Screening Recommendations for a 40-Year-Old with No Risk Factors
For this 40-year-old patient with no personal or family history of disease, prostate screening is not recommended, and colorectal cancer screening should not yet be initiated.
Prostate Cancer Screening
Do not screen this patient for prostate cancer at age 40. 1, 2
The most recent high-quality evidence from the USPSTF (2018) recommends that PSA-based screening should only be considered for men aged 55-69 years through shared decision-making, and explicitly recommends against screening men 70 years and older. 2
For average-risk men (which includes this patient with no family history), screening discussions should begin at age 50, not 40. 1
The American Urological Association (2013) does recommend obtaining a baseline PSA at age 40, but this is specifically for risk stratification purposes, not for routine screening. 1 However, this recommendation is superseded by more recent USPSTF guidance that does not support routine testing at this age for average-risk individuals. 2
Important Caveats for Prostate Screening
If this patient were African American or had a first-degree relative diagnosed with prostate cancer before age 65, then discussions about screening should begin at age 45. 1
If multiple family members were diagnosed with prostate cancer before age 65, discussions should begin at age 40. 1
The evidence shows that PSA screening may prevent approximately 1.3 deaths per 1,000 men screened over 13 years, but causes significant harms including false positives, overdiagnosis, and treatment complications (1 in 5 men develop urinary incontinence, 2 in 3 develop erectile dysfunction after radical prostatectomy). 2
Colorectal Cancer Screening
Do not initiate colorectal cancer screening at age 40 for this average-risk patient. 1
The most recent USPSTF guidelines (2021) recommend starting colorectal cancer screening at age 45 years for average-risk adults (B recommendation), with the strongest recommendation for ages 50-75 years (A recommendation). 1
This represents a change from older guidelines that recommended starting at age 50, reflecting the nearly 15% increase in colorectal cancer incidence among adults aged 40-49 years from 2000-2016. 1
Multiple screening options are acceptable once screening begins, including: 1
- Annual high-sensitivity fecal occult blood testing or fecal immunochemical testing
- Flexible sigmoidoscopy every 5 years
- Colonoscopy every 10 years
- CT colonography every 5 years
When to Start Earlier Than Age 45
This patient should begin screening before age 45 only if: 1, 3
- One first-degree relative was diagnosed with colorectal cancer before age 60, OR
- Two or more first-degree relatives were diagnosed at any age
In these higher-risk scenarios, screening should begin at age 40 or 10 years before the youngest affected relative's diagnosis age (whichever comes first), using colonoscopy every 5 years. 1, 3
Clinical Pitfall to Avoid
The evidence demonstrates that in practice, men are screened more frequently for prostate cancer (where benefit is uncertain) than for colorectal cancer (where mortality benefit is proven). 4 Among men aged 50-69,54% reported up-to-date PSA screening versus only 45% for colorectal cancer screening, despite colorectal cancer screening having established mortality reduction. 4 Ensure this patient understands that when he reaches age 45, colorectal cancer screening should be the priority, not prostate cancer screening.