What are the current guidelines for prostate-specific antigen (PSA) screening for prostate cancer?

From the Guidelines

The current guidelines for prostate-specific antigen (PSA) screening recommend shared decision-making between men and their healthcare providers, with screening generally offered to men aged 55-69 years. For men in this age group, the decision to undergo screening should be individualized after discussing potential benefits and harms. The benefits include early detection and treatment of aggressive cancers, potentially reducing mortality, while harms include false positives, overdiagnosis, and complications from unnecessary treatment. Men with higher risk factors, including African American race or family history of prostate cancer, may consider beginning screening earlier, around age 40-45, as suggested by the American Cancer Society 1. The typical screening interval is every 1-2 years if screening is pursued. For men under 55 or over 70 with limited life expectancy, routine PSA screening is generally not recommended due to limited benefit, as stated by the US Preventive Services Task Force 1. The PSA test itself measures a protein produced by prostate cells, with levels above 4.0 ng/mL traditionally considered abnormal, though this threshold may vary based on age and other factors. If elevated PSA is detected, further evaluation typically includes repeat testing, possibly a digital rectal exam, and referral for consideration of prostate biopsy or additional testing such as MRI.

Some key points to consider in the shared decision-making process include:

• The potential benefits of early detection and treatment of aggressive cancers
• The harms of false positives, overdiagnosis, and complications from unnecessary treatment
• The individual's risk factors, such as African American race or family history of prostate cancer
• The individual's overall health and life expectancy
• The potential for anxiety and other psychological effects related to screening and diagnosis

It's also important to note that different organizations have slightly different recommendations for PSA screening, as outlined in a 2018 clinical practice guideline published in the BMJ 1. However, most guidelines agree on the importance of shared decision-making and individualized screening decisions.

In terms of specific screening intervals, the European Association of Urology recommends screening for men aged >50 years, or >45 years for men with positive family history or African-American ethnicity, with an individualised, risk-adapted strategy for early detection 1. The American Urological Association also recommends shared decision making for men aged 55-69 years and against routine screening in men aged <40 years or those with life expectancy <10-15 years 1.

Ultimately, the decision to undergo PSA screening should be made on an individual basis, taking into account the potential benefits and harms, as well as the individual's personal preferences and values.

From the Research

Current Guidelines for Prostate Cancer Screening

The current guidelines for prostate-specific antigen (PSA) screening for prostate cancer are as follows:

• 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 with their clinician, as the decision to undergo screening should be an individual one 2.
• The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older, as the potential benefits do not outweigh the expected harms 2.
• For men aged 55 to 69 years, the benefits of PSA-based screening include preventing approximately 1.3 deaths from prostate cancer over 13 years per 1000 men screened and 3 cases of metastatic cancer per 1000 men screened 2, 3.
• However, the harms of screening include frequent false-positive results, psychological harms, and potential complications from treatment, such as erectile dysfunction, urinary incontinence, and bowel symptoms 2, 3.

Screening Strategies and Cost-Effectiveness

• An organized and age-targeted screening strategy may reduce the associated harms while retaining or enhancing the benefits of prostate cancer screening 4.
• A micro-simulation study found that screening with 3-year intervals at ages 55-64 resulted in an incremental cost-effectiveness ratio (ICER) of €19 733 per QALY, with a 27% prostate cancer mortality reduction and 28 life years gained (LYG) per 1000 men 4.
• Starting screening before age 55 or continuing screening beyond age 64 is not a favored strategy based on cost-effectiveness analysis 4.

Screening Practices and Patient Risk Categories

• Primary care physicians (PCPs) generally discuss the possible benefits and risks of PSA testing with patients and recommend the test, especially for high-risk asymptomatic men, such as those with a family history of prostate cancer 5.
• PCPs are more likely to discuss and recommend PSA testing for men with a family history of prostate cancer, and may attempt to persuade patients who initially decline the test 5.