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

From the Guidelines

Prostate-Specific Antigen (PSA) testing guidelines recommend shared decision-making between men and their healthcare providers, with screening typically offered to men aged 55-69 years where the benefits may outweigh the risks. For men at higher risk, including African Americans and those with a family history of prostate cancer, screening discussions should begin earlier, around age 40-45 1. The standard screening interval is generally annual, though every 2-4 years may be appropriate for men with low PSA levels. Testing involves a simple blood draw measuring PSA levels, with results typically considered elevated if above 4.0 ng/mL, though this threshold varies by age and other factors 1. Men over 70 or with less than 10-year life expectancy generally should not be screened routinely. PSA testing aims to detect prostate cancer early when treatment is most effective, but carries risks of false positives leading to unnecessary biopsies and potential overdiagnosis of slow-growing cancers that might never cause symptoms. This balance of benefits and harms makes individualized decision-making essential rather than universal screening. Some key points to consider in shared decision-making include:

• The potential benefits and harms of screening, including the risk of false positives and overdiagnosis 1
• The patient's general health and life expectancy, as well as their preferences and values 1
• The use of risk assessment tools, such as the Prostate Cancer Prevention Trial (PCPT) Prostate Cancer Risk Calculator, to estimate a man's overall risk of prostate cancer and high-grade prostate cancer 1
• The importance of informed decision-making, with patients having the opportunity to learn about the potential benefits, limitations, and harms associated with testing for early detection and treatment of early-stage prostate cancer 1. Overall, the goal of PSA testing is to detect prostate cancer early, when treatment is most effective, while minimizing the risks of false positives and overdiagnosis. By prioritizing individualized decision-making and shared decision-making between men and their healthcare providers, we can ensure that PSA testing is used in a way that maximizes benefits and minimizes harms.

From the Research

Guidelines for Prostate-Specific Antigen (PSA) Testing

• The US Preventive Services Task Force (USPSTF) recommends that men aged 55 to 69 years discuss the potential benefits and harms of PSA-based screening for prostate cancer with their clinician, as the net benefit of screening in this age group is small 2.
• For men aged 70 years and older, the USPSTF recommends against PSA-based screening for prostate cancer, as the potential benefits do not outweigh the expected harms 2.
• Most guidelines recommend PSA screening to start no later than at age 55 and involve 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 suggest starting conversations at age 45 for all men 3.
• Re-screening intervals can be risk-stratified based on 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.

Shared Decision Making

• Shared decision making between a physician and a patient is crucial, involving a discussion about the pros and cons of PSA testing 3, 4, 5.
• Studies have shown that many men do not receive adequate information about the potential benefits and harms of PSA testing, with only 10% of men reporting receiving all necessary information 4.
• Black men and men with lower levels of education are less likely to be provided with this information, highlighting the need for improved patient-provider communication 4, 5.

Screening Intervals and Methods

• The use of PSA density as a cutoff for biopsy has been compared to serum PSA concentration alone, with results suggesting that PSA density may not be predictive for cancer due to difficulties in estimating transrectal ultrasound volume 6.
• A relationship exists among transrectal ultrasound volume, PSA, and positive predictive value for cancer, with PSA concentrations of less than 4.0 ng./ml. not indicating a need for biopsy unless digital rectal examination findings are suspicious for cancer 6.