Prostate Cancer Screening Recommendations
Men aged 55-69 years should undergo PSA screening only after a shared decision-making process that thoroughly discusses both potential benefits and harms, as this is the only age group where benefits may outweigh harms. 1
Screening Recommendations by Age and Risk Group
Average-Risk Men:
- Ages 55-69: Consider PSA screening after shared decision-making
- Ages <55 or >70: Routine PSA screening NOT recommended
Higher-Risk Men:
- African American men: Begin PSA testing at age 45
- Men with first-degree relative diagnosed with prostate cancer before age 65: Begin PSA testing at age 45
- Men with multiple family members diagnosed with prostate cancer before age 65: Begin PSA testing at age 40
Screening Method and Frequency
- Primary screening method: PSA blood test with or without digital rectal examination (DRE)
- Recommended screening intervals 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 and Harms of Screening
Benefits:
- PSA screening reduces prostate cancer mortality by approximately 21% 1
- May prevent approximately 1.3 deaths from prostate cancer per 1,000 men screened over 13 years 1, 2
- May prevent approximately 3 cases of metastatic prostate cancer per 1,000 men screened 2
Harms:
- Overdiagnosis of clinically insignificant cancers
- False-positive results requiring additional testing and possible prostate biopsy
- Treatment complications including urinary incontinence (affects 1 in 5 men after radical prostatectomy), erectile dysfunction (affects 2 in 3 men), and bowel symptoms 1, 2
- Psychological harms from false positives and diagnosis
Shared Decision-Making Process
Before screening, clinicians should discuss:
- Patient's personal risk factors (age, race, family history)
- Potential benefits of early detection
- Potential harms of screening (false positives, unnecessary biopsies)
- Potential harms of treatment (incontinence, erectile dysfunction)
- Patient's values and preferences regarding these outcomes
Management After Abnormal PSA
- Repeat PSA test to confirm elevation
- If still elevated, consider:
- Multiparametric MRI
- Assessment of urine or blood biomarkers
- Referral to urology 3
- If biopsy indicated: Minimum of 10-12 cores should be obtained during transrectal ultrasound-guided prostate biopsy under antibiotic cover and local anesthesia 1
Importance of Digital Rectal Examination
While PSA is more sensitive, DRE remains important as:
- 20% of prostate cancers detected by DRE alone have features associated with clinically aggressive tumors despite normal PSA levels 4
- 20% of cancers detected by DRE alone were non-organ-confined and 20% had a Gleason score of 7 or higher 4
- Omission of DRE from screening protocols might compromise treatment outcomes 4
Common Barriers to Screening
- Lack of symptoms (misconception that prostate cancer always causes urinary symptoms)
- Lack of family history (misconception about risk)
- Embarrassment over DRE
- Fear of cancer diagnosis
- Confusion about screening procedure
- Skepticism about benefits 5
Key Pitfalls to Avoid
- Assuming urinary symptoms indicate prostate cancer risk: Many men avoid screening due to lack of urinary symptoms, but early prostate cancer is typically asymptomatic
- Screening without discussion: No organization endorses universal or mass screening without shared decision-making 6
- Screening men with limited life expectancy: Men with <10 years life expectancy are unlikely to benefit from screening 6
- Ignoring race as a risk factor: African American men have substantially higher prostate cancer incidence and mortality rates 6
- Relying solely on PSA or DRE: Using both tests together provides more complete evaluation 1
Remember that the primary intent of screening is to identify patients with clinically significant prostate cancer who may benefit from curative treatment while minimizing the detection of clinically insignificant cancer 3.