What are the guidelines for Prostate-Specific Antigen (PSA) screening?

PSA Screening Guidelines

For men aged 55-69 years, PSA screening should be offered after a shared decision-making process that discusses both potential benefits and harms, as this age group may experience a small reduction in prostate cancer mortality with screening. 1

Age-Based Recommendations

• Ages 40-45:

  • Begin screening at age 40 for men with multiple first-degree relatives diagnosed with prostate cancer before age 65 1
  • Begin screening at age 45 for high-risk populations including African American men and those with a family history of prostate cancer 1

• Ages 50-55:

  • Average-risk men should begin PSA testing at age 50-55 years if they have at least 10-15 years life expectancy 1

• Ages 55-69:

  • This is the primary target group for PSA screening
  • Screening may prevent approximately 1.3 deaths from prostate cancer per 1,000 men screened over 13 years 1, 2
  • Also prevents approximately 3 cases of metastatic prostate cancer per 1,000 men screened 2

• Ages 70 and older:

  • PSA screening is not recommended due to limited benefit and increased harms 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 1

Risk-Stratified Screening Intervals

Based on baseline PSA level, the recommended screening intervals are 1:

PSA Level	Recommended Rescreen Interval
< 1.0 ng/mL	Every 2-4 years
1.0-2.5 ng/mL	Every 2 years
≥ 2.5 ng/mL	Annually

Potential Benefits of Screening

• Reduces prostate cancer mortality by approximately 21% 1
• May prevent 1 death per 781 men invited for screening 1
• Allows for early detection of clinically significant cancers 1, 2

Potential Harms of Screening

• Overdiagnosis of clinically insignificant cancers 1, 2
• False-positive results requiring additional testing and possible prostate biopsy 1
• Treatment complications including:
  • Urinary incontinence (affects approximately 1 in 5 men who undergo radical prostatectomy) 2
  • Erectile dysfunction (affects approximately 2 in 3 men after treatment) 2
  • Bowel symptoms 1, 2

Important Considerations Before PSA Testing

• Avoid vigorous exercise (such as cycling) in the 2 days prior to PSA testing, as this may result in false positive elevation 3
• Avoid ejaculation in the 2 days prior to PSA testing, as this may result in false positive elevation 3
• Some medications (finasteride, dutasteride) can lower PSA levels 3

Shared Decision-Making Process

Despite the availability of PSA screening for over 20 years, the practice remains controversial due to limited sensitivity and specificity 4. The most recent guidelines emphasize that men should be fully informed about both potential benefits and harms before undergoing screening 1, 2.

Research shows that many men (72%) report not receiving information about both advantages and disadvantages of PSA testing before screening 5, highlighting the need for improved communication between providers and patients.

Cost-Effectiveness Considerations

Screening between ages 55-69 combined with active surveillance for low-risk men may be cost-effective only if:

• Screening frequency remains low (every four years)
• Active surveillance is offered to all men with low-risk prostate cancer (Gleason score ≤6 and stage ≤T2a) 3

More frequent screening intervals or immediate treatment strategies for all men are not considered cost-effective 3.