At what age should routine Prostate-Specific Antigen (PSA) testing be stopped?

When to Stop Routine PSA Screening

Routine PSA screening should be discontinued at age 75 for most men, and should not be performed in men with less than 10 years life expectancy regardless of age. 1

Age-Based Recommendations

• Ages 55-69: PSA screening should be offered after shared decision-making discussing benefits and harms 1
• Ages 70-74: Individualized PSA testing with caution, considering increasing PSA threshold for biopsy to reduce overdiagnosis 1
• Age 75 and older: Discontinue routine PSA screening 1, 2
  • Men with PSA levels <3.0 ng/mL at age 75 are unlikely to die from prostate cancer and can safely discontinue screening 3, 1

Special Considerations for Stopping PSA Screening

Life Expectancy Assessment

• PSA screening should be discontinued in men with life expectancy <10 years regardless of age 1
• The USPSTF concludes with moderate certainty that potential benefits of PSA screening in men ≥70 years do not outweigh expected harms 2

PSA-Based Risk Stratification

• Men aged 75-80 years with PSA <3.0 ng/mL are unlikely to die or experience aggressive prostate cancer during their remaining lifetime 3
• Men with lower baseline PSA levels at age 60 (<1 ng/mL) have very low risk (0.2%) of prostate cancer death 3

Rationale for Age-Based Discontinuation

Reduced Benefits in Older Men

• Microsimulation models show that decreasing screening cessation age from 74 to 69 years leads to:
  • 27% relative reduction in probability of life saved
  • Nearly 50% reduction in probability of overdiagnosis 3

Increased Harms in Older Men

• Harms of screening are at least moderate and greater in men >70 years due to:
  • Increased false-positive results
  • Complications from diagnostic biopsies
  • Treatment complications (erectile dysfunction, urinary incontinence, bowel symptoms) 2
• Treatment complications are particularly concerning in older men: radical prostatectomy is associated with 11% increased risk of urinary incontinence and 37% increased risk of erectile dysfunction 1

Screening in High-Risk Populations

For high-risk men (African American men and those with family history of prostate cancer):

• Begin screening at age 45 1
• For men with multiple first-degree relatives diagnosed with prostate cancer before age 65, begin at age 40 1
• The same age-based discontinuation guidelines apply to these populations

Common Pitfalls to Avoid

1. Using strict age cutoffs without considering health status: Despite recommendations to stop at age 75, studies show that 42% of men predicted to live less than 5 years still received PSA screening 4

2. Continuing screening in all elderly men: Before USPSTF recommendations, many men with limited life expectancy were still being screened unnecessarily 4, 5

3. Stopping too early in healthy older men: Some healthy men >75 years with >10-year life expectancy might still benefit from screening 4

4. Ignoring baseline PSA values: Men with very low PSA levels at age 60-75 have minimal risk of developing clinically significant prostate cancer 3, 6

By following these evidence-based guidelines for discontinuing PSA screening, clinicians can minimize harms while preserving benefits for men most likely to benefit from early detection of clinically significant prostate cancer.