At what age should Prostate-Specific Antigen (PSA) blood screening start?

PSA Blood Screening Recommendations by Age and Risk Group

PSA screening should begin at age 55 for average-risk men, age 45 for high-risk men, and age 40 for very high-risk men, with screening decisions based on shared decision-making for men aged 55-69 and no screening recommended for men 70 years and older. 1

Age-Based Screening Recommendations

Average-Risk Men

• Start age: 50-55 years 1, 2
• End age: 69 years 1, 3
• Frequency: Based on baseline PSA level 1
  • 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

High-Risk Men

• Start age: 45 years 4, 1
• Who qualifies as high-risk:
  • African American men
  • Men with a first-degree relative diagnosed with prostate cancer before age 65

Very High-Risk Men

• Start age: 40 years 4, 1
• Who qualifies as very high-risk:
  • Men with multiple first-degree relatives diagnosed with prostate cancer before age 65

Screening Protocol

1. Initial PSA test serves as a strong predictor of future prostate cancer risk 5, 6
2. Risk stratification based on initial PSA results:
   • If PSA <1.0 ng/mL: Low risk, rescreen every 2-4 years 1
   • If PSA 1.0-2.5 ng/mL: Intermediate risk, rescreen every 2 years 1
   • If PSA ≥2.5 ng/mL: Higher risk, annual screening 1
   • If PSA ≥3.0 ng/mL: Consider prostate biopsy with MRI 1, 7

Evidence Quality and Considerations

The most recent guidelines from the American Urological Association and National Comprehensive Cancer Network (NCCN) recommend PSA screening for men aged 55-69 years after shared decision-making 1. This recommendation is supported by evidence showing that screening in this age group may prevent approximately 1.3 deaths from prostate cancer per 1,000 men screened over 13 years 3.

For high-risk populations, including African American men and those with a family history of prostate cancer, screening should begin earlier at age 45 4, 1. Men with multiple first-degree relatives diagnosed with prostate cancer before age 65 should begin screening at age 40 4, 1.

Research demonstrates that a single PSA measurement at or before age 50 is a strong predictor of advanced prostate cancer occurring up to 25 years later 6. Two-thirds of advanced cancer cases occurred in men with PSA levels of 0.9 ng/mL or higher, suggesting the value of early baseline testing for risk stratification 6.

Important Caveats

1. Potential harms of screening include:

   • False-positive results requiring additional testing
   • Overdiagnosis of clinically insignificant cancers
   • Complications from treatment including erectile dysfunction, urinary incontinence, and bowel symptoms 1, 3

2. No screening recommended for men ≥70 years as the harms outweigh the benefits in this age group 1, 3

3. Recent data shows low prevalence of aggressive prostate cancer in 45-year-old men, with only 4 cases of ISUP grade ≥3 cancer detected among 23,301 men screened 7

4. Risk-adapted screening intervals based on baseline PSA can reduce unnecessary testing while maintaining effectiveness 1, 5

By following these age and risk-based recommendations, clinicians can maximize the mortality benefit of PSA screening while minimizing potential harms through appropriate patient selection and testing intervals.