What is the age cut-off for Prostate-Specific Antigen (PSA) testing?

From the Guidelines

Men over 69 years old or those with a life expectancy less than 10 years should not be offered prostate cancer screening using the prostate-specific antigen (PSA) test, as the harms of screening outweigh the benefits in this population. The American College of Physicians (ACP) 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 individual risk factors, general health, life expectancy, and patient preferences 1. The AUA guideline also recommends shared decision-making for men aged 55 to 69 years, as the benefits of screening may outweigh the harms in this age group, but emphasizes that the test should not be offered in settings where shared decision-making is not practical 2.

Key points to consider when making decisions about PSA screening include:

• The potential benefits of screening, including the reduction of prostate cancer-specific mortality
• The harms associated with screening, including false positives, unnecessary biopsies, overtreatment, and the potential for decreased quality of life
• Individual risk factors, such as family history and African American ancestry
• General health and life expectancy, as men with limited life expectancy are unlikely to benefit from aggressive treatment for localized prostate cancer
• Patient preferences and values, as the decision to undergo PSA screening should be based on a man's individual priorities and concerns.

In terms of specific age cutoffs, the ACP recommends against routine screening in men under 50 years old, unless they have risk factors such as family history or African American ancestry, and against screening in men over 69 years old or those with a life expectancy less than 10 years 1. The AUA guideline recommends shared decision-making for men aged 55 to 69 years, and suggests that men with a life expectancy less than 10 to 15 years are unlikely to benefit from screening 2.

Overall, the decision to undergo PSA screening should be based on a careful consideration of the potential benefits and harms, as well as individual risk factors and patient preferences. The most recent and highest quality evidence suggests that men over 69 years old or those with a life expectancy less than 10 years should not be offered PSA screening, as the harms of screening outweigh the benefits in this population 1, 2.

From the Research

Age Cut-off for Prostate-Specific Antigen (PSA) Testing

• The recommended age for PSA testing varies, but for 'average-risk' men, it ranges from 50-55 to 70 years, considering life expectancy 3.
• 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 3.
• The US Preventive Services Task Force guidelines advise against PSA screening for prostate cancer in males older than 69 years due to the risk of false-positive results and overdiagnosis of indolent disease 4.
• A study found that older male respondents were overscreened for prostate cancer despite the age cutoff for PSA screening recommended in national guidelines, with 55.3% of males in the 70-to-74-year age group and 39.4% in the 80-year-or-older group undergoing recent PSA screening 4.

Age-Specific PSA Cutoff Values

• A study compared the predictive performance of age-specific percentile-based PSA thresholds with a conventional cutoff of >4 ng/mL for the risk of prostate cancer, finding that the 75th percentile PSA cutoff had better discrimination performance among patients aged <60-year-old 5.
• Another study found that using age-dependent PSA cut-offs can reduce the number of unnecessary biopsies in patients with benign prostatic disease, without missing significant prostate cancer, with optimal cut-offs of 1.75 ng/ml for men ≤49 years and 50-59 years, 2.25 ng/ml for men aged 60-69 years, and 3.25 ng/ml for men ≥70 years 6.

Screening Intervals and False-Positive Biopsy Recommendations

• A study found that men with PSA ≤1 ng/mL can wait 3-4 years before having a new PSA test, while men with PSA >1 ng/mL have an increased risk of being diagnosed with high-grade prostate cancer with longer than annual testing intervals 7.
• The study also found that shorter testing intervals increase the risk of false-positive biopsy recommendations, with a twofold increase for annual vs biennial and threefold increase for annual vs triennial testing intervals 7.