At what age should men start discussing Prostate-Specific Antigen (PSA) screening with their healthcare provider?

From the Guidelines

Men should start discussing Prostate-Specific Antigen (PSA) screening with their healthcare provider at age 45, though some guidelines suggest beginning these conversations at age 40 for men with higher risk factors, such as a family history of prostate cancer or being of African American descent. The discussion should focus on the potential benefits and limitations of PSA screening, including the risk of overdiagnosis and overtreatment, as well as the potential for early detection and improved treatment outcomes 1.

Key Considerations

• The American Cancer Society recommends that men at average risk receive information about PSA screening starting at age 50, while men at higher risk, including African American men and those with a family history of prostate cancer, should receive this information starting at age 45 1.
• The US Preventive Services Task Force recommends against PSA-based screening for prostate cancer in all age groups, citing the potential harms of overdiagnosis and overtreatment 1.
• However, other guidelines, such as those from the American Urological Association and the European Association of Urology, recommend shared decision-making and individualized screening strategies for men aged 50-69 years 1.

Screening Recommendations

• Men at average risk should receive information about PSA screening starting at age 50, while those at higher risk should start discussions at age 45 or 40, depending on their individual risk factors 1.
• Screening intervals can be extended to every 2 years for men with PSA levels less than 2.5 ng/mL, and screening should be conducted yearly for men with PSA levels of 2.5 ng/mL or higher 1.
• A PSA level of 4.0 ng/mL or higher has historically been used to recommend referral for further evaluation or biopsy, although individualized risk assessment and shared decision-making are recommended 1.

Risk Factors

• African American men and those with a family history of prostate cancer are at higher risk and should start discussions about PSA screening at an earlier age 1.
• Other risk factors, such as increasing age and abnormal digital rectal examination (DRE) findings, should also be taken into account when making decisions about PSA screening 1.

Quality of Life and Mortality

• The potential benefits of PSA screening, including early detection and improved treatment outcomes, must be weighed against the potential harms, including overdiagnosis and overtreatment, as well as the impact on quality of life 1.
• Men should be informed about the potential risks and benefits of PSA screening and involved in shared decision-making to determine the best approach for their individual situation 1.

From the Research

Age to Start Discussing PSA Screening

• Men should discuss Prostate-Specific Antigen (PSA) screening with their healthcare provider at an age when the benefits and harms of screening can be weighed, typically around 45 to 55 years old 2, 3.
• 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 3.
• Some studies suggest that men with familial predisposition and men of African-American descent may need to start screening in early midlife, around 40 to 45 years old 2, 4.

Factors to Consider When Discussing PSA Screening

• Men's preferences and trade-offs for PSA screening should be considered, including the potential benefits and harms of screening, such as false-positive results, unnecessary biopsies, and treatment complications 5.
• The decision to undergo periodic PSA-based screening for prostate cancer should be an individual one, taking into account a man's age, general health, and PSA value 2, 3.
• Clinicians should not screen men who do not express a preference for screening, and should consider a man's family history, race/ethnicity, comorbid medical conditions, and patient values when discussing screening options 3.

Screening Intervals and Strategies

• Re-screening intervals can be risk-stratified, with longer intervals for men at lower risk and shorter intervals for men at higher risk 2.
• Strategies to mitigate the potential harms of screening include considering biennial screening, a higher PSA threshold for biopsy, and conservative therapy for men receiving a new diagnosis of prostate cancer 6.
• Magnetic resonance imaging in the pre-diagnostic setting holds promise in pilot studies and large-scale prospective studies are ongoing 2.