From the Guidelines
Men should begin regular PSA screening at age 50, though those with risk factors should start earlier at age 45, and high-risk individuals, including African American men and those with a family history of prostate cancer, should begin at age 40. This recommendation is based on the most recent and highest quality study available, which suggests that prostate cancer screening should not occur without an informed decision-making process 1. The American Cancer Society guidelines, as outlined in the 2019 study, recommend 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 beginning at age 45, and those at appreciably higher risk should receive this information beginning at age 40.
Key Considerations
- Men should either receive this information directly from their healthcare providers or be referred to reliable and culturally appropriate sources 1.
- Patient decision aids are helpful in preparing men to make a decision whether to be tested 1.
- For men who are unable to decide, the screening decision can be left to the discretion of the healthcare provider, who should factor into the decision his or her knowledge of the patient’s general health preferences and values 1.
- Asymptomatic men who have less than a 10-year life expectancy based on age and health status should not be offered prostate cancer screening 1.
Screening Intervals and PSA Levels
- For men who choose to be screened for prostate cancer after a process of shared or informed decision making, screening is recommended with the PSA test with or without the DRE (DRE is recommended along with PSA for men with hypogonadism because of reduced sensitivity of PSA) 1.
- For men whose PSA is less than 2.5 ng/mL, screening intervals can be extended to every 2 years, and screening should be conducted yearly for men whose PSA level is 2.5 ng/mL or higher 1.
- A PSA level of 4.0 ng/mL or higher has historically been used to recommend referral for further evaluation or biopsy, which remains a reasonable approach for men who are at average risk for prostate cancer 1.
From the Research
Prostate-Specific Antigen (PSA) Testing Age
- The age at which to start checking PSA levels is a topic of debate, with different studies and guidelines recommending different ages.
- A study published in 2011 2 suggests that it is reasonable to start with PSA testing at the age of 40 years, as this allows for a baseline value to be established and can help identify men at risk for significant prostate cancer.
- However, other guidelines recommend starting screening at age 50-55 years for average-risk men, with some recommending screening as early as 40 years for high-risk men (such as those of African descent or with a family history of prostate cancer) 3, 4, 5.
- A study published in 2019 6 found that men with PSA ≤1 ng/mL can wait 3-4 years before having a new PSA test, while men with PSA >1 ng/mL may need to be screened more frequently to balance the benefits and harms of screening.
- The American family physician guidelines recommend screening every 2 to 4 years in men 55 to 69 years of age at average risk 3.
- The Memorial Sloan Kettering Cancer Center recommendations suggest starting PSA testing at age 45, with a schema for screening that maximizes benefits and minimizes harms 4.
Screening Intervals and Risk Factors
- Screening intervals can vary depending on the individual's risk factors and PSA level, with some guidelines recommending annual, biennial, or longer intervals between tests 3, 4, 6.
- Risk factors such as family history, age, and ethnicity can influence the recommended screening age and interval 3, 4, 5.
- Shared decision-making between patients and clinicians is strongly recommended before initiating screening, taking into account the potential benefits and harms of PSA testing 3, 5.