When should a Prostate-Specific Antigen (PSA) test be done?

When to Perform PSA Screening

PSA screening should begin at age 45 for average-risk men with at least 10 years life expectancy, with earlier initiation at age 40 for high-risk groups including African American men and those with a family history of prostate cancer. 1, 2

Age-Based Screening Initiation

Baseline Testing at Age 40

• Obtain a baseline PSA at age 40 for all men to establish future risk stratification and determine appropriate screening intervals. 3, 1, 2
• A baseline PSA above the median (0.6-0.7 ng/mL) at age 40 is a stronger predictor of future prostate cancer risk than family history or race. 3, 1
• PSA measurement is more specific for cancer in younger men because prostatic enlargement is less likely to confound interpretation. 3, 1
• Establishing baseline values before age 50 helps identify men with life-threatening prostate cancer when cure is still possible. 3, 1

Standard Risk Men (Age 45-50)

• The National Comprehensive Cancer Network recommends initiating PSA screening at age 45 for average-risk men. 1, 2
• Men aged 50 with at least 10 years life expectancy should begin screening if not already started. 3, 2
• 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. 1, 4

High-Risk Groups Requiring Earlier Screening

African American men should begin PSA screening at age 45. 3, 1, 2

Men with a first-degree relative diagnosed with prostate cancer before age 65 should start screening at age 45. 3, 1, 2

Men with multiple first-degree relatives diagnosed with prostate cancer before age 65 should begin screening at age 40. 3, 1, 2

Screening Intervals After Initiation

PSA-Based Interval Determination

• Re-screening intervals should be based on the initial PSA result rather than fixed annual testing. 3, 1, 2

For men with PSA <1.0 ng/mL:

• Repeat testing every 2-4 years is appropriate. 1, 2
• Men aged 50-74 with PSA ≤1 ng/mL can safely wait 3-4 years before the next PSA test. 5
• Less than 3% of these men will have PSA >3 at the next testing, and only 5% of those biopsied will have Gleason score ≥7 cancer. 5

For men with PSA ≥1.0 ng/mL:

• Repeat testing every 1-2 years. 1, 2
• Men with PSA >1 ng/mL have increased risk of Gleason score ≥7 prostate cancer with longer than annual testing intervals (risk ratios 1.4 to 3.2 depending on PSA level). 5

For men with PSA 1-2.5 ng/mL:

• Annual testing is recommended. 3

For men with PSA ≥2.5 ng/mL:

• Further evaluation with biopsy is indicated. 3

When to Stop PSA Screening

Discontinue routine PSA screening at age 70 in most men. 1, 2, 4

• The US Preventive Services Task Force recommends against PSA screening in men aged 70 years and older. 1, 4
• Continue screening beyond age 70 only in very healthy men with minimal comorbidity, prior elevated PSA values, and life expectancy >10-15 years. 3, 1
• 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. 1
• Randomized trials demonstrated benefits only in men up to age 70. 1

Shared Decision-Making Requirements

All PSA screening decisions should involve informed discussion of potential benefits and harms. 2, 4

Benefits to Discuss:

• PSA screening in men aged 55-69 may prevent approximately 1.3 deaths from prostate cancer per 1,000 men screened over 13 years. 1, 4
• Screening may prevent approximately 3 cases of metastatic prostate cancer per 1,000 men screened. 4

Harms to Discuss:

• Frequent false-positive results requiring additional testing and possible biopsy. 4
• Overdiagnosis of indolent cancers that would never cause symptoms. 4
• Treatment complications including erectile dysfunction (2 in 3 men), urinary incontinence (1 in 5 men after radical prostatectomy), and bowel symptoms. 4
• The 12-year cumulative probability of false-positive biopsy increases markedly with shorter testing intervals (twofold for annual vs biennial, threefold for annual vs triennial). 5

Common Pitfalls to Avoid

• Starting screening too late may miss opportunities to identify aggressive cancers when still curable. 1, 2
• Not accounting for race and family history when determining screening initiation age leads to delayed diagnosis in high-risk populations. 1, 2
• Continuing screening beyond age 70 in men with limited life expectancy increases harms without clear benefit. 1, 2
• Using fixed annual screening intervals for all men rather than risk-stratifying based on baseline PSA results in unnecessary testing and false-positives. 3, 1, 2
• Failing to discuss both benefits and harms before initiating screening violates informed consent principles. 2, 4
• Screening men who do not express a preference for screening should be avoided. 4