At what age should men start Prostate-Specific Antigen (PSA) testing?

When to Start PSA Screening

Men at average risk should begin PSA screening discussions at age 50, while high-risk men (African Americans or those with a family history of prostate cancer) should begin at age 45, and men at very high risk (multiple family members diagnosed at an early age) should begin at age 40. 1, 2

Risk-Based Screening Approach

Age to Begin Screening Discussions:

• Average risk men: Age 50 2, 1
• High-risk men: Age 45 2, 1
  • African American men
  • Men with a first-degree relative (father or brother) diagnosed with prostate cancer before age 65
• Very high-risk men: Age 40 2, 1
  • Men with multiple family members diagnosed with prostate cancer before age 65

Important Considerations:

1. Informed Decision-Making is Mandatory

   • PSA screening should only occur after thorough discussion of benefits and harms 2, 1
   • Benefits include potential reduction in prostate cancer mortality
   • Harms include false positives, unnecessary biopsies, overdiagnosis, and treatment complications

2. Life Expectancy Requirement

   • Only screen men with at least 10-15 years life expectancy 2, 1
   • Do not screen men aged 70 and older 3
   • Do not screen men with significant comorbidities that limit life expectancy

3. Screening Intervals

   • For men with PSA < 2.5 ng/mL: Every 2 years 2, 1
   • For men with PSA ≥ 2.5 ng/mL: Annual screening 2, 1
   • Consider baseline PSA at age 40 to determine future screening intervals 2

Evidence Quality and Recommendations

The recommendations from major guidelines are based on moderate-quality evidence. The European Randomized Study of Screening for Prostate Cancer (ERSPC) showed a 21% relative reduction in prostate cancer mortality after 11 years of follow-up 3, while the Prostate, Lung, Colorectal and Ovarian (PLCO) trial showed no mortality benefit 4.

The US Preventive Services Task Force (2018) gives a "C" recommendation for men aged 55-69, indicating that the decision should be individualized, and a "D" recommendation (against screening) for men 70 and older 3.

Common Pitfalls to Avoid

1. Screening without informed consent

   • Never order PSA testing without first discussing benefits and harms with the patient 1, 5
   • Studies show that discussing only advantages of PSA testing leads to increased uptake 5, 6

2. Screening men with limited life expectancy

   • Screening men over 70 or those with <10 years life expectancy provides more harm than benefit 3
   • Despite guidelines, overscreening of older men remains common 6

3. Using PSA as a standalone test without context

   • PSA is prostate-tissue specific, not prostate-cancer specific 1
   • Consider PSA in context with other risk factors

4. Failing to adjust screening intervals based on PSA results

   • Men with lower PSA levels can be screened less frequently 2, 1
   • This reduces harms while maintaining benefits

By following these evidence-based guidelines for when to initiate PSA screening based on risk stratification, clinicians can help ensure that the potential benefits of early detection are maximized while minimizing the harms of overdiagnosis and overtreatment.