What are the guidelines for Prostate-Specific Antigen (PSA) screening?

PSA Screening Guidelines

For men aged 55-69 years, PSA screening should be offered after a shared decision-making process that discusses both potential benefits and harms, as this is the only age group where benefits may outweigh harms. 1, 2

Age-Based Screening Recommendations

Men Under 40 Years

• Routine PSA screening is not recommended 2
• Exception: Very high-risk men (multiple family members diagnosed with prostate cancer before age 65) should begin PSA testing at age 40 1

Men 40-54 Years

• Routine PSA screening is not recommended for average-risk men 2
• Higher-risk men (African American men or those with a first-degree relative diagnosed with prostate cancer before age 65) should begin PSA testing at age 45 1

Men 55-69 Years

• This is the target age group where benefits may outweigh harms 2
• Shared decision-making is essential before initiating screening 1
• Benefits: May prevent approximately 1.3 deaths from prostate cancer per 1000 men screened over 13 years 1, 3
• Harms: Overdiagnosis, false positives, unnecessary biopsies, and treatment complications 1

Men 70 Years and Older

• Routine PSA screening is not recommended 2, 3
• Potential harms outweigh benefits in this age group 3

Screening Frequency and Interpretation

If screening is chosen, the NCCN recommends frequency based on baseline PSA:

• PSA < 1.0 ng/mL: Every 2-4 years
• PSA 1.0-2.5 ng/mL: Every 2 years
• PSA ≥ 2.5 ng/mL: Annually 1

Benefits vs. Harms of Screening

Potential Benefits

• 21% reduction in prostate cancer mortality 1
• Prevention of approximately 3 cases of metastatic prostate cancer per 1000 men screened 3

Potential Harms

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

Special Considerations

• For accurate PSA results, patients should abstain from ejaculation for 48 hours 1
• Finasteride and dutasteride can lower PSA levels by approximately 50% 1
• PSA velocity (change over time) provides additional risk information 1

Shared Decision-Making Process

When discussing PSA screening with patients aged 55-69, clinicians should:

1. Explain that screening may prevent 1 prostate cancer death per 781 men screened 1
2. Clarify that screening advances diagnosis by approximately 1.53 years on average 4
3. Discuss that 17.43% of screened men may have their cancer diagnosed nearly 9 years earlier than without screening 4
4. Acknowledge that many men base decisions on underlying beliefs rather than statistical information 5

Common Pitfalls to Avoid

• Failing to engage in proper shared decision-making before ordering PSA tests
• Screening men outside the 55-69 age range without strong indications
• Not accounting for medications like finasteride that affect PSA levels
• Overlooking the psychological impact of false-positive results
• Not discussing the potential quality of life impacts of treatment

The evidence clearly shows that PSA screening involves a delicate balance of modest benefits against substantial potential harms. For this reason, individualized decision-making is essential, particularly for men aged 55-69 years, the only group where guidelines support offering screening after thorough discussion.