At what age should I start checking my Prostate-Specific Antigen (PSA) levels?

PSA Screening Age Recommendations

PSA testing should be offered annually beginning at age 50 for average-risk men with a life expectancy of at least 10 years, while high-risk men including those of African descent or with a family history of prostate cancer should begin testing at age 45, and men with multiple first-degree relatives diagnosed before age 65 should start at age 40. 1, 2

Risk-Stratified Approach to PSA Screening Initiation

• For average-risk men with at least 10 years life expectancy, PSA screening should begin at age 50 1, 2
• Men at high risk should begin screening earlier:
  • African American men should start at age 45 1, 2
  • Men with a first-degree relative diagnosed with prostate cancer before age 65 should start at age 45 1, 2
  • Men with multiple first-degree relatives diagnosed with prostate cancer before age 65 should begin at age 40 1, 2

Evidence Supporting Earlier Screening

• Baseline PSA levels are strong predictors of future prostate cancer risk - even stronger than family history or race 3
• A baseline PSA level between the age-specific median and 2.5 ng/mL was associated with a 14.6-fold increased risk of prostate cancer in men aged 40-49 and a 7.6-fold increased risk in men aged 50-59 3
• Early PSA measurement provides more specific cancer detection in younger men since prostatic enlargement is less likely to confound results 2
• A single PSA test taken at or before age 50 is a strong predictor of advanced prostate cancer diagnosed up to 25 years later 4
• Two-thirds of advanced cancer cases occurred in men with PSA levels of 0.9 ng/ml or higher at baseline (top 20% of values) 4

Follow-up Testing Guidelines

• If PSA level is less than 1 ng/mL in high-risk men screened at age 40-45, no additional testing is needed until age 45-50 1
• If PSA level is greater than 1 ng/mL but less than 2.5 ng/mL, annual testing is recommended 1
• If PSA level is 2.5 ng/mL or greater, further evaluation with biopsy is indicated 1

Upper Age Limit Considerations

• The US Preventive Services Task Force recommends against PSA screening in men aged 70 years and older 5
• The potential benefits of PSA-based screening for men 70 years and older do not outweigh the expected harms 5

Common Pitfalls to Avoid

• Starting screening too late may miss opportunities to identify aggressive cancers when still curable 2
• Not accounting for risk factors (race, family history) when determining screening initiation age 2
• Continuing screening beyond age 70 in men with limited life expectancy increases harms without clear benefit 2, 5
• Failing to consider baseline PSA values, which are stronger predictors of future cancer risk than family history or race 3

Screening Intervals

• After initial screening, intervals can be risk-stratified based on the man's age, general health, and initial PSA value 6
• Longer intervals for those at lower risk and shorter intervals for those at higher risk 6