before making a decision. By considering the individual patient's preferences and values, and by weighing the potential benefits and harms of PSA screening, healthcare providers can make informed decisions about whether to offer PSA testing to asymptomatic patients.

From the Research

PSA Testing for Asymptomatic Patients

• The decision to offer Prostate-Specific Antigen (PSA) testing to asymptomatic patients is a complex one, with various guidelines and studies providing different recommendations 2, 3.
• Population-based PSA testing of asymptomatic men is not widely recommended, with guidelines emphasizing shared patient-clinician decision making 2.
• The recommended age for screening 'average-risk' men varies from 50-55 to 70 years, alongside consideration of life expectancy (ranging from 7-15 years) 2.
• For high-risk men, such as those of African descent or with a family history of prostate cancer, the earliest age for screening is 40 years, but recommendations often defer to clinical judgement 2, 3.

Benefits and Harms of PSA Testing

• PSA screening reduces prostate cancer mortality, but may lead to harm in terms of overdiagnosis and overtreatment 3.
• The use of PSA in conjunction with digital rectal examination enhances early prostate cancer detection, with PSA detecting significantly more tumors than digital rectal examination alone 4.
• However, digital rectal examination may not be a useful predictor of prostate cancer at serum PSA level 3.0-3.9 ng/ml, with free/total PSA ratio being a more effective additional screening test 5.

Guideline Recommendations

• Most guidelines recommend PSA screening to start no later than at age 55, involving well-informed men in good health and a life expectancy of at least 10-15 years 3.
• Some guidelines suggest starting screening in early midlife for men with familial predisposition and men of African-American descent, while others suggest starting conversations at age 45 for all men 3, 6.
• Initiating screening at age 40 to obtain a baseline value is recommended for primary care providers, and is supported by the most recent evidence 6.