At what point can Prostate-Specific Antigen (PSA) checks be stopped?

When to Stop PSA Screening

Stop routine PSA screening at age 70 in most men, as the harms outweigh benefits beyond this age. 1, 2

Primary Age-Based Stopping Point

• The USPSTF explicitly recommends against PSA-based screening in men 70 years and older (Grade D recommendation), reflecting moderate certainty that potential benefits do not outweigh expected harms. 2

• Multiple major guidelines including the American College of Physicians align with this age 70 cutoff for routine screening discontinuation. 1

• The strongest randomized trial evidence (ERSPC, PLCO, Göteborg) demonstrated mortality benefits only in men screened up to age 70, with no proven benefit beyond this age. 3, 1

Life Expectancy as the Critical Determinant

PSA screening should only continue in men with at least 10 years of remaining life expectancy, regardless of chronological age. 3, 1

• Men with significant comorbidities and reduced life expectancy face all the harms of screening (false positives, overdiagnosis, treatment complications) without mortality benefit. 3

• Physicians often overvalue age and undervalue comorbidity when estimating life expectancy—use validated life tables rather than age alone. 3

Special Considerations for Ages 70-75

For very healthy men aged 70-74 with minimal comorbidities and life expectancy >10-15 years, screening may be continued only if they have prior elevated PSA values warranting surveillance. 3, 1

• A microsimulation model showed that stopping screening at age 69 versus 74 reduces lives saved by 27% but decreases overdiagnosis by nearly 50%. 3

• This reflects that most cancers detected after age 70 would never affect life expectancy. 3, 1

PSA Level-Based Stopping Strategy

Men aged 75 or older with PSA <3.0 ng/mL can safely discontinue screening, as they are unlikely to die from prostate cancer. 1

• In the Baltimore Longitudinal Study of Aging, no men aged 75-80 with PSA <3.0 ng/mL died of prostate cancer. 1

• Men aged 60 with PSA <1.0 ng/mL have only 0.5% risk of metastases and 0.2% risk of prostate cancer death by age 85, supporting extended intervals or discontinuation. 3, 1

• In the PLCO trial, no men aged ≥65 with PSA ≤0.5 ng/mL died from prostate cancer within 15 years. 4

Why Harms Increase with Age

Overdiagnosis becomes the dominant outcome in elderly men, as most detected cancers will never cause symptoms or death. 3, 1

• Older men have increased risk of false-positive results requiring additional biopsies. 3, 2

• Treatment complications (incontinence, erectile dysfunction, bowel symptoms) are more severe and less well-tolerated in elderly men. 2

• About 1 in 5 men undergoing radical prostatectomy develop long-term urinary incontinence, and 2 in 3 experience long-term erectile dysfunction—burdens that disproportionately affect quality of life in older men. 2

Common Pitfalls to Avoid

• Do not continue screening based solely on patient requests without discussing the evidence that harms exceed benefits after age 70. 2

• Avoid screening men with <10 years life expectancy—this provides no benefit and only causes harm. 3, 1

• Do not assume all "healthy" 75-year-olds benefit from screening; even without comorbidities, overdiagnosis rates are unacceptably high. 3, 1

Practical Algorithm for Stopping PSA Screening

1. Age ≥70 with average health or comorbidities → Stop screening 1, 2

2. Age 70-74, excellent health, minimal comorbidities, prior elevated PSA → Consider individualized continuation with shared decision-making 3, 1

3. Age ≥75 with PSA <3.0 ng/mL → Stop screening regardless of health status 1

4. Any age with life expectancy <10 years → Stop screening 3, 1

5. Age ≥65 with PSA ≤0.5 ng/mL → Consider stopping screening 4