PSA Screening Guidelines for Men
PSA screening should involve shared decision-making between patients and providers, with screening discussions beginning at age 45 for most men and continuing until age 69 for those with at least a 10-year life expectancy. 1, 2
Age-Based Recommendations for PSA Screening
When to Start Screening
- Average-risk men should begin discussions about PSA screening at age 50 1
- African American men should begin discussions at age 45 due to increased risk 1, 2
- Men with a first-degree relative diagnosed with prostate cancer before age 65 should begin discussions at age 45 1, 2
- Men with multiple first-degree relatives diagnosed with prostate cancer before age 65 should begin discussions at age 40 1
- The NCCN recommends baseline PSA testing at age 45 for all men 1, 2
When to Stop Screening
- Screening is not recommended for men aged 70 years and older 1, 3
- Men with less than a 10-year life expectancy should not undergo PSA screening regardless of age 1, 4
PSA Threshold Values and Screening Intervals
- A PSA level of 4.0 ng/mL has historically been used as the threshold for recommending further evaluation or biopsy 1
- For PSA levels between 2.5 and 4.0 ng/mL, individualized risk assessment incorporating other risk factors should be considered 1
- For men with PSA levels less than 2.5 ng/mL, screening intervals can be extended to every 2 years 1
- For men with PSA levels of 2.5 ng/mL or higher, annual screening is recommended 1
- For younger men (under 50 years), a PSA value of 1.0 ng/mL or greater (above the 75th percentile for this age group) warrants more frequent testing (1-2 year intervals) 1, 2
Benefits and Harms of PSA Screening
Potential Benefits
- PSA screening may reduce prostate cancer-specific mortality by approximately 20% in men aged 55-69 years 1, 5
- Screening may prevent approximately 3 cases of metastatic prostate cancer per 1,000 men screened 3, 5
Potential Harms
- False-positive results (up to 80% when PSA cutoff is between 2.5 and 4.0 µg/L) 1, 6
- Overdiagnosis of tumors that may not become clinically significant 1
- Complications from prostate biopsies including infections, bleeding, and pain 1, 3
- Treatment-related side effects including erectile dysfunction (affects up to 2/3 of men after radical prostatectomy), urinary incontinence (affects about 1/5 of men), and bowel symptoms 3, 6
Shared Decision-Making Approach
- All guidelines emphasize the importance of shared or informed decision-making before PSA testing 1
- Clinicians should discuss both potential benefits and harms of screening 1, 7
- Patient values and preferences should be incorporated into the screening decision 1
- Men who are unable to decide may defer the decision to their healthcare provider 1
Risk Stratification Considerations
- A baseline PSA test can help stratify future risk, particularly in younger men 1, 2
- African American race, family history, advancing age, and abnormal DRE are factors that increase risk of prostate cancer 1, 2
- Risk calculators (such as the PCPT Prostate Cancer Risk Calculator) can help estimate an individual's risk of prostate cancer and guide biopsy decisions 1
Common Pitfalls to Avoid
- Screening men over 70 years or those with limited life expectancy increases harms without clear benefit 3, 4
- Not accounting for risk factors when determining screening initiation age 2, 6
- Failing to have informed discussions about benefits and limitations before ordering PSA tests 1
- Using a one-size-fits-all approach rather than risk-stratified screening intervals 1, 2