Prostate Cancer Screening Recommendations
For men aged 55-69 years, PSA screening should be offered after shared decision-making that thoroughly discusses potential benefits and harms, while men 70 years and older should not undergo routine PSA screening. 1, 2, 3
Current Recommendations by Age Group
- Ages 40-44: Consider baseline PSA for men at very high risk (multiple first-degree relatives diagnosed with prostate cancer before age 65) 2
- Ages 45-49: Consider baseline PSA for men at high risk (African American men and those with a first-degree relative diagnosed with prostate cancer before age 65) 2, 1
- Ages 50-54: Consider baseline PSA for average-risk men 2
- Ages 55-69: Offer PSA screening after thorough shared decision-making 1, 2, 3
- Ages 70+: Recommend against routine PSA screening 1, 3
Risk Stratification
Higher Risk Groups Requiring Earlier Screening:
- African American men: 70% higher incidence rate and 2-4 times higher mortality rate than white men 1, 2
- Family history: 2.1-2.5 fold increased risk with first-degree relatives with prostate cancer 2
- Lower socioeconomic status: Higher baseline risk of prostate cancer mortality (about 4 per 1,000 men dying at 10 years) 1
Benefits of PSA Screening
- Reduces prostate cancer mortality by approximately 21% 2
- Prevents approximately 1.3 deaths from prostate cancer per 1,000 men screened over 13 years 2, 3
- Prevents approximately 3 cases of metastatic prostate cancer per 1,000 men screened 3
Harms of PSA Screening
- False positives: 80% false-positive rate when PSA cutoff is between 2.5-4.0 μg/L 1
- Overdiagnosis: Detection of cancers that would never become clinically significant 1, 4
- Psychological effects: Anxiety and persistent worry 1
- Treatment complications:
Recommended Screening Protocol
Testing Method:
- PSA blood test with or without digital rectal examination (DRE) 2
Screening Frequency Based on Baseline PSA:
- 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 2
Pre-Test Considerations:
- Avoid vigorous exercise (e.g., cycling) in the 2 days prior to PSA testing
- Avoid ejaculation in the 2 days prior to PSA testing
- Note that medications like finasteride and dutasteride can lower PSA levels 1, 2
Shared Decision-Making Process
Despite guidelines emphasizing the importance of shared decision-making, studies show significant gaps:
- Only 10% of men report receiving complete information about PSA testing 5
- Only 55% report being informed they could choose whether to undergo testing 5
- Only 22% report being informed that some doctors recommend PSA testing while others do not 5
- Only 14% report being informed that no one is sure if PSA testing actually saves lives 5
Key Information to Discuss with Patients:
- PSA testing is a choice, not a requirement
- Medical opinions on PSA testing vary among physicians
- The evidence on mortality benefit is modest
- The potential harms of screening and subsequent treatment
- The patient's values and preferences regarding benefits and harms
Common Pitfalls to Avoid
Failing to engage in proper shared decision-making: Studies show Black men and men with lower education levels are less likely to receive complete information about PSA testing 5, 6
Screening men with limited life expectancy: Men with less than 10 years life expectancy should not undergo PSA screening as harms outweigh benefits 2
Not considering risk factors: African American men and those with family history should be offered screening at earlier ages 1, 2
Ignoring PSA test limitations: PSA lacks sensitivity and specificity for early disease 4
Not discussing potential treatment complications: Many men are not fully informed about the significant side effects of prostate cancer treatment 3, 5