At what age should men start prostate cancer screening with a Prostate-Specific Antigen (PSA) blood test and Digital Rectal Exam (DRE)?

Prostate Cancer Screening Age Requirements

Men should begin prostate cancer screening at age 50 for average-risk individuals, age 45 for high-risk individuals (such as African American men or those with one first-degree relative with prostate cancer), and age 40 for very high-risk individuals (those with two or more first-degree relatives with prostate cancer before age 65). 1

Risk-Stratified Screening Approach

The recommended age to begin prostate cancer screening varies based on risk factors:

• Average-risk men: Begin at age 50
• High-risk men (African American race or one first-degree relative with prostate cancer): Begin at age 45
• Very high-risk men (two or more first-degree relatives with prostate cancer before age 65): Begin at age 40 2, 1

Screening Tests and Frequency

• Screening modalities: PSA blood test with or without Digital Rectal Examination (DRE)
• Screening intervals:
  • 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 1

Upper Age Limit and Life Expectancy Considerations

• Age cutoff: Discontinue routine PSA screening in men aged 70 years and older 1
• Life expectancy: Do not screen men with a life expectancy less than 10 years, regardless of age 1, 3

The US Preventive Services Task Force (USPSTF) specifically recommends against PSA-based screening for prostate cancer in men 70 years and older (D recommendation) due to evidence that potential harms outweigh benefits in this age group 3.

Benefits and Harms of Screening

Benefits:

• PSA screening may prevent approximately 1.3 deaths from prostate cancer per 1000 men screened over 13 years
• May prevent approximately 3 cases of metastatic prostate cancer per 1000 men screened 1, 3

Harms:

• False-positive results requiring additional testing
• Complications from prostate biopsy
• Overdiagnosis of clinically insignificant cancers
• Treatment complications including:
  • 11% increased risk of urinary incontinence
  • 37% increased risk of erectile dysfunction
  • Bowel symptoms 1, 3

Important Clinical Considerations

1. Baseline PSA testing: Establishing baseline PSA values in a man's 40s can help identify those at higher risk who require more vigilant monitoring 1

2. Medication effects: Finasteride and dutasteride can lower PSA levels, potentially masking elevated values. PSA values should be doubled for comparison with normal ranges in men taking these medications 1

3. Avoid PSA testing: Within 2 days of ejaculation or vigorous exercise, as these may cause false elevations 1

4. PSA threshold: A PSA level of 4.0 ng/mL or higher is traditionally used as the threshold for referral for further evaluation or biopsy 1

Shared Decision-Making

Before initiating prostate cancer screening, clinicians should engage patients in shared decision-making, discussing both potential benefits and harms 4, 3. This is particularly important for men aged 55-69 years, where the USPSTF gives a "C" recommendation (individual decision based on values and preferences) 3.

The decision to undergo PSA screening should be made after a thorough discussion of the potential benefits (small reduction in prostate cancer mortality) versus the substantial risks (overdiagnosis, overtreatment, and treatment complications) 1, 3.