At what age is prostate screening supposed to start?

Prostate Cancer Screening Age Guidelines

Prostate cancer screening should begin at age 50 for average-risk men, at age 45 for high-risk men (African American men or those with a first-degree relative diagnosed with prostate cancer before age 65), and at age 40 for very high-risk men (multiple family members diagnosed with prostate cancer before age 65). 1

Screening Recommendations by Risk Category

Average-Risk Men:

• Begin screening at age 50 after thorough discussion of benefits and harms 1
• Do not screen men under age 50 as harms outweigh benefits 2
• Do not screen men over age 69 as benefits diminish while harms persist 2, 1

High-Risk Men:

• African American men: Begin at age 45 1
• Men with a first-degree relative diagnosed with prostate cancer before age 65: Begin at age 45 1

Very High-Risk Men:

• Men with multiple family members diagnosed with prostate cancer before age 65: Begin at age 40 2, 1

Screening Method and Intervals

• PSA blood test with or without digital rectal examination (DRE) is the recommended screening method 1
• Risk-stratified re-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

Benefits and Harms of Screening

Benefits:

• PSA screening in men aged 55-69 may prevent approximately 1.3 deaths from prostate cancer per 1,000 men screened over 13 years 1, 3
• May prevent approximately 3 cases of metastatic prostate cancer per 1,000 men screened 3
• Research shows a substantial decrease in risk of metastases (57% reduction) and prostate cancer death (71% reduction) with screening 4

Harms:

• Overdiagnosis of clinically insignificant cancers 1
• False-positive results requiring unnecessary biopsies 1, 3
• Treatment complications including:
  • Urinary incontinence (occurs in about 20% of men after radical prostatectomy)
  • Erectile dysfunction (occurs in about 67% of men after treatment)
  • Bowel dysfunction 1, 3

When to Stop Screening

• Do not screen men aged 70 years and older 2, 1, 3
• Do not screen men with life expectancy less than 10-15 years, regardless of age 2, 1
• Do not screen men with significant comorbidities 1

Important Clinical Considerations

• The cumulative risk of prostate cancer diagnosis increases dramatically with age: approximately 8% at age 60,15% at age 65, and 21% at age 70 for men who have been screened 4 or more times 5
• Starting screening at an earlier age appears to advance the time of diagnosis but does not necessarily increase the overall risk of being diagnosed 5
• Baseline PSA testing at age 40-45 can help with risk stratification; men with PSA levels in the top 10% for their age group are at particularly high risk and should receive more intensive monitoring 1

Common Pitfalls to Avoid

1. Failing to discuss benefits and harms: Always engage in shared decision-making before initiating screening 1
2. Over-screening older men: Screening men over 70 years provides minimal benefit while maintaining significant harms 2, 1, 3
3. Under-screening high-risk populations: Not starting screening early enough for African American men or those with family history 1
4. Ignoring life expectancy: Screening should not be performed in men with less than 10-15 years life expectancy 2, 1
5. Using PSA threshold alone: Consider age, risk factors, and PSA velocity in addition to absolute PSA values 1

Remember that the number needed to invite to PSA screening to prevent one prostate cancer death is approximately 176, and the number needed to diagnose is about 16 4.