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

When to Stop PSA Screening for Prostate Cancer

PSA screening should stop at age 70 for most men, with rare exceptions for very healthy men aged 70-74 who have minimal comorbidities and understand the limited benefits. 1, 2

Primary Age-Based Stopping Points

Routine screening should definitively stop at age 70 years. The US Preventive Services Task Force explicitly recommends against PSA-based screening in men 70 years and older (Grade D recommendation), and multiple major guidelines including the American College of Physicians align with this cutoff. 3, 1, 2 The benefits of screening observed in major randomized controlled trials only extend up to age 70. 1

Ages 70-74: Highly Selective Continuation Only

For men aged 70-74 years, PSA testing should be individualized and approached with extreme caution, reserved only for exceptionally healthy men with minimal comorbidities. 3, 1 This represents a category 2B recommendation (nonuniform consensus) because:

• A large proportion of men in this age group harbor cancers that would never affect their life expectancy 3
• Routine screening substantially increases overdetection rates 3
• If screening continues in this narrow window, consider increasing the PSA threshold for biopsy to reduce overdiagnosis while maintaining detection of clinically significant cancers 3

Age 75 and Beyond: Stop Screening

Very few men older than 75 years benefit from PSA testing. 3, 1 The NCCN panel uniformly agrees on this point, and the potential harms clearly outweigh any marginal benefits. 3

Life Expectancy as the Critical Determinant

Regardless of chronological age, PSA screening should only occur in men with at least 10-15 years of life expectancy. 3, 1, 4 This is the single most important factor:

• Men with significant comorbidities and reduced life expectancy face all potential harms of screening without meaningful benefit 1
• The American Urological Association and European Association of Urology both emphasize this life expectancy threshold over strict age cutoffs 3

PSA Level-Based Discontinuation Strategy

Men aged 75 years or older with PSA <3.0 ng/mL can safely discontinue screening permanently. 3, 1 This evidence-based strategy comes from:

• The Baltimore Longitudinal Study of Aging showed zero prostate cancer deaths in men aged 75-80 years with PSA <3.0 ng/mL 3, 1
• Time to death or aggressive prostate cancer diagnosis was significantly longer in men with PSA <3.0 ng/mL 3
• Men with PSA below median (<1 ng/mL) at age 60 have only 0.5% risk of metastases and 0.2% risk of prostate cancer death 1

Three Evidence-Based Stopping Strategies

The NCCN guidelines outline three acceptable approaches to reduce overdiagnosis in older populations: 3

1. Discontinue screening at age 69 years (most conservative, reduces overdiagnosis by ~50%)
2. Continue to age 74 with increased PSA threshold for biopsy (balances detection and overdiagnosis)
3. Discontinue at age 75 for men with PSA <3.0 ng/mL (risk-stratified approach)

Critical Pitfalls to Avoid

Do not screen men unlikely to benefit based on age and/or comorbidity. 3 Common errors include:

• Continuing routine screening beyond age 70 without careful consideration of health status 1, 5
• Screening men with less than 10-year life expectancy 1
• Failing to have explicit discussions about stopping screening with older patients 6

Research shows that 42% of men predicted to live less than 5 years still received PSA screening, and over 75% of older individuals with limited life expectancy intend to continue screening because less than 25% recall physicians discussing that screening may no longer be necessary. 7, 6 Proactive conversations about stopping are essential.

The Harm-Benefit Calculus in Older Men

The harms of screening are greater in men over 70 due to: 2

• Increased false-positive results requiring additional testing and biopsies
• Higher rates of overdiagnosis (detecting cancers that would never cause symptoms)
• Greater treatment complications (1 in 5 men develop long-term urinary incontinence, 2 in 3 experience long-term erectile dysfunction after radical prostatectomy) 2
• Reduced life expectancy means less time to benefit from early detection 1

The goal beyond age 70 is maximizing reduction in overdiagnosis while minimizing impact on cancer-specific mortality. 3, 1