PSA Screening Age Recommendations
PSA screening should begin at age 50 for average-risk men, age 45 for high-risk men, and age 40 for very high-risk men, after appropriate shared decision-making regarding risks and benefits. 1
Risk-Stratified Screening Initiation
The appropriate age to begin PSA screening depends on a patient's risk profile:
Average-risk men: Begin at age 50
- Men with no family history of prostate cancer
- Non-African American men
High-risk men: Begin at age 45
- African American men
- Men with a positive family history in a first-degree relative
Very high-risk men: Begin at age 40
- Men with multiple first-degree relatives diagnosed with prostate cancer at an early age
Rationale for Early Screening
The American Urological Association (AUA) previously recommended screening at age 50 for average-risk men but has lowered this age based on important evidence 2:
- A baseline PSA level above the median value for age (0.6-0.7 ng/ml) in men in their 40s is a stronger predictor of future prostate cancer risk than family history or race
- Establishing baseline PSA values can help identify men at higher risk who require more vigilant monitoring
- PSA testing is more specific for cancer in younger men as prostatic enlargement is less likely to confound results
Risk-Stratified Screening Intervals
After initial PSA testing, screening intervals should be tailored based on baseline PSA results 1:
- PSA < 1.0 ng/mL: Rescreen every 2-4 years
- PSA 1.0-2.5 ng/mL: Rescreen every 2 years
- PSA ≥ 2.5 ng/mL: Rescreen annually
Benefits and Harms of Screening
When discussing PSA screening with patients, it's essential to address:
Benefits: PSA screening may prevent approximately 1.3 deaths from prostate cancer per 1000 men screened over 13 years and prevent approximately 3 cases of metastatic prostate cancer 1, 3
Harms: Potential for false positives, overdiagnosis, complications from biopsy, and treatment side effects including erectile dysfunction and urinary incontinence 1, 3
When to Discontinue Screening
Screening should be discontinued in:
- Men over age 69-70 years
- Men with a life expectancy less than 10-15 years, regardless of age 1
Important Considerations
- A single elevated PSA should not prompt immediate biopsy and should be verified by a second test 1
- PSA testing should be avoided 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; PSA values should be doubled for comparison with normal ranges in untreated men 1
Common Pitfalls to Avoid
- Overreliance on age alone: While age-based recommendations provide a framework, individual risk factors should guide screening decisions
- Immediate biopsy after a single elevated PSA: Verification with a second test is recommended
- Continuing screening beyond age 70: For most men over 70, the harms of screening outweigh the benefits
- Failing to account for medications: Some medications can artificially lower PSA values
- Not considering life expectancy: Screening is most beneficial for men with at least 10-15 years of life expectancy
The most recent evidence supports a risk-stratified approach to PSA screening that begins earlier than previously recommended, with careful consideration of individual risk factors and appropriate counseling about potential benefits and harms.