What is the recommended frequency for Prostate-Specific Antigen (PSA) screening?

PSA Screening Recommendations: When and How Often

PSA screening should begin at age 45 for most men, with testing every 2-4 years if PSA is <1.0 ng/mL and every 1-2 years if PSA is ≥1.0 ng/mL, continuing until age 70 for men with good health status and life expectancy ≥10 years. 1, 2

Age to Begin Screening

• General population: Begin at age 45 1, 2
• High-risk groups: Begin earlier
  • African American men: Age 45 1
  • Family history (first-degree relative with prostate cancer): Age 45 1
  • Multiple first-degree relatives diagnosed before age 65: Age 40 1

Screening Frequency Based on PSA Level

The National Comprehensive Cancer Network (NCCN) recommends tailoring screening intervals based on baseline PSA levels to maximize survival benefits while minimizing unnecessary testing 1:

• If PSA <1.0 ng/mL: Screen every 2-4 years

  • Men with very low PSA (<1.0 ng/mL) have extremely low risk of developing prostate cancer in the next 4-8 years (0.23% at 4 years, 0.49% at 8 years) 1
  • A study showed men aged 40-49 with baseline PSA <1.0 ng/mL had only 0.6% risk of prostate cancer by age 55 3

• If PSA ≥1.0 ng/mL: Screen every 1-2 years

  • Higher baseline PSA values correlate with increased risk of future prostate cancer diagnosis 1, 2
  • Men aged 40-49 with baseline PSA ≥1.0 ng/mL had 15.7% risk of prostate cancer by age 55 3

Age to Discontinue Screening

• Age 70: Discontinue routine screening for most men 1, 4
• Exception: Continue with caution in healthy men with little or no comorbidity and life expectancy ≥10 years 1, 2
• Rationale: The USPSTF concludes that potential benefits of PSA screening for men ≥70 years do not outweigh the expected harms 4

Risk Stratification Considerations

• Baseline PSA is a stronger predictor of future prostate cancer risk than family history or race 1
• PSA velocity (change over time) may provide additional risk information, especially in patients with history of prostatitis 2
• Recent evidence shows that men with PSA <1.0 ng/mL between ages 65-69 have extremely low 10-year prostate cancer mortality risk (0.10%), even among Black men in the healthiest quintile (0.08%) 5

Clinical Pitfalls to Avoid

1. Overscreening: Annual screening for all men leads to unnecessary biopsies and overdiagnosis

   • Biennial screening retains 87-95% of life-years saved while reducing unnecessary biopsies by nearly 50% 1

2. Underscreening high-risk populations: African American men and those with family history have higher baseline risk and may benefit from earlier and potentially more frequent screening 1

3. Continuing screening too long: For men >70 years with comorbidities or life expectancy <10 years, harms of screening outweigh benefits 4

4. Ignoring baseline PSA: A baseline PSA at age 45 is highly informative for determining future screening intervals 1, 3

5. Failing to account for factors affecting PSA: Recent ejaculation, vigorous exercise, or prostatitis can cause false elevations in PSA levels 1

By following these evidence-based recommendations, clinicians can optimize the benefits of prostate cancer early detection while minimizing the harms of overdiagnosis and unnecessary procedures.