At what age is it recommended to stop screening for prostate cancer?

When to Stop Prostate Cancer Screening

Prostate cancer screening should be discontinued at age 70 for most men, and should not be offered to any man with a life expectancy of less than 10 years. 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) 2
• Multiple major guidelines, including those from the American College of Physicians, recommend against screening in men aged ≥70 years 3
• The benefits of screening are only observed in men up to 70 years of age in major randomized controlled trials 1
• The American Urological Association recommends against routine screening in men with life expectancy <10-15 years 3

Life Expectancy Considerations

• PSA screening should only be offered to men with a life expectancy of at least 10 years, regardless of chronological age 3, 1
• Men with significant comorbidities and reduced life expectancy are unlikely to benefit from PSA screening but still face all the potential harms 3
• Physicians tend to overvalue age and undervalue comorbidity when estimating life expectancy 3

Special Considerations for Men 70-75 Years

• For very healthy men aged 70-74 years with minimal comorbidities, some guidelines suggest PSA testing may be individualized but should be approached with caution 3
• The National Comprehensive Cancer Network (NCCN) panel supports screening in men until age 75, but then continuing screening only in very select patients (category 2B recommendation) 3
• A microsimulation model showed that decreasing the screening stopping age from 74 to 69 years would lead to a 27% reduction in lives saved but an almost 50% reduction in overdiagnosis 3

PSA Level-Based Discontinuation Strategy

• 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 3, 4
• 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 3
• Recent research from the European Randomized Study of Screening for Prostate Cancer found that men aged 70-74 who had previously undergone PSA screening without receiving a prostate cancer diagnosis had only a 0.54% risk of dying from prostate cancer by age 85 4
• This risk was even lower (0.11%) in men with PSA <2 ng/ml 4

Harms of Continued Screening in Elderly Men

• Overdiagnosis is particularly problematic in older men, as many will harbor cancers that would never affect their life expectancy 1, 5
• Approximately 33% of older men with a high likelihood of 9-year mortality were screened despite minimal clinical benefit 5
• Autopsy studies show that while older men (>70 years) have more prostate cancer, much of it would never have become clinically significant during their lifetime 6
• Potential harms of screening and subsequent treatment include false-positive results, psychological harms, erectile dysfunction, urinary incontinence, and bowel symptoms 2

Balancing Benefits and Harms

• The goal of refined testing beyond age 70 years should be to maximize reduction in overdiagnosis while minimizing impact on cancer-specific mortality 3
• Mathematical modeling suggests men should not be screened for prostate cancer beyond 70 years old, as this results in the net benefit of "do nothing" exceeding the benefit of biopsy 7
• Twice as many men recalled discussing the potential advantages of screening compared with the disadvantages, suggesting inadequate shared decision making 5

Common Pitfalls to Avoid

• Continuing screening based solely on chronological age without considering overall health status and life expectancy 3
• Failing to recognize that the harms of screening in men older than 70 years are at least moderate and greater than in younger men 2
• Overlooking that 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 3