PSA Screening Recommendations
PSA screening should involve shared decision-making for men aged 55-69 years, with screening generally not recommended for men aged 70 years and older due to limited mortality benefit and increased potential harms. 1
Age-Based Recommendations
- For average-risk men, PSA screening discussions should begin at age 50 if life expectancy is at least 10 years 2, 3
- African American men should begin PSA screening discussions earlier at age 45 due to higher risk of aggressive disease 2, 3
- Men with a family history of prostate cancer (first-degree relative diagnosed before age 65) should start discussions at age 45 2, 3
- Men with multiple first-degree relatives diagnosed with prostate cancer before age 65 should begin screening discussions at age 40 3
- The NCCN recommends initiating PSA screening at age 45 for all men 2, 3
- Screening is generally not recommended for men aged 70 years and older 2, 1
Risk-Based Screening Approach
- Baseline PSA levels strongly predict future risk of clinically significant prostate cancer 4, 5
- Men with baseline PSA <1.0 ng/mL at ages 55-69 have very low risk of developing clinically significant prostate cancer (1.5% or less at 13 years) 4, 5
- Men with baseline PSA ≥3.0 ng/mL have substantially higher risk (13.3-13.8%) of developing clinically significant prostate cancer 4
- 92% of lethal prostate cancers occur in men with PSA above the median (1.21 ng/mL) 4
- No prostate cancer deaths occurred within 5 years among men with PSA ≤1 ng/mL 6
Screening Intervals
- Five-year screening intervals may be appropriate for men with PSA ≤1 ng/mL 6
- More frequent screening (1-2 years) is appropriate for men with higher baseline PSA levels 4
- Men aged ≥65 years with PSA ≤0.5 ng/mL could consider stopping screening entirely 6
- For men initially screened at age 60-61 with baseline PSA <2 ng/mL, continuing screening beyond age 70 provides limited benefit 4
Benefits and Harms
Benefits:
- PSA screening in men aged 55-69 years may prevent approximately 1.3 deaths from prostate cancer per 1,000 men screened over 13 years 2, 1
- Screening may prevent approximately 3 cases of metastatic prostate cancer per 1,000 men screened 1
Harms:
- False-positive results requiring additional testing and possible prostate biopsy 1
- Overdiagnosis of indolent cancers that would never cause symptoms 2, 1
- Treatment complications including erectile dysfunction (affects 2 in 3 men after radical prostatectomy), urinary incontinence (affects 1 in 5 men), and bowel symptoms 1
- Psychological distress from false positives and diagnosis 2
Special Considerations
- African American men have higher rates of aggressive disease even with PSA ≤1 ng/mL (1.6% vs 0.4% 10-year rate compared to white men) 6
- Cost-effectiveness is optimized with screening every four years between ages 55-69 and offering active surveillance to men with low-risk disease 2
- PSA levels can be affected by medications (finasteride, dutasteride) and recent activities (vigorous exercise, ejaculation within 2 days) 2
Practical Implementation
- Avoid PSA testing within 2 days of vigorous exercise or ejaculation to prevent false positive elevations 2
- PSA testing requires a simple blood sample, usually taken at primary care offices 2
- Elevated results typically lead to additional testing, which may include prostate biopsy 2
- Prostate biopsy is usually performed transrectally with ultrasound guidance and requires antibiotic prophylaxis 2
- Common side effects of biopsy include soreness, blood in semen/urine/stool for days to weeks 2