PSA Screening Recommendations for Average and High-Risk Men
For men at average risk, PSA screening should begin at age 50, while men at high risk (African American men or those with a family history of prostate cancer) should begin screening at age 45, and men with multiple first-degree relatives diagnosed with prostate cancer before age 65 should begin screening at age 40. 1
Risk Stratification for PSA Screening
Average-Risk Men:
- Begin PSA screening at age 50 if life expectancy is at least 10-15 years 1
- Screening should involve shared decision-making about benefits and harms
- Routine PSA screening is not recommended for men aged 70 and older 1, 2
High-Risk Men:
- African American men: Begin screening at age 45 3, 1
- Men with a first-degree relative diagnosed with prostate cancer before age 65: Begin screening at age 45 3, 1
- Men with multiple first-degree relatives diagnosed with prostate cancer before age 65: Begin screening at age 40 3, 1
Recommended Screening Intervals
The frequency of PSA screening should be determined based on baseline PSA levels:
| 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 [1] |
Evidence Supporting Early PSA Testing
Research has demonstrated that a single PSA measurement at or before age 50 can be highly predictive of future prostate cancer risk, including advanced disease diagnosed up to 30 years later 4. This supports the value of early baseline PSA testing to identify men who may benefit from more intensive monitoring.
Benefits and Harms of PSA Screening
Benefits:
- PSA screening in men aged 55-69 may prevent approximately 1.3 deaths from prostate cancer per 1,000 men screened over 13 years 1, 2
- May prevent approximately 3 cases of metastatic prostate cancer per 1,000 men screened 2
Potential Harms:
- Overdiagnosis of clinically insignificant cancers
- False-positive results requiring additional testing
- Complications from prostate biopsies
- Treatment complications including urinary incontinence (affects about 1 in 5 men after radical prostatectomy) and erectile dysfunction (affects about 2 in 3 men) 1, 2
When to Discontinue Screening
- Men aged 75 years and older with PSA levels less than 3.0 ng/mL are unlikely to die from prostate cancer and may safely discontinue screening 1
- Men with less than 10 years life expectancy should not undergo PSA screening 3
Important Considerations Before PSA Testing
- Avoid vigorous exercise (such as cycling) and ejaculation in the 2 days prior to PSA testing, as these may cause false positive elevations 1
- Certain medications like finasteride and dutasteride can lower PSA levels and should be considered when interpreting results 1
Common Pitfalls to Avoid
Failure to risk-stratify: Not all men should begin screening at the same age. Risk factors like race and family history should determine when to start.
Overscreening elderly men: Screening men over 70 years of age or those with less than 10 years life expectancy provides minimal benefit while exposing them to potential harms.
Rigid screening intervals: The interval between screenings should be based on baseline PSA levels rather than applying a one-size-fits-all approach.
Neglecting shared decision-making: Men should be informed about both potential benefits and harms of PSA screening before testing begins.