At what age and frequency should a Prostate-Specific Antigen (PSA) test be checked?

When Should a PSA Be Checked?

Begin PSA screening at age 45 for all men with at least 10 years life expectancy, after shared decision-making about benefits and harms. 1, 2

Starting Age for PSA Screening

Average-Risk Men

• Initiate baseline PSA testing at age 45 years for men expected to live at least 10 more years 3, 1, 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
• However, 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 3, 1
• A single PSA test before age 50 predicts subsequent prostate cancer up to 30 years later with robust accuracy (AUC 0.72-0.75) 3, 1

High-Risk Men Requiring Earlier Screening

• African American men should begin at age 45 due to higher incidence and mortality rates 1, 2
• Men with one first-degree relative diagnosed before age 65 should start at age 45 1, 2
• Men with multiple first-degree relatives diagnosed before age 65 should begin at age 40 1, 2
• Baseline PSA above the median at age 40 is a stronger predictor of future prostate cancer risk than family history or race alone 3, 1

Screening Frequency After Initiation

Use risk-stratified intervals based on PSA results rather than fixed annual testing:

• PSA ≥1.0 ng/mL: Repeat every 1-2 years 3, 1, 2
• PSA <1.0 ng/mL: Repeat every 2-4 years 3, 1, 2

The evidence strongly supports this approach: 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% 3, 1. Men with PSA ≤1 ng/mL have very low risk of clinically significant prostate cancer—only 0.5% risk of metastases and 0.2% risk of prostate cancer death—making longer intervals safe 3, 1.

When to Stop PSA Screening

Discontinue routine PSA screening at age 70 in most men. 3, 1, 2

• 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, 2
• The USPSTF recommends against PSA screening in men aged 70 years and older because harms outweigh benefits 1, 4
• Men aged 75 years or older with PSA <3.0 ng/mL are unlikely to die from prostate cancer and may safely discontinue screening 3
• Randomized trials demonstrated mortality benefits only in men up to age 70 1

Mandatory Shared Decision-Making

PSA screening should never occur without an informed decision-making process. 2, 4

Essential discussion points before testing:

• Small potential benefit (1.3 deaths prevented per 1,000 men screened over 13 years) 4
• High false-positive rate requiring additional testing 2, 4
• Risk of overdiagnosis and overtreatment 2, 4
• Biopsy complications 2
• Treatment harms including erectile dysfunction (2 in 3 men), urinary incontinence (1 in 5 men after radical prostatectomy), and bowel symptoms 4

Common Pitfalls to Avoid

• Starting screening too late (after age 50) may miss opportunities to identify aggressive cancers when still curable 1
• Using fixed annual screening intervals for all men leads to unnecessary testing and false-positives—instead, risk-stratify based on baseline PSA results 1
• Continuing screening beyond age 70 in men with limited life expectancy increases harms without clear benefit 1, 4
• Proceeding directly to testing without informed consent violates guideline recommendations and may lead to unwanted downstream consequences 1, 2
• Not accounting for risk factors (race, family history) when determining screening initiation age 1, 2

Pre-Test Preparation

• Avoid ejaculation and vigorous exercise for 48 hours before testing 2
• Be aware that 5-alpha reductase inhibitors lower PSA levels 2