At what age should prostate screening start?

From the Guidelines

Prostate cancer screening should generally begin at age 50 for men with average risk, but men with higher risk factors, such as African American men or those with a first-degree relative diagnosed with prostate cancer before age 65, should start earlier, at age 45, as recommended by the American Cancer Society guideline published in 2010 1. The decision to start screening at an earlier age should be based on an informed discussion between the patient and their healthcare provider, taking into account the individual's risk factors, preferences, and values.

• Men at average risk should receive information about the benefits, risks, and uncertainties associated with prostate cancer screening starting at age 50 years.
• Men at higher risk, including African American men and men with a family member (father or brother) diagnosed with prostate cancer before age 65 years, should receive this information beginning at age 45 years.
• Men at appreciably higher risk (multiple family members diagnosed with prostate cancer before age 65 years) should receive this information beginning at age 40 years. The screening process typically involves a prostate-specific antigen (PSA) blood test, sometimes accompanied by a digital rectal examination (DRE), with the frequency of screening depending on initial PSA levels, as outlined in the guideline 1.
• For men who choose to be screened for prostate cancer after a process of shared or informed decision making, screening is recommended with a PSA test, with or without DRE.
• For men with PSA levels less than 2.5 ng/mL, screening intervals can be extended to every 2 years, and screening should be conducted yearly for men with PSA levels of 2.5 ng/mL or higher. It is essential to weigh the potential benefits of early detection against the potential harms of overdiagnosis and overtreatment, as prostate cancer often grows slowly and may not require immediate intervention, as noted in the guideline 1 and supported by other studies 1. Before beginning screening, men should discuss with their healthcare provider the potential benefits, risks, and limitations of prostate cancer screening to make an informed decision based on their individual risk factors and preferences, as emphasized in the American College of Physicians guidance statement on screening for prostate cancer 1.

From the Research

Prostate Screening Age

The age at which prostate screening should start is a topic of ongoing debate. Several studies have investigated the benefits and harms of prostate-specific antigen (PSA)-based screening for prostate cancer in different age groups.

• A study published in JAMA in 2018 2 found that PSA-based screening programs in men aged 55 to 69 years may prevent approximately 1.3 deaths from prostate cancer over approximately 13 years per 1000 men screened.
• However, the same study also found that the harms of screening in men older than 70 years are at least moderate and greater than in younger men.
• A randomized trial published in the International Journal of Cancer in 2022 3 found that the prevalence of screen-detected aggressive prostate cancer in 45-year-old men is very low.
• Another study published in The Journal of Urology in 2016 4 found that starting screening at an early age appears to advance the time of prostate cancer diagnosis but does not seem to increase the risk of being diagnosed with the disease.
• A study published in the South African Medical Journal in 2011 5 suggested that baseline PSA testing should be performed in men aged 40 to detect those aged 50 or less who are at risk of aggressive prostate cancer.
• A population-based cohort study published in European Urology in 2017 6 found that PSA screening starting at age 50-54 years can decrease prostate cancer mortality among men in this age group.

Key Findings

• The US Preventive Services Task Force recommends against PSA-based screening for prostate cancer in men 70 years and older 2.
• The decision to undergo periodic PSA-based screening for prostate cancer in men aged 55 to 69 years should be an individual one and should include discussion of the potential benefits and harms of screening with their clinician 2.
• PSA screening for prostate cancer can decrease prostate cancer mortality among men aged 50-54 years 6.
• The prevalence of screen-detected aggressive prostate cancer in 45-year-old men is very low 3.

Age Recommendations

• Men aged 55 to 69 years: The decision to undergo periodic PSA-based screening for prostate cancer should be an individual one and should include discussion of the potential benefits and harms of screening with their clinician 2.
• Men older than 70 years: The US Preventive Services Task Force recommends against PSA-based screening for prostate cancer 2.
• Men aged 50-54 years: PSA screening for prostate cancer can decrease prostate cancer mortality among men in this age group 6.
• Men aged 40-49 years: Baseline PSA testing may be considered to detect those at risk of aggressive prostate cancer 5.