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

PSA Screening Age Guidelines

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

Risk-Stratified Screening Approach

When to Start Screening:

• Average-risk men: Age 50
• High-risk men: Age 45
  • African American men
  • Men with a first-degree relative diagnosed with prostate cancer before age 65
• Very high-risk men: Age 40
  • Men with multiple first-degree relatives diagnosed with prostate cancer before age 65

When to Stop Screening:

• Screening should be discontinued at age 70 for most men 1
• Men with less than 10-15 years of life expectancy should not be screened regardless of age 2, 1
• For men over 75 with PSA levels <3.0 ng/mL, screening can be safely discontinued 2

Screening Intervals

• For men with PSA <2.5 ng/mL: Screen every 2 years 1
• For men with PSA ≥2.5 ng/mL: Screen annually 1
• Consider baseline PSA at initial screening to determine future screening intervals 1

Shared Decision-Making

Before initiating PSA screening, physicians must discuss:

1. Potential benefits:

   • Reduction in prostate cancer mortality (approximately 1.3 deaths prevented per 1,000 men screened over 13 years) 3
   • Prevention of approximately 3 cases of metastatic disease per 1,000 men screened 3

2. Potential harms:

   • False-positive results requiring additional testing
   • Unnecessary biopsies
   • Overdiagnosis of indolent cancers
   • Treatment complications (erectile dysfunction, urinary incontinence, bowel problems) 1, 3

Important Considerations

• Despite guidelines, screening rates remain high even among men with limited life expectancy (34% of men ≥75 years with >75% predicted 9-year mortality) 4
• Men are twice as likely to recall discussions about screening benefits than harms, suggesting inadequate informed decision-making 4
• The ratio of men diagnosed through screening to prostate cancer deaths prevented is high (37:1 after 11 years of follow-up) but may decrease with longer follow-up 5

Common Pitfalls to Avoid

1. Screening without discussion: Never order PSA testing without first discussing benefits and harms with the patient 1

2. One-size-fits-all approach: Men of different ages and risk profiles have different benefit-harm trade-offs 6

3. Screening men with limited life expectancy: Screening men with <10 years life expectancy provides minimal benefit while exposing them to potential harms 2, 1

4. Failing to consider risk factors: Not accounting for family history or race/ethnicity when determining screening initiation age 1

5. Overscreening elderly men: Continuing screening beyond age 70 for average-risk men with no prior concerning PSA values 1, 3

By following these evidence-based guidelines for PSA screening, clinicians can help maximize the benefits while minimizing the harms of prostate cancer screening.