PSA Screening for Average-Risk Men
PSA screening for men at average risk of prostate cancer should begin at age 50 after a thorough informed decision-making process, while high-risk men should begin discussions at age 45, and those at very high risk at age 40. 1, 2
Recommended Screening Ages by Risk Category
- Average risk men: Begin discussions at age 50 2, 1
- High-risk men: Begin discussions at 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: Begin discussions at age 40 2, 1
- Multiple family members diagnosed with prostate cancer before age 65
Screening Protocol
- Initial approach: Baseline PSA testing at age 40 can be useful for risk stratification 2
- Follow-up intervals: 2, 1
- PSA < 1.0 ng/mL: Rescreen at age 45
- PSA 1.0-2.5 ng/mL: Screen every 2 years
- PSA ≥ 2.5 ng/mL: Screen annually
- Testing method: PSA test with or without digital rectal examination (DRE) 2
- DRE is specifically recommended alongside PSA for men with hypogonadism due to reduced PSA sensitivity
PSA Thresholds and Follow-up
- PSA ≥ 4.0 ng/mL: Referral for further evaluation or biopsy 2
- PSA 2.5-4.0 ng/mL: Individualized risk assessment incorporating other risk factors 2
- PSA > 10 ng/mL: >67% likelihood of harboring prostate cancer; TRUS-guided biopsy recommended 2
Important Considerations
- Life expectancy requirement: Only screen men with at least 10-year life expectancy 2, 1
- Age limits: Screening should not be routinely offered to men over 70 years 1, 3
- Discontinuation: For men over 75 with PSA levels <3.0 ng/mL, screening can be safely discontinued 1
Benefits vs. Harms
- Benefits: PSA screening may prevent approximately 1.3 deaths from prostate cancer per 1000 men screened over 13 years 3
- Harms: 1, 3
- False positives requiring additional testing
- Unnecessary biopsies (with risks of pain, infection, bleeding)
- Overdiagnosis of indolent cancers
- Treatment complications (erectile dysfunction, urinary incontinence, bowel symptoms)
Informed Decision-Making Process
Before ordering PSA testing, ensure patients understand:
- PSA is prostate-tissue specific, not prostate-cancer specific 1
- The uncertainties, risks, and potential benefits of screening 2
- The possibility of false positives and the need for follow-up testing 1
- The potential for diagnosis of cancers that may not require immediate treatment 2
Patient decision aids are helpful in preparing men to make informed decisions about PSA screening 2, 4.
Biopsy Considerations
If biopsy is indicated:
- TRUS-guided biopsy is the recommended technique 2
- Extended-pattern 12-core biopsy (sextant 6 and lateral peripheral zone 6) is preferred over traditional sextant biopsy alone 2
- Transition zone biopsies are not recommended for initial biopsies 2
By following these evidence-based guidelines, clinicians can help men make informed decisions about PSA screening while maximizing benefits and minimizing harms.