At what age or under what conditions should Prostate-Specific Antigen (PSA) testing be stopped?

When to Stop PSA Screening

PSA screening should be discontinued at age 75 years for most men, and should not be performed in any man with a life expectancy less than 10 years regardless of age.

Age-Based Recommendations for PSA Discontinuation

The decision to stop PSA screening should be based primarily on age and life expectancy:

1. Age 70-74 years:

   • PSA testing should be individualized and performed with caution
   • Only appropriate in very healthy men with little or no comorbidity
   • Consider increasing PSA threshold for biopsy in this group to reduce overdiagnosis 1

2. Age 75 years and older:

   • PSA screening should be discontinued for most men 1, 2
   • Men aged 75 years with PSA levels less than 3.0 ng/mL are unlikely to die from prostate cancer and may safely discontinue screening 1
   • The American College of Physicians recommends against PSA screening in men aged 70 years and older as the harms outweigh the benefits 2
   • The USPSTF recommends against PSA screening for men 70 years and older (D recommendation) 3

3. Any age with limited life expectancy:

   • PSA screening should not be performed in men with a life expectancy less than 10 years, regardless of age 1, 2
   • The harms of screening (overdiagnosis, false positives, complications from treatment) outweigh potential benefits in this population

Evidence-Based Strategies for Discontinuing PSA Screening

The NCCN guidelines outline three evidence-based strategies to reduce overdiagnosis in older men 1:

1. Discontinue screening at age 69 years
2. Continue screening up to age 74 years but increase the PSA threshold for biopsy
3. Discontinue screening at age 75 years for men with a PSA level less than 3.0 ng/mL

Current Screening Practices and Concerns

Despite guidelines recommending against PSA screening in elderly men with limited life expectancy, studies show that screening remains common in this population:

• 41.35% of men older than 74 years receive PSA screening 4
• 45% of men with limited life expectancy in the VA system received PSA screening 5
• 42% of men predicted to live less than 5 years reported having recent PSA screening 6

This represents significant overscreening in populations unlikely to benefit from early detection of prostate cancer.

Factors Associated with Overscreening

Several factors are associated with continued PSA screening in elderly men with limited life expectancy:

• Medical center characteristics (non-academic centers, higher ratio of midlevel providers to physicians, and location in the Southern US) 5
• Cardiovascular drug treatment is associated with more frequent PSA testing in men over 74 4
• Lack of attention to prognosis when making screening recommendations 7

Clinical Pitfalls to Avoid

1. Continuing screening based solely on chronological age - Life expectancy should be the primary consideration
2. Failure to consider comorbidities - Multiple comorbidities significantly reduce potential benefit from screening
3. Overestimating benefit in elderly - The time to benefit from PSA screening exceeds life expectancy in many elderly men
4. Underestimating harms - Elderly men experience more false positives and complications from diagnostic procedures and treatments

Conclusion

The decision to discontinue PSA screening should be based primarily on age and life expectancy, with screening generally discontinued at age 75 for most men and not performed in any man with a life expectancy less than 10 years. This approach helps balance the minimal potential benefits against the known harms of screening in elderly populations.