At what age should Prostate-Specific Antigen (PSA) screening start for men at average risk of prostate cancer?

PSA Screening Age for Average-Risk Men

For men at average risk of prostate cancer, PSA screening discussions should begin at age 50 years, with individualized decision-making based on a shared discussion of benefits and harms. 1

Screening Recommendations by Risk Category

Average-Risk Men:

• Begin discussions about PSA screening at age 50 years 1
• Only proceed with screening after informed decision-making
• Continue screening consideration until age 69-70 years 1
• Screening is not recommended for men aged 70 years and older 1, 2

Higher-Risk Men:

• African American men: Begin discussions at age 45 years 1
• Men with first-degree relative diagnosed with prostate cancer before age 65: Begin discussions at age 45 years 1
• Men with multiple first-degree relatives diagnosed with prostate cancer at an early age: Begin discussions at age 40 years 1

Evidence-Based Rationale

The 2018 BMJ clinical practice guideline synthesizes recommendations from multiple professional organizations 1. Most major guidelines, including the American Cancer Society (ACS), American College of Physicians (ACP), and US Preventive Services Task Force (USPSTF), recommend beginning screening discussions at age 50 for average-risk men 1.

The USPSTF (2018) found that PSA screening in men aged 55-69 years may prevent approximately 1.3 deaths from prostate cancer per 1,000 men screened over 13 years 2. However, screening also leads to false positives, unnecessary biopsies, and potential overtreatment with significant side effects including erectile dysfunction and urinary incontinence 2, 3.

Shared Decision-Making Process

Before PSA testing, clinicians should discuss:

1. Potential mortality benefit (small but significant)
2. Risk of false positives requiring unnecessary biopsies
3. Risk of overdiagnosis and overtreatment
4. Potential treatment complications (erectile dysfunction, urinary incontinence, bowel problems)
5. Patient's values and preferences regarding these trade-offs

Research shows men are willing to accept certain trade-offs to prevent prostate cancer death, but these preferences vary by age and individual values 4. Unfortunately, many men (72%) report not receiving balanced information about both advantages and disadvantages of PSA testing before undergoing the test 5.

Important Caveats

• Life expectancy consideration: Only consider screening in men with at least 10-15 years life expectancy 1
• Testing interval: Consider biennial rather than annual screening to reduce harms 3
• Follow-up plan: Have a clear plan for abnormal results before initiating screening
• Avoid screening without discussion: Clinicians should not screen men who do not express a preference for screening after discussion 2

Common Pitfalls to Avoid

1. Automatic screening without discussion: All guidelines emphasize informed decision-making before PSA testing
2. One-size-fits-all approach: Screening recommendations differ by age and risk factors
3. Continuing screening too long: Benefits diminish and harms increase after age 70
4. Ignoring patient preferences: Men's values regarding potential benefits and harms should guide decisions
5. Failing to recognize higher-risk groups: African American men and those with family history require earlier discussions

The evidence suggests that while PSA screening offers a small mortality benefit for men aged 55-69, this must be weighed against potential harms. Starting discussions at age 50 for average-risk men allows for appropriate consideration of individual factors and preferences.