At what age is a Prostate-Specific Antigen (PSA) test typically ordered?

When to Order a PSA Test

Recommended Age to Initiate PSA Screening

Begin PSA screening at age 45 for all men after informed discussion about benefits and harms, with earlier initiation at age 40 for men with multiple first-degree relatives diagnosed with prostate cancer before age 65. 1

Standard Risk Men

• Initiate baseline PSA testing at age 45 years for average-risk men with at least 10 years life expectancy 2, 1, 3
• The strongest randomized trial evidence supports testing at age 55, showing approximately 1.3 fewer prostate cancer deaths per 1,000 men screened over 13 years 2, 4
• However, observational data demonstrates that baseline PSA levels in men aged 45-49 strongly predict future prostate cancer death, with 44% of deaths occurring in men in the highest tenth of PSA distribution 2
• A single PSA test before age 50 predicts subsequent prostate cancer up to 30 years later with robust accuracy (AUC 0.72-0.75) 2

High-Risk Men Requiring Earlier Screening

• African American men should begin PSA screening discussions at age 45 due to higher risk of aggressive disease 1, 3
• Men with a first-degree relative diagnosed with prostate cancer before age 65 should start at age 45 1, 3
• Men with multiple first-degree relatives diagnosed before age 65 should begin screening at age 40 1
• Baseline PSA level is a stronger predictor of future prostate cancer risk than family history or race alone 2, 1

Screening Frequency After Initiation

• For men with PSA ≥1.0 ng/mL (above 75th percentile), repeat testing every 1-2 years 2
• For men with PSA <1.0 ng/mL, repeat testing every 2-4 years 2, 1
• Screening every 2 years reduces advanced prostate cancer diagnosis by 43% compared to every 4 years, though it increases low-risk cancer detection by 46% 2

When to Stop PSA Screening

Discontinue routine PSA screening at age 70 in most men, continuing only in very healthy men with minimal comorbidity and prior elevated PSA values. 2, 1, 5

• The US Preventive Services Task Force recommends against PSA screening in men aged 70 and older 1, 4
• Randomized trials (ERSPC, Göteborg) demonstrated benefits only in men up to age 70 2
• However, men older than 70 with elevated PSA are at increased risk of death from prostate cancer at any PSA level, with 10-year mortality reaching 51% for PSA 7-10 ng/mL in men aged 80-89 6
• Men aged 60 with PSA <1 ng/mL have only 0.5% risk of metastases and 0.2% risk of prostate cancer death, suggesting screening can safely stop in this group 2

Pre-Test Counseling Requirements

Always conduct shared decision-making discussions about both benefits and harms before ordering PSA testing. 1, 3, 4

Benefits to Discuss:

• Potential reduction in prostate cancer mortality (1.3 deaths prevented per 1,000 screened over 13 years) 4
• Prevention of approximately 3 cases of metastatic disease per 1,000 men screened 4

Harms to Discuss:

• Overdiagnosis of indolent cancers that would never cause symptoms 3, 4
• False-positive results requiring additional testing and biopsies 3, 4
• Treatment complications: 20% develop long-term urinary incontinence, 67% experience long-term erectile dysfunction after radical prostatectomy 4
• Psychological distress from diagnosis and testing 3

Pre-Test Preparation

Instruct patients to avoid ejaculation and vigorous exercise (especially cycling) for 48 hours before PSA testing. 3

• Confirm absence of active urinary tract infection or prostatitis, which artificially elevate PSA 3
• Be aware that 5-alpha reductase inhibitors (finasteride, dutasteride) lower PSA by approximately 50% 3
• If PSA is initially elevated, confirm with repeat testing after a few weeks under standardized conditions 3

Common Pitfalls to Avoid

• Starting screening too late (after age 50) may miss opportunities to identify aggressive cancers when still curable 1, 7
• Continuing routine screening beyond age 70 without considering health status increases harms without clear benefit 1, 5, 4
• Failing to discuss both benefits AND harms—studies show 54.6% of discussions focus only on benefits 8
• Not accounting for risk factors (race, family history) when determining screening age 1
• Ordering PSA in men with life expectancy <10 years, where harms outweigh benefits 3, 4