From the Guidelines
Prostate cancer screening should begin at age 50 for most men with average risk, but earlier at age 45 for those with higher risk (African American men or those with a first-degree relative diagnosed with prostate cancer before age 65), as recommended by the American Cancer Society 1.
Guidelines for Prostate-Specific Antigen (PSA) Screening
The primary screening method is the prostate-specific antigen (PSA) blood test, often combined with a digital rectal examination (DRE).
- For men with normal PSA levels (typically under 4 ng/mL), screening every 1-2 years is recommended.
- The frequency may increase with higher PSA levels or other risk factors. Some key points to consider:
- Men at even higher risk, with multiple first-degree relatives diagnosed before age 65, should start screening at age 40.
- Screening decisions should always involve a discussion with your healthcare provider about the potential benefits and harms, including false positives, unnecessary biopsies, and overtreatment of slow-growing cancers.
- Screening is generally not recommended for men with less than 10 years of life expectancy or after age 70, as the potential harms may outweigh the benefits, as stated by the US Preventive Services Task Force 1.
Risk Factors and Screening Recommendations
Factors that increase the risk of prostate cancer include:
- African American race
- A family history of prostate cancer
- Increasing age
- An abnormal DRE
- Age-specific PSA level The American Urological Association recommends shared decision making for men aged 55-69 years and against routine screening in men aged <40 years or those with life expectancy <10-15 years 1.
Balancing Benefits and Harms
This approach balances early detection of aggressive cancers with avoiding unnecessary procedures for indolent cancers that may never cause symptoms, as discussed in the European Association of Urology guidelines 1.
- The European Association of Urology recommends against PSA testing without prior counselling on potential risks and benefits and offers an individualised, risk-adapted strategy for early detection to well-informed men with good performance status and life expectancy ≥10-15 years.
From the Research
Guidelines for Prostate-Specific Antigen (PSA) Screening
- The recommended age for PSA screening varies, but most guidelines suggest starting at age 50-55 for 'average-risk' men and considering life expectancy of at least 7-15 years 2.
- For men at high risk, such as those of African descent or with a family history of prostate cancer, screening may start as early as 40 years old, but recommendations often defer to clinical judgement 2.
- Screening intervals can be biennial, annual, or determined from baseline PSA, with longer intervals for those at lower risk and shorter intervals for those at higher risk 2, 3.
- Shared decision-making between the patient and clinician is strongly recommended before initiating screening, considering the potential benefits and harms of PSA testing 4, 5.
Screening Recommendations by Age
- For men aged 55-69, the decision to undergo periodic PSA-based screening should be individual and include discussion of potential benefits and harms with their clinician 5.
- The US Preventive Services Task Force (USPSTF) recommends against PSA-based screening for prostate cancer in men 70 years and older 5.
- Some guidelines suggest starting conversations about screening at age 45 for all men, with PSA testing starting at age 45 for those choosing to be screened 6.
Considerations for Screening
- Population-based PSA testing of asymptomatic men is not widely recommended, and guidelines emphasize balancing the potential harms and benefits of PSA testing 2, 4.
- The development of clinical decision aids and international consensus on guidelines may help reduce national and international variation on how men are counselled 2.
- Reflex tests, such as magnetic resonance imaging, and assessment of urine or blood biomarkers, can be informative in some patients and help reduce overdiagnosis and overtreatment 4, 6.