What are the recommendations for Prostate-Specific Antigen (PSA) screenings and prostate exams?

PSA Screening and Prostate Exams Recommendations

For men aged 55-69 years, PSA screening should be offered after a shared decision-making process that discusses potential benefits and harms, while men aged 70 years and older should not undergo routine PSA screening. 1, 2

Age-Based Recommendations

Average-Risk Men:

• PSA screening should be offered to men aged 55-69 years after discussing potential benefits and harms 1, 3
• Screening should not be performed in men aged 70 years and older due to limited benefit and increased harm 1, 2
• Men should have a life expectancy of at least 10 years to benefit from screening 1, 3

High-Risk Men:

• African American men should begin PSA screening discussions at age 45 1, 4
• Men with a first-degree relative diagnosed with prostate cancer before age 65 should begin screening discussions at age 45 1, 4
• Men with multiple first-degree relatives diagnosed with prostate cancer before age 65 should consider screening at age 40 1, 4

Benefits and Harms of Screening

Potential Benefits:

• PSA screening may prevent approximately 1.3 deaths from prostate cancer per 1,000 men screened over 13 years 2
• Screening may prevent approximately 3 cases of metastatic prostate cancer per 1,000 men screened 2

Potential Harms:

• False-positive results leading to unnecessary biopsies and psychological distress 1, 3
• Overdiagnosis of indolent cancers that would never cause symptoms 1, 5
• Complications from treatment including urinary incontinence (affects 1 in 5 men after radical prostatectomy) and erectile dysfunction (affects 2 in 3 men) 2

Screening Approach

Testing Methods:

• PSA test with or without digital rectal examination (DRE) 1, 3
• In men for whom DRE is an obstacle to testing, PSA alone is an acceptable alternative 1

Follow-up of Abnormal Results:

• A single elevated PSA level should be verified by a second measurement before proceeding to biopsy 3
• Decision to proceed with prostate biopsy should consider multiple factors including DRE findings, ethnicity, age, comorbidities, and previous biopsy history 3
• Multi-parametric MRI before biopsy can improve diagnostic accuracy 3

Special Considerations

Factors Affecting PSA Levels:

• PSA levels can be affected by medications (finasteride, dutasteride) and recent activities (vigorous exercise, ejaculation within 2 days) 5, 3
• Avoid PSA testing within 2 days of vigorous exercise or ejaculation to prevent false positive elevations 5

Screening Intervals:

• Evidence suggests that screening intervals can be risk-stratified based on baseline PSA values 4
• Many guidelines recommend biennial rather than annual screening to reduce harms while maintaining benefits 6

Common Pitfalls to Avoid

• Failing to have informed discussions about the benefits and limitations of PSA screening 1
• Continuing screening beyond age 70 in men with limited life expectancy increases harms without clear benefit 1, 3
• Proceeding to biopsy based on a single elevated PSA without confirmation 3
• Not accounting for risk factors (race, family history) when determining screening initiation age 4, 3

Guideline Differences

• The US Preventive Services Task Force (2018) recommends individualized decision-making for men aged 55-69 years and against screening for men 70 years and older 2
• The American Cancer Society recommends informed decision-making starting at age 50 for average-risk men with at least 10-year life expectancy 1
• The American Urological Association recommends shared decision-making for men aged 55-69 years and against routine screening in men with life expectancy <10-15 years 1