At what age should Prostate-Specific Antigen (PSA) testing be stopped?

When to Stop PSA Screening for Prostate Cancer

PSA screening should be discontinued at age 70 years for most men, and should not be performed in any men with a life expectancy less than 10 years regardless of age. 1, 2

Age-Based Recommendations for PSA Discontinuation

• The US Preventive Services Task Force (USPSTF) explicitly recommends against PSA-based screening for prostate cancer in men 70 years and older (Grade D recommendation) 1, 2
• Multiple guidelines, including those from the American College of Physicians, recommend against screening in men aged ≥70 years 1
• The benefits of screening are only observed in men up to 70 years of age in major randomized controlled trials 1
• Screening men older than 70 years carries at least moderate harms and greater risks than in younger men due to increased false-positive results, diagnostic harms from biopsies, and treatment complications 2

Life Expectancy Considerations

• PSA screening should only be offered to men with a life expectancy of at least 10 years, regardless of age 1, 3
• Men with significant comorbidities and reduced life expectancy are unlikely to benefit from PSA screening but still face all the potential harms 1
• Studies show that men with fair or poor health are less likely to receive PSA screening than those with excellent or very good health (adjusted OR 0.51) 4
• Despite this, approximately 42% of men predicted to live less than 5 years still reported having recent PSA screening, indicating significant overscreening 4

Special Considerations for Men 70-75 Years

• For men aged 70-74 years who are very healthy with minimal comorbidities, PSA testing may be individualized but should be approached with caution 1
• If screening is continued in this age group, consider increasing the PSA threshold for biopsy to reduce overdiagnosis while maintaining cancer detection 1
• A microsimulation model showed that decreasing the screening stopping age from 74 to 69 years would lead to a 27% reduction in lives saved but an almost 50% reduction in overdiagnosis 1

PSA Level-Based Discontinuation Strategy

• Men aged 75 years or older with a PSA level less than 3.0 ng/mL are unlikely to die from prostate cancer and may safely discontinue screening 1
• In the Baltimore Longitudinal Study of Aging, no men aged 75-80 years with PSA less than 3.0 ng/mL died of prostate cancer 1
• Men with PSA levels below median (<1 ng/mL) at age 60 have only a 0.5% risk of metastases and 0.2% risk of prostate cancer death 1

Harms of Continued Screening in Elderly Men

• Overdiagnosis is particularly problematic in older men, as many will harbor cancers that would never affect their life expectancy 1
• Routine screening in men over 70 substantially increases rates of overdetection 1
• Treatment complications such as erectile dysfunction, urinary incontinence, and bowel symptoms are significant concerns that may outweigh minimal benefits in older men 2
• Recent data shows a small shift toward less intensive PSA testing in men ≥70 years between 2010 and 2018, but testing intensity still remains higher in this age group than in younger men 5

Balancing Benefits and Harms

• The goal of refined testing beyond age 70 years should be to maximize reduction in overdiagnosis while minimizing impact on cancer-specific mortality 1
• The National Comprehensive Cancer Network (NCCN) panel agrees that very few men older than 75 years benefit from PSA testing 1
• Lowering the PSA threshold to 2.5 ng/mL would double the number of men defined as abnormal, potentially leading to unnecessary biopsies and treatments 6