At what age is Prostate-Specific Antigen (PSA) testing recommended?

PSA Screening Age Recommendations

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

Risk-Stratified Approach to PSA Screening Initiation

• The National Comprehensive Cancer Network (NCCN) recommends initiating PSA screening at age 45 for all men 1, 2
• African American men should begin PSA screening discussions at age 45 due to higher risk of aggressive disease 1, 2
• Men with a first-degree relative diagnosed with prostate cancer before age 65 should start screening discussions at age 45 1, 3
• Men with multiple first-degree relatives diagnosed with prostate cancer before age 65 should begin screening at age 40 1
• The American Cancer Society recommends informed decision-making starting at age 50 for average-risk men expected to live at least 10 more years 3, 2

Evidence Supporting Earlier Screening

• A baseline PSA level above the median value for age is a stronger predictor of future prostate cancer risk than family history or race 1
• Early PSA measurement provides a more specific test for cancer in younger men compared to older men because prostatic enlargement is less likely to confound PSA interpretation 1
• A single PSA test before age 50 years can predict subsequent prostate cancer up to 30 years later, suggesting value in early baseline testing 3
• The risk of prostate cancer death is strongly correlated with baseline PSA level in men aged 45 to 49 years and 51 to 55 years 3

Upper Age Limit Considerations

• The US Preventive Services Task Force (USPSTF) recommends against PSA-based screening for prostate cancer in men aged 70 years and older 4
• The USPSTF concluded 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 4
• Testing beyond age 70 should be done with caution and only in very healthy men with little or no comorbidity 5
• Men should have at least a 10-year life expectancy to benefit from PSA screening 5

Screening Intervals After Initiation

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

Common Pitfalls to Avoid

• Starting screening too late may miss opportunities to identify aggressive cancers when still curable 1
• Not accounting for risk factors (race, family history) when determining screening initiation age 1
• Continuing screening beyond age 70 in men with limited life expectancy increases harms without clear benefit 1, 4
• Failing to have informed discussions about the benefits and limitations of PSA screening 1, 2
• Focusing only on benefits of screening without discussing potential harms with patients 6

Shared Decision-Making Approach

• Before PSA testing, a risk and benefit discussion should occur, including potential benefits (reduced risk of advanced disease and prostate cancer mortality) and harms (false positives, unnecessary biopsies, overdiagnosis, and complications from treatment) 5
• 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 4
• Potential harms include false-positive results, psychological distress, overdiagnosis, and treatment complications such as erectile dysfunction and urinary incontinence 4