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

PSA Screening Age Recommendations for Average and High-Risk Men

For men at average risk of prostate cancer, PSA screening should begin at age 50, while high-risk men (African American men or those with a family history of prostate cancer diagnosed before age 65) should begin at age 45, and men at very high risk (multiple first-degree relatives diagnosed before age 65) should begin at age 40. 1

Risk-Stratified Screening Recommendations

Average-Risk Men

• Begin PSA screening discussions at age 50 1
• Screening should only occur after informed decision-making process 1
• Screening should be offered to men with at least 10-year life expectancy 1
• Consider discontinuing screening at age 70 1

High-Risk Men

• African American men: Begin at age 45 1
• Men with a first-degree relative diagnosed with prostate cancer before age 65: Begin at age 45 1
• Men with multiple first-degree relatives diagnosed with prostate cancer before age 65: Begin at age 40 1
  • If initial PSA <1.0 ng/mL at age 40, no additional testing needed until age 45 1
  • If PSA >1.0 but <2.5 ng/mL, annual testing recommended 1
  • If PSA ≥2.5 ng/mL, consider biopsy 1

Evidence Supporting These Recommendations

The American Cancer Society (ACS) recommends that men at average risk should receive information about prostate cancer screening beginning at age 50, while men at higher risk should receive this information before age 50 1. This is consistent with the 2018 US Preventive Services Task Force (USPSTF) recommendation that for men aged 55-69, the decision to undergo PSA screening should be individualized after discussion of potential benefits and harms 1, 2.

Research shows that a single PSA measurement at or before age 50 can be highly predictive of subsequent prostate cancer diagnosis up to 30 years later 3. This supports the value of early baseline PSA testing, particularly for risk stratification.

Shared Decision-Making Approach

All major guidelines emphasize that PSA screening should not occur without an informed decision-making process 1, 4. This should include discussion of:

• Potential benefits: Reduced risk of metastatic disease and prostate cancer mortality
• Potential harms: False positives, overdiagnosis, overtreatment, and treatment complications
• Individual risk factors and life expectancy

Screening Interval Considerations

• The optimal screening interval is not definitively established
• Most guidelines suggest annual screening for those who choose to be screened 1
• Some evidence suggests a 2-year interval may reduce harms while maintaining benefits 4

Common Pitfalls to Avoid

1. Screening without discussion: Never order PSA testing without first discussing benefits and harms with the patient 4
2. Ignoring risk factors: Failing to identify high-risk men who should begin screening earlier
3. Screening men with limited life expectancy: PSA screening should not be offered to men with less than 10 years life expectancy 1, 4
4. Using PSA alone without context: PSA is prostate-tissue specific, not prostate-cancer specific 1

Conclusion

The evidence supports a risk-stratified approach to PSA screening, with different starting ages based on individual risk factors. The decision to screen should always involve shared decision-making, weighing potential benefits against harms, with particular attention to the patient's values and preferences.