How often should Prostate-Specific Antigen (PSA) screenings be performed?

PSA Screening Frequency Recommendations

PSA testing should be performed every 1-2 years for men with PSA levels ≥1.0 ng/mL and every 2-4 years for men with PSA levels <1.0 ng/mL, with screening beginning at age 45 for most men and continuing until age 70 for those with good health and life expectancy of at least 10 years. 1

Initial Screening Age

• Begin PSA screening at age 45 for most men, as this allows for baseline risk assessment and future screening interval determination 1
• Consider earlier screening at age 40 for men at higher risk, including those with multiple first-degree relatives diagnosed with prostate cancer before age 65 1
• African American men and those with a first-degree relative diagnosed with prostate cancer before age 65 should also begin screening at age 45 1

Screening Intervals Based on PSA Levels

For men with PSA <1.0 ng/mL:

• Repeat testing every 2-4 years 1
• This value is below the 75th percentile for younger men (<50 years) 1
• Men with very low PSA levels have minimal risk of developing advanced prostate cancer within 4-8 years (only 0.23% at 4 years and 0.49% at 8 years) 1
• Extended intervals for men with low PSA reduce unnecessary testing while maintaining most mortality benefits 1

For men with PSA ≥1.0 ng/mL:

• Repeat testing every 1-2 years 1
• More frequent testing is warranted as these men have higher risk of developing prostate cancer 1
• Men with PSA >1.0 ng/mL have increased risk of being diagnosed with higher Gleason score cancers when screened with intervals longer than annual 2

Age to Discontinue Screening

• Consider discontinuing routine PSA screening at age 70 1
• For men over 70, individualize screening decisions based on health status and comorbidities 1
• Very few men older than 75 years benefit from PSA testing 1
• PSA testing should only be offered to men with a life expectancy of at least 10 years 1, 3

Risk-Based Screening Approach

• A baseline PSA test in men in their 40s is a stronger predictor of future prostate cancer risk than family history or race 1, 4
• Men with PSA levels above the median for their age group (0.6-0.7 ng/mL for ages 40-49) are at higher risk for prostate cancer 1
• Two-thirds of advanced prostate cancer cases occur in men with PSA levels in the top 20% (≥0.9 ng/mL) at or before age 50 4
• Risk calculators that incorporate multiple factors (age, family history, ethnicity, DRE results, and PSA) can help estimate individual risk 1

Benefits and Limitations of Different Screening Intervals

• Biennial screening (every 2 years) may provide comparable survival benefits to annual screening while reducing overdiagnosis by 13% and unnecessary testing by approximately 50% 1
• Compared to screening every 4 years, biennial screening showed a 43% reduction in diagnosis of advanced prostate cancer but a 46% increase in diagnosis of low-risk prostate cancer 1
• The average delay in diagnosis when moving from annual to biennial screening is estimated to be only 5-6 months 1
• Men with initial PSA levels ≤1.0 ng/mL have very low rates of conversion to PSA >4.0 ng/mL within 2-4 years (only 0.24% after 1 year and 0.51% after 2 years) 1

Clinical Considerations and Caveats

• Always engage in shared decision-making before initiating PSA screening, discussing potential benefits and harms 1, 3
• Consider using a PSA threshold of 3.0 ng/mL (rather than 2.5 ng/mL) for biopsy decisions to reduce overdetection risk 1
• The prevalence of screen-detected aggressive prostate cancer in 45-year-old men is very low (only 0.2% overall detection rate with just 0.02% having ISUP grade ≥3 cancers) 5
• Digital rectal examination alone has very poor detection rates (0.03%) and should be combined with PSA testing 5
• For men over 70, consider raising the PSA threshold for biopsy to reduce overdiagnosis while still detecting clinically significant cancers 1