At what age should men start prostate cancer screening with Prostate-Specific Antigen (PSA) tests and Digital Rectal Exams (DRE)?

Prostate Cancer Screening Recommendations

Men at average risk should begin prostate cancer screening at age 50, high-risk men at age 45, and very high-risk men at age 40, with screening involving PSA blood tests with or without Digital Rectal Examination (DRE). 1

Risk Stratification for Screening Initiation

The age to begin prostate cancer screening should be stratified based on risk factors:

• Average-risk men: Begin at age 50
• High-risk men (including African American men and those with a family history of prostate cancer): Begin at age 45
• Very high-risk men (multiple affected first-degree relatives): Begin at age 40 1, 2

Screening Methods and Intervals

• Primary screening tool: PSA blood test (with or without DRE)
• Recommended screening intervals based on PSA results:
  • 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

When to Discontinue Screening

• Routine PSA screening should be discontinued in men aged 70 years and older
• Men with a life expectancy less than 10 years should not be screened, regardless of age 1, 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

Potential Harms

• False-positive results requiring additional testing
• Complications from prostate biopsy
• Overdiagnosis of indolent cancers
• Overtreatment and associated complications:
  • 11% increased risk of urinary incontinence
  • 37% increased risk of erectile dysfunction
  • Bowel dysfunction 1, 3

Shared Decision-Making

Before initiating screening, clinicians should engage patients in informed decision-making, discussing:

• The uncertainties, risks, and potential benefits of screening
• The controversy surrounding PSA screening
• The potential harms of subsequent diagnostic procedures and treatments 1, 4

Follow-up of Abnormal Results

• A single elevated PSA should not prompt immediate biopsy but should be verified by a second test
• Traditional threshold for further evaluation: PSA ≥ 4.0 ng/mL
• Men with PSA 2.5-4.0 ng/mL should undergo individualized risk assessment
• Before repeat biopsy, multi-parametric MRI is recommended 1

Importance of Baseline PSA

Research indicates that baseline PSA testing in early midlife (40s) can help with risk stratification:

• Men with PSA levels in the top 10% for their age group are at particularly high risk
• 81% of advanced prostate cancer cases occur in men with PSA above the median (0.63 ng/mL) at ages 44-50 1, 5

Common Pitfalls to Avoid

• Overscreening: Screening men with life expectancy less than 10 years provides minimal benefit while exposing them to potential harms
• Immediate biopsy after a single elevated PSA: Verify with a second test to avoid unnecessary procedures
• Neglecting shared decision-making: Patients should be fully informed about the potential benefits and harms before screening
• One-size-fits-all approach: Screening should be risk-stratified based on age, family history, and race/ethnicity