From the Guidelines
The American Cancer Society recommends that men discuss PSA screening with their doctor starting at age 50 for those at average risk, and at age 45 for men at high risk (African Americans and those with a first-degree relative diagnosed with prostate cancer before age 65). Men at very high risk (multiple first-degree relatives diagnosed before age 65) should begin discussions at age 40. The screening involves a blood test measuring PSA levels, with values under 4.0 ng/mL generally considered normal, though cancer can still be present at lower levels. If PSA is elevated, additional testing like repeat PSA, free PSA percentage, PSA velocity, digital rectal examination, or prostate biopsy may be recommended.
Key Considerations
- The decision to screen should be individualized based on personal risk factors, life expectancy, and personal preferences, as screening carries potential harms including false positives, overdiagnosis, and complications from unnecessary treatment.
- Many men can safely discontinue screening after age 70, especially those with limited life expectancy.
- PSA screening remains controversial because while it can detect cancer early, it hasn't definitively been shown to significantly reduce mortality in all populations, which is why shared decision-making between patient and provider is essential 1.
- The US Preventive Services Task Force recommends against screening for prostate cancer in men aged 70 years or older, and suggests that the decision to screen should be based on a discussion of the potential benefits and harms of screening 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, and that the decision to screen should be based on a discussion of the benefits and harms of screening, as well as the patient's general health and life expectancy 1.
Screening Guidelines
- Men at average risk should receive information about the potential benefits and risks of screening starting at age 50.
- Men at high risk, including African American men and men with a first-degree relative diagnosed with prostate cancer before age 65, should receive this information starting at age 45.
- Men at very high risk, including those with multiple first-degree relatives diagnosed with prostate cancer before age 65, should receive this information starting at age 40.
- Asymptomatic men with a life expectancy of less than 10 years should not be offered prostate cancer screening.
Shared Decision-Making
- Clinicians should help men understand the potential benefits and harms of screening, as well as the limitations of the PSA test.
- Men should be informed that the PSA test is not a perfect test, and that false positives and false negatives can occur.
- Clinicians should also discuss the potential harms of screening, including overdiagnosis and overtreatment, as well as the potential benefits of early detection and treatment.
From the Research
Guidelines for Prostate-Specific Antigen (PSA) Screening
- The American family physician recommends screening via prostate-specific antigen testing for men aged 55 to 69 years at average risk, with a screening interval of every 2 to 4 years 2.
- Most guidelines suggest starting PSA screening no later than at age 55 and involving well-informed men in good health and a life expectancy of at least 10-15 years 3.
- Some studies suggest starting screening in early midlife for men with familial predisposition and men of African-American descent, while others recommend starting conversations at age 45 for all men 3.
Risk Stratification and Re-screening Intervals
- Re-screening intervals can be risk-stratified as guided by the man's age, general health, and PSA-value, with longer intervals for those at lower risk and shorter intervals for those at higher risk 3.
- A systematic review and meta-analysis found that screening probably has no effect on all-cause mortality and may have no effect on prostate-specific mortality, but may have a small effect on prostate-specific mortality in studies at lower risk of bias 4.
Harms Associated with Screening
- Harms associated with screening include false-positive results, complications of biopsy and treatment, overdiagnosis, and overtreatment 2, 5, 4.
- A study found that prostate biopsy is associated with short-term exacerbation of urinary symptoms, anxiety, and temporary erectile dysfunction 6.
- Modeling studies suggest that the high ratio of additional men receiving diagnoses to prostate cancer deaths prevented will decrease during a longer follow-up 5.
Shared Decision-Making
- Shared decision-making is strongly recommended by all national guidelines before initiating screening, involving a discussion about the pros and cons of PSA screening between a physician and a patient 3, 2, 5.
- Clinicians and patients considering PSA-based screening need to weigh the benefits against the potential short and long-term harms of screening 4.