Prostate Cancer Screening Recommendations
Prostate cancer screening should begin at age 50 for average-risk men, age 45 for high-risk men (African Americans and those with a first-degree relative diagnosed with prostate cancer before age 65), and age 40 for very high-risk men (multiple first-degree relatives diagnosed with prostate cancer before age 65). 1
Age to Start Screening
The recommended age to start prostate cancer screening varies based on risk factors:
- Average-risk men: Begin at age 50 2, 1
- High-risk men: Begin at age 45 1
- African American men
- Men with a first-degree relative diagnosed with prostate cancer before age 65
- Very high-risk men: Begin at age 40 1
- Men with multiple first-degree relatives diagnosed with prostate cancer before age 65
Screening Frequency
Screening intervals should be risk-stratified based on PSA levels:
- PSA < 1.0 ng/mL: Rescreen every 2-4 years 2, 1
- PSA 1.0-2.5 ng/mL: Rescreen every 2 years 2, 1
- PSA ≥ 2.5 ng/mL: Rescreen annually 2, 1
Screening Method
- Primary screening tool: PSA test with or without digital rectal examination (DRE) 2, 1
- A PSA level of 4.0 ng/mL or higher has traditionally been used as the threshold for referral for further evaluation or biopsy 2
- For PSA levels between 2.5 and 4.0 ng/mL, individualized risk assessment incorporating other risk factors should be considered 2, 1
When to Stop Screening
- Age-based discontinuation: Do not screen men over age 69-70 years 2, 1, 3
- Life expectancy-based discontinuation: Do not screen men with a life expectancy less than 10-15 years, regardless of age 2, 1
- PSA-based discontinuation: Men over 75 years with PSA levels < 3.0 ng/mL can safely discontinue screening 1
Benefits and Harms of Screening
Benefits
- PSA screening may reduce prostate cancer mortality by approximately 1.3 deaths per 1000 men screened over 13 years 1, 3
- The European Randomized Study of Screening for Prostate Cancer (ERSPC) showed a 21% relative reduction in prostate cancer mortality 2, 1
Harms
- False-positive results requiring additional testing and possible prostate biopsy
- Overdiagnosis and overtreatment
- Treatment complications including erectile dysfunction, urinary incontinence, and bowel symptoms 1, 3
Risk Stratification Using Baseline PSA
Baseline PSA testing can help with risk stratification:
- Men with PSA levels in the top 10% for their age group (approximately ≥ 1.5 ng/mL before age 50) are at particularly high risk and should receive more intensive monitoring 1, 4
- Men with very low PSA levels at baseline may benefit from less frequent screening 4
Important Considerations
- Avoid PSA testing within 2 days of ejaculation or vigorous exercise, as these may cause false elevations 1
- Certain medications like finasteride and dutasteride can lower PSA levels, potentially masking elevated values 1
- A single elevated PSA should not prompt immediate biopsy and should be verified by a second test 1
- Before repeat biopsy, multi-parametric MRI is recommended 1
Special Considerations for High-Risk Populations
African American men and those with a family history of prostate cancer have an increased risk and should begin screening earlier (age 45) 1, 3
By following these evidence-based recommendations, clinicians can help reduce prostate cancer mortality while minimizing the harms associated with overdiagnosis and overtreatment.