Why Men Over 80 Should Not Get PSA Screening
Men over 80 years old should not receive PSA screening because approximately 75% or more of detected cancers in this age group represent overdiagnosis—cancers that would never cause symptoms or death—while the harms of screening, biopsy, and potential treatment substantially outweigh any mortality benefit. 1
The Evidence Against Screening in Men Over 80
Overwhelming Rate of Overdiagnosis
In men over 80 years, three-fourths (≥75%) of cases detected by PSA screening with PSA <10 ng/mL and Gleason score ≤6 are overdiagnosed, meaning these cancers would never have caused clinical problems during the patient's remaining lifetime. 1
This overdiagnosis rate is substantially higher than in younger age groups (men 70-79 have approximately 50% overdiagnosis rate for similar low-risk cancers). 1
Lack of Mortality Benefit
The ERSPC randomized trial demonstrated no reduction in prostate cancer mortality among men aged 70 years or older who underwent screening. 1
Men over 80 have significantly increased competing mortality from other causes, making it extremely unlikely they would live long enough to benefit from early prostate cancer detection. 1
The median age of death from prostate cancer is 80 years, meaning most men dying from this disease are at or below this age threshold. 2
Substantial Harms Without Offsetting Benefits
The harms of PSA screening in elderly men are well-documented and include:
Biopsy complications: Infection, bleeding, pain, and hospitalization risk from prostate biopsies performed for elevated PSA. 1
Treatment-related morbidity: Approximately 20% of men undergoing radical prostatectomy develop long-term urinary incontinence, and 67% experience long-term erectile dysfunction. 2
Psychological distress: Anxiety from false-positive results and cancer diagnosis, even when the cancer poses no threat. 2
Bowel dysfunction: Treatment-related bowel symptoms that impair quality of life. 2
Guideline Consensus
Major Society Recommendations
AUA Guidelines (2013): Do not recommend routine PSA screening in men over age 70 years or any man with less than 10-15 year life expectancy (Grade C recommendation). 1
NCCN Guidelines (2014): The panel agreed that very few men older than 75 years benefit from PSA testing and uniformly discouraged PSA testing in men unlikely to benefit based on age and/or comorbidity. 1
USPSTF (2018): Recommends against PSA-based screening for prostate cancer in men 70 years and older (D recommendation—moderate certainty that harms outweigh benefits). 2
ESMO Guidelines (2013): Evidence shows that harms of screening men >75 years outweigh the benefits. 1
The Life Expectancy Principle
Screening only makes sense when life expectancy exceeds 10-15 years:
Men over 80 rarely have a 10-15 year life expectancy, which is the minimum timeframe needed to potentially benefit from early prostate cancer detection and treatment. 1
Even among men aged 75-80 years with PSA <3.0 ng/mL, no deaths from prostate cancer occurred in longitudinal studies, and these men are unlikely to die from or experience aggressive prostate cancer during their remaining lifetime. 1, 3
Special Considerations for the Rare Exception
While routine screening is not recommended, there may be extremely rare circumstances:
Only men over 80 in exceptional health with documented life expectancy >10 years and PSA >10 ng/mL might warrant individualized consideration, as these men have higher likelihood of clinically significant disease. 1, 3
However, even in this scenario, the patient must understand that the ratio of harm to benefit is extremely unfavorable, and overdiagnosis risk remains very high. 1
Common Pitfalls to Avoid
Continuing "routine" annual screening: Many physicians continue PSA testing in elderly men simply because it was done previously, without reassessing appropriateness. 4, 5
Screening rates paradoxically increase with age: Research shows that 34-50% of men aged 85+ still receive PSA testing, which is counter to all guideline recommendations. 4, 5
Discussing only benefits, not harms: Studies show that when PSA discussions occur in elderly men, clinicians focus predominantly on potential benefits while neglecting to discuss the substantial harms. 5, 6
Ignoring comorbidities: Health status matters more than chronological age—men with significant comorbidities have even less potential benefit and should definitely not be screened. 1
The Bottom Line for Clinical Practice
For men over 80, the clinical approach should be:
Do not order PSA screening as part of routine health maintenance. 1, 2
If a PSA is incidentally obtained and is <3.0 ng/mL, reassure the patient and do not pursue further testing. 1, 3
If PSA is 3.0-10.0 ng/mL, recognize that most detected cancers would represent overdiagnosis; avoid reflexive biopsy referral. 1, 3
Only if PSA is >10 ng/mL in an exceptionally healthy octogenarian should further evaluation even be considered, and only after extensive shared decision-making about the high likelihood of net harm. 1, 3