At what age should Prostate-Specific Antigen (PSA) screening be stopped?

Age to Stop PSA Screening for Prostate Cancer

Stop routine PSA screening at age 70 years for most men, with very limited exceptions for exceptionally healthy men aged 70-74 years who have minimal comorbidities and understand the high risk of overdiagnosis. 1, 2, 3

Primary Age Cutoff: 70 Years

• The USPSTF explicitly recommends against PSA-based screening in men 70 years and older (Grade D recommendation), indicating that harms outweigh benefits in this population 2, 3
• Multiple major guidelines including the American College of Physicians and European Association of Urology recommend stopping screening at age 70 years 1, 2
• The benefits of screening observed in randomized controlled trials are only seen in men up to age 70 years 2

Limited Exceptions for Ages 70-74 Years

If continuing screening between ages 70-74 years, apply these strict criteria:

• Only screen men who are exceptionally healthy with minimal or no comorbidities 1, 2
• Increase the PSA threshold for biopsy (consider >4.0 ng/mL rather than standard cutoffs) to reduce overdiagnosis 1
• Ensure the patient has at least 10-15 years life expectancy 1, 2
• Recognize that discontinuing screening at age 69 versus 74 years reduces overdiagnosis by nearly 50% while only reducing lives saved by 27% 2

Absolute Cutoff: Age 75 Years

Very few men older than 75 years benefit from PSA testing, and screening should stop 1, 2

PSA-Based Discontinuation Strategy at Age 75+

• Men aged 75-80 years with PSA <3.0 ng/mL are extremely unlikely to die from prostate cancer and may safely discontinue screening 1, 2
• In the Baltimore Longitudinal Study, no men aged 75-80 years with PSA <3.0 ng/mL died of prostate cancer 1, 2
• Men with PSA ≥3.0 ng/mL at age 75+ have longer time to death or aggressive cancer diagnosis, but screening still carries substantial overdiagnosis risk 1

Life Expectancy Requirement at Any Age

PSA screening should only occur in men with at least 10 years life expectancy, regardless of chronological age 1, 2, 4

• Men with significant comorbidities face all screening harms but are unlikely to benefit from early cancer detection 2
• Before the 2008 USPSTF guidelines, 42% of men predicted to live <5 years were still being inappropriately screened 5

Rationale: Why Stop at Age 70?

Harms Increase Substantially

• Overdiagnosis is particularly problematic in older men, as most harbor cancers that will never affect life expectancy 1, 2
• False-positive rates increase with age, leading to unnecessary biopsies and psychological distress 2, 3
• Treatment complications (erectile dysfunction in 67% of men, urinary incontinence in 20%) are more severe in older men 3

Benefits Diminish

• The median age of death from prostate cancer is 80 years, meaning most men diagnosed after age 70 will die with, not from, prostate cancer 3
• Routine screening in men over 70 substantially increases overdetection rates without meaningful mortality reduction 1

Common Pitfalls to Avoid

• Do not continue routine screening based solely on "good health" without considering the 10-year life expectancy threshold 2, 4
• Do not screen men who have not had explicit discussion of harms versus benefits 1, 4
• Do not use the same PSA threshold for biopsy in men 70-74 years as in younger men—if screening at all in this age group, increase the threshold to reduce overdiagnosis 1
• Avoid screening men with competing comorbidities—approximately 33% of elderly US men with high risk of dying from other causes were inappropriately screened 1

Implementation in Practice

For a 70-year-old man presenting for routine care:

1. Discontinue PSA screening for average-risk men 1, 2, 3
2. For exceptionally healthy men aged 70-74 years requesting continued screening, counsel extensively about the high overdiagnosis risk (nearly 50% reduction if stopping at 69 vs 74) 2
3. If proceeding with screening in ages 70-74, use PSA threshold >4.0 ng/mL for biopsy consideration 1
4. At age 75, stop all PSA screening regardless of health status, with possible exception only for men with PSA ≥3.0 ng/mL who are extraordinarily healthy 1, 2