At what age is prostate testing recommended?

Prostate Cancer Screening Age Recommendations

Prostate cancer screening should begin at age 45-50 for most men, continue until age 70, and be discontinued after age 70 in men with PSA levels below 3.0 ng/mL. 1, 2

When to Start Screening

• Average-risk men: Begin PSA testing at age 50-55 years

  • The National Comprehensive Cancer Network (NCCN) uniformly recommends baseline PSA testing for healthy, well-informed men aged 50-70 years 2
  • Most guidelines recommend starting no later than age 55 for men in good health with at least 10-15 years life expectancy 1, 3

• Higher-risk men: Begin PSA testing at age 45

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

• Very high-risk men: Begin PSA testing at age 40

  • Men with multiple family members diagnosed with prostate cancer before age 65 1

Screening Intervals Based on PSA Results

PSA Level	Recommended Rescreen Interval
< 1.0 ng/mL	Every 2-4 years
1.0-2.5 ng/mL	Every 2 years
≥ 2.5 ng/mL	Annually [1]

Men with PSA values below the median (0.6-0.7 ng/mL) in their 40s have a very low risk of developing clinically significant prostate cancer. A study found only 0.16% of men with baseline PSA below the age-specific median were diagnosed with prostate cancer before age 50, compared to 4.6% of those above the median 4.

When to Stop Screening

• Age 70 years: Discontinue routine screening for most men

  • The USPSTF recommends against PSA-based screening in men 70 years and older due to limited benefit and increased harms 5
  • Men over 70 with PSA levels below 3.0 ng/mL are unlikely to die from prostate cancer and can safely discontinue screening 2

• Limited life expectancy: Discontinue screening regardless of age

  • Men with less than 10-15 years life expectancy should not be screened 1
  • The NCCN panel uniformly discourages PSA testing in men unlikely to benefit based on age and/or comorbidity 2

Benefits and Harms of Screening

Benefits

• PSA screening reduces prostate cancer mortality by approximately 21% 1
• Screening men aged 55-69 may prevent approximately 1.3 deaths from prostate cancer per 1,000 men screened over 13 years 1, 5
• Prevents approximately 3 cases of metastatic prostate cancer per 1,000 men screened 5

Harms

• Overdiagnosis of clinically insignificant cancers
• False-positive results requiring additional testing and possible prostate biopsy
• Treatment complications including:
  • Urinary incontinence (affects about 1 in 5 men who undergo radical prostatectomy)
  • Erectile dysfunction (affects about 2 in 3 men)
  • Bowel symptoms 1, 5

Common Pitfalls in Prostate Cancer Screening

1. Screening men too young or too old:

   • Despite guidelines, studies show that 17% of PSA tests are performed in men younger than 50 years and 33% in men 70 years and older 6
   • Up to a third of men older than 75 years undergo PSA testing despite limited benefit 7

2. Not using risk-stratified screening intervals:

   • Men with lower baseline PSA levels require less frequent screening
   • Men with PSA below age-specific median have very low short-term risk of prostate cancer 4

3. Not considering life expectancy:

   • Screening should be limited to men with at least 10-15 years life expectancy
   • Benefits of screening take years to materialize, while harms are immediate

4. Failure to use shared decision-making:

   • Before screening, men should be informed about benefits and harms
   • Discussion should include potential for false-positive results and need for biopsies 1

By following these evidence-based recommendations, clinicians can optimize the benefits of prostate cancer screening while minimizing potential harms.