At what life expectancy should Prostate-Specific Antigen (PSA) checks be stopped?

When to Stop PSA Screening for Prostate Cancer

PSA screening should be discontinued in men with a life expectancy of less than 10 years, regardless of age, and routinely discontinued in men aged 70 years and older. 1, 2

Age-Based Recommendations

• 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, 3
• Multiple guidelines, including those from the American College of Physicians, recommend against screening in men aged ≥70 years 1, 2
• The European Society for Medical Oncology (ESMO) guidelines clearly state that testing for prostate cancer in asymptomatic men should not be done in men with a life expectancy < 10 years 1
• The National Comprehensive Cancer Network (NCCN) panel agrees that very few men older than 75 years benefit from PSA testing 1, 2

Life Expectancy Considerations

• The benefits of screening are only observed in men with a life expectancy of at least 10-15 years 2, 4
• Men with significant comorbidities and reduced life expectancy face all the potential harms of screening without the potential benefits 2, 3
• The European Association of Urology recommends against routine screening for men with life expectancy <15 years 1
• The median age of death from prostate cancer is 80 years, suggesting limited benefit of screening in men approaching this age 3

Risk-Based Discontinuation Strategies

• 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, 2
• 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, 2
• 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 2, 5
• 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, 2

Harms of Continued Screening in Elderly Men

• Overdiagnosis is particularly problematic in older men, as many will harbor indolent cancers that would never affect their life expectancy 1, 2
• Potential harms of screening include frequent false-positive results, psychological harms, and unnecessary biopsies 3
• Harms of prostate cancer treatment include erectile dysfunction (affecting 2 in 3 men after radical prostatectomy), urinary incontinence (affecting 1 in 5 men), and bowel symptoms 3
• The USPSTF concludes with moderate certainty that the potential benefits of PSA-based screening for prostate cancer in men 70 years and older do not outweigh the expected harms 3

Algorithm for Discontinuing PSA Screening

1. For all men: Discontinue PSA screening if life expectancy is less than 10 years due to age or comorbidities 1, 2
2. For men ≥70 years: Routinely discontinue PSA screening regardless of health status 1, 3
3. For men aged 75 years or older: Definitely discontinue screening, especially if PSA <3.0 ng/mL 1, 2
4. For men aged 70-74 years who are exceptionally healthy: Consider individualized screening only after careful discussion of limited benefits and potential harms 1, 2
5. For men of any age with PSA <1 ng/mL at age 60: Consider early discontinuation of screening due to very low risk of clinically significant prostate cancer 2, 5

Common Pitfalls to Avoid

• Continuing screening based solely on chronological age without considering life expectancy 2, 6
• Screening men with significant comorbidities who are unlikely to benefit but still face all potential harms 2, 3
• Failing to recognize that the harms of screening in men older than 70 years are greater than in younger men due to increased risk of false-positive results, diagnostic harms from biopsies, and complications from treatment 3
• Continuing routine screening in men over 75 years, which substantially increases rates of overdetection without meaningful mortality benefit 1, 2