At what age should routine Prostate-Specific Antigen (PSA) screening be discontinued?

Age to Discontinue Routine PSA Screening

Routine PSA screening should be discontinued at age 70 for most men, and should not be performed in any man with less than a 10-15 year life expectancy. 1

Evidence-Based Recommendations

The decision to discontinue PSA screening should be based on the following factors:

Age Cutoffs

• Age 70 years: Primary recommended cutoff age for discontinuing routine screening 1
• Age 75 years: Maximum age for routine screening, with screening beyond this age only in very select patients 1

PSA-Based Stratification for Men ≥70 Years

For men over 70 who are in excellent health with >10 year life expectancy, consider:

• PSA <3.0 ng/mL: Discontinue screening (very low risk of prostate cancer death) 1
• PSA >3.0 ng/mL: May consider continued selective screening 1
• PSA >10 ng/mL: Higher likelihood of benefit from continued screening 1

Rationale for Age-Based Discontinuation

1. Limited Evidence of Benefit:

   • The European Randomized Study of Screening for Prostate Cancer (ERSPC) showed no mortality reduction among men age 70 years or older 1
   • The benefit-to-harm ratio decreases significantly with age 1

2. Increased Harms in Older Men:

   • Higher rates of overdiagnosis in men aged 70-79 years (>50% of detected cases) 1
   • Even higher rates of overdiagnosis in men over 80 years (>75% of detected cases) 1
   • Increased competing mortality compared to younger men 1

3. Recent Long-term Data:

   • Men aged 70-74 years who previously underwent PSA screening without prostate cancer diagnosis have very low risk of dying from prostate cancer by age 85 2
   • Particularly low risk (0.11%) in men with PSA <2 ng/mL 2

Special Considerations

Life Expectancy Assessment

• Screening should only be offered to men with a life expectancy of at least 10-15 years 1
• Physicians tend to overvalue age and undervalue comorbidity when estimating life expectancy 1
• Consider using life insurance tables or other validated tools to estimate life expectancy 1

Balancing Approaches for Older Men Who Desire Screening

For men over 70 who still desire screening after understanding the risks:

1. Increase the PSA threshold for biopsy (reduces overdiagnosis) 1
2. Discontinue screening in those with PSA <3 ng/mL (very low risk of lethal cancer) 1
3. Consider screening only until age 74 while using age-dependent PSA thresholds 1

Potential Harms of Continued Screening in Older Men

• Overdiagnosis: Detection of cancers that would never cause symptoms or death
• Psychological harms: Anxiety from false positives and cancer diagnosis
• Treatment complications: Erectile dysfunction (affects 2/3 of men after radical prostatectomy), urinary incontinence (affects 1/5 of men), and bowel symptoms 3

Conclusion

While discontinuing PSA screening at age 70 is generally recommended, a small subset of very healthy older men with higher PSA levels may still benefit from selective screening. The decision should be made with full understanding that the harm-to-benefit ratio increases substantially with age, and the likelihood of overdiagnosis is extremely high in this population.