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

PSA Screening Age Recommendations

PSA screening should begin at age 45-50 for average-risk men with at least 10-year life expectancy, with earlier screening at age 45 for African American men and those with a family history of prostate cancer, and at age 40 for men with multiple first-degree relatives diagnosed with prostate cancer before age 65. 1, 2

When to Start PSA Screening

Risk-Stratified Approach:

• Average-risk men: Begin informed decision-making about PSA screening at age 50 if life expectancy is at least 10 years 2, 1
• African American men: Begin PSA screening discussions at age 45 due to higher risk of aggressive disease 2, 1, 3
• Men with a first-degree relative diagnosed with prostate cancer before age 65: Begin at age 45 2, 1
• Men with multiple first-degree relatives diagnosed before age 65: Begin at age 40 1, 2

Evidence Supporting Earlier Screening:

• A baseline PSA test in men aged 40-50 provides valuable risk stratification for future prostate cancer risk 2
• A single PSA test before age 50 can predict subsequent prostate cancer up to 30 years later with a robust area under the curve (AUC) of 0.72 2, 4
• The risk of prostate cancer death is strongly correlated with baseline PSA levels in men aged 45-49 years 2
• 44% of prostate cancer deaths occur in men in the highest tenth of PSA distribution, suggesting a strong rationale for baseline testing before age 55 2

Screening Intervals After Initiation

• For men with PSA levels less than 2.5 ng/mL, screening intervals can be extended to every 2 years 2
• Annual screening is recommended for men with PSA levels of 2.5 ng/mL or higher 2
• Re-screening intervals should be based on results of the initial PSA test rather than fixed annual testing 1, 3

When to Stop PSA Screening

• Several guidelines recommend against routine PSA screening in men aged 70 years and older 1, 5
• The US Preventive Services Task Force recommends against PSA screening in men 70 years and older due to limited benefit and increased potential harms 5
• Consider individual health status and life expectancy when determining when to stop screening 2

Benefits and Potential Harms

• 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 5
• Potential harms include false-positive results, overdiagnosis, and complications from treatment including erectile dysfunction and urinary incontinence 5
• The European Randomized Study of Screening for Prostate Cancer (ERSPC) and Göteborg trials reported decreased disease-specific mortality in men aged 55-69 and 50-64 years, respectively 2

Special Considerations

• A baseline serum PSA level is a stronger predictor of future prostate cancer risk compared to family history or race 2
• PSA testing is more specific for cancer in younger men because prostatic enlargement is less likely to confound interpretation 2
• Median PSA levels for men aged 40-49 and 50-59 years are 0.7 ng/mL and 0.9 ng/mL, respectively 2

Common Pitfalls to Avoid

• Starting screening too late may miss opportunities to identify aggressive cancers when still curable 1, 6
• Not accounting for risk factors (race, family history) when determining screening initiation age 1, 3
• Continuing screening beyond age 70 in men with limited life expectancy increases harms without clear benefit 1, 5
• Failing to have informed discussions about the benefits and limitations of PSA screening 2, 1