When to Stop PSA Screening for Prostate Cancer
PSA screening should be discontinued at age 70 years for most men, with rare exceptions only for very healthy men aged 70-74 years who have minimal comorbidities and at least a 10-year life expectancy. 1, 2
Age-Based Stopping Points
Age 70 and Older: Stop Screening
- The USPSTF explicitly recommends against PSA-based screening in men 70 years and older (Grade D recommendation) 1, 2
- The harms of screening in men over 70 substantially outweigh any potential benefits due to increased false-positive results, biopsy complications, and treatment-related harms 3, 2
- Major randomized trials only demonstrate mortality benefits in men up to age 70 1
Age 75 and Older: Definitive Stopping Point
- Very few men older than 75 benefit from PSA testing 3, 1
- The average life expectancy at age 75 is approximately 10 years, which is the minimum time needed to realize any mortality benefit from screening 3
- Overdiagnosis is particularly problematic in this age group, as many will harbor cancers that would never affect their lifespan 3, 1
Life Expectancy-Based Approach
The 10-Year Rule
- PSA screening should only be offered to men with at least a 10-year life expectancy, regardless of chronological age 3, 1
- Men with significant comorbidities and reduced life expectancy face all the harms of screening without any realistic benefit 1
PSA Level-Based Discontinuation Strategy
For Men Age 75+ with Low PSA
Men aged 75 years or older with PSA <3.0 ng/mL can safely discontinue screening permanently. 3, 1
- In the Baltimore Longitudinal Study, no men aged 75-80 years with PSA <3.0 ng/mL died of prostate cancer 3, 1
- Men with PSA below median (<1 ng/mL) at age 60 have only a 0.5% risk of metastases and 0.2% risk of prostate cancer death 1
Special Considerations for Ages 70-74
Highly Selective Screening Only
If considering screening in men aged 70-74 years, apply all of these criteria: 3, 1
- Excellent health status with minimal to no comorbidities
- Life expectancy clearly exceeding 10 years
- Patient strongly desires screening after informed discussion
- Consider using a higher PSA threshold (e.g., >4.0 ng/mL) for biopsy to reduce overdiagnosis 3, 1
Quantifying the Trade-offs
- Decreasing the screening stopping age from 74 to 69 years would reduce lives saved by 27% but would reduce overdiagnosis by almost 50% 1
- This demonstrates that stopping at age 69-70 provides the optimal balance between benefit and harm 1
Common Pitfalls to Avoid
Continuing Screening Without Considering Health Status
- Approximately 33% of older men with high likelihood of 9-year mortality continue to be screened despite minimal clinical benefit 4
- Many men aged 75+ with fair or poor health continue receiving PSA tests when they cannot benefit 5
Failing to Use PSA History
- Men aged 60+ with PSA <1-2 ng/mL have extremely low risk of future aggressive prostate cancer and should discontinue screening 6
- Prior PSA values are powerful predictors and should guide discontinuation decisions 6
Not Discussing Harms
- Only 25% of screened older men recall discussing disadvantages of screening, while 55% recall discussing advantages 4
- Treatment complications include long-term urinary incontinence in 1 in 5 men and erectile dysfunction in 2 in 3 men after radical prostatectomy 2
Practical Algorithm for Stopping PSA Screening
Age ≥75 years: Stop screening for all men 1, 2
Age 70-74 years:
- Stop screening for most men 1, 2
- Consider continuing only if ALL apply: excellent health, life expectancy >10 years, patient preference after informed discussion, and use higher PSA threshold for biopsy 3, 1
Age 70-74 years with PSA <3.0 ng/mL: Stop screening definitively 3, 1
Age <70 years with life expectancy <10 years: Stop screening regardless of age 3, 1