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

PSA Screening Guidelines for Prostate Cancer

PSA screening should be offered to men aged 55-69 years after a shared decision-making process that discusses potential benefits and harms, while screening is not recommended for men aged 70 years and older due to unfavorable risk-benefit ratio. 1, 2, 3

Recommended Age-Based Screening Approach

Average-Risk Men:

• Begin PSA screening discussions at age 50-55 years 1, 2
• Only screen men with at least 10-15 years life expectancy 1, 2
• Do not screen men aged ≥70 years 1, 2, 3

High-Risk Men (Earlier Screening):

• African American men: Begin discussions at age 45 1, 2
• Men with first-degree relative diagnosed with prostate cancer before age 65: Begin at age 45 1, 2
• Men with multiple first-degree relatives diagnosed with prostate cancer before age 65: Begin at age 40 1, 2

Screening Intervals Based on PSA Level

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 [1,2]

Benefits vs. Harms of Screening

Benefits:

• May prevent approximately 1.3 deaths from prostate cancer per 1,000 men screened over 13 years 2, 3
• May prevent approximately 3 cases of metastatic prostate cancer per 1,000 men screened 3
• Small gain in life expectancy (0.08 years on average) 4

Harms:

• Overdiagnosis and overtreatment of clinically insignificant cancers 1, 2, 3
• False positive results (up to 80% with PSA cutoff between 2.5-4.0 μg/L) 2
• Biopsy complications: blood in semen (93%), blood in urine (66%), pain (44%), fever (18%), hospitalization for sepsis (1-2%) 2
• Treatment complications: erectile dysfunction (67%), urinary incontinence (20%), and bowel symptoms 2, 3
• Earlier diagnosis without mortality benefit (expected time to diagnosis decreased by 1.53 life-years) 4

Practical Considerations for PSA Testing

Before Testing:

• Avoid vigorous exercise (e.g., cycling) and ejaculation in the 2 days prior to PSA testing 2
• Note that medications like finasteride and dutasteride can lower PSA levels 2

PSA Interpretation:

• A PSA level of 4.0 ng/mL or higher has historically been used as a threshold for biopsy referral 1
• For PSA levels between 2.5-4.0 ng/mL, consider individualized risk assessment incorporating other risk factors 1
• Percent free PSA can improve prediction of clinically significant and fatal prostate cancer, particularly in men with PSA ≥2 ng/mL 5

Key Points for Patient Discussion

When discussing PSA screening with patients, emphasize:

1. Screening may prevent approximately 1 death from prostate cancer per 1,000 men screened over 13 years 3
2. 37 additional men will receive a cancer diagnosis for every 1 prostate cancer death prevented 6
3. Treatment complications include erectile dysfunction (67%), urinary incontinence (20%), and bowel symptoms 2, 3
4. The decision to screen should depend on how the patient values the potential benefits versus harms 1, 3

Common Pitfalls to Avoid

1. Screening without discussion: Never perform PSA screening without first engaging in shared decision-making about benefits and harms 1, 3
2. Screening older men: Avoid screening men aged ≥70 years as harms outweigh benefits 1, 2, 3
3. Ignoring life expectancy: Do not screen men with less than 10 years life expectancy regardless of age 1, 2
4. Overlooking high-risk groups: Remember to begin screening discussions earlier for African American men and those with family history 1, 2
5. Misinterpreting PSA values: Consider factors that can affect PSA levels (medications, recent activities) 2