At what age should Prostate-Specific Antigen (PSA) testing be stopped in men?

When to Stop PSA Screening in Men

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

Age-Based Stopping Points

Standard Stopping Age: 70 Years

• The US Preventive Services Task Force explicitly recommends against PSA screening in men 70 years and older (Grade D recommendation). 2
• The American College of Physicians similarly recommends against screening at age ≥70 years. 1, 2
• Major randomized controlled trials demonstrate screening benefits only in men up to age 70. 2
• The NCCN recommends that PSA testing after age 70 should be individualized and performed with caution, only in very healthy men with little or no comorbidity. 3

Absolute Stopping Age: 75 Years

• The NCCN panel agrees that very few men older than 75 years benefit from PSA testing. 3, 2
• Memorial Sloan Kettering Cancer Center recommends PSA testing should end at age 75 for all men. 4

PSA Level-Based Stopping Strategies

Early Discontinuation Based on Low PSA

• 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, 1, 2
• In the Baltimore Longitudinal Study of Aging, no men aged 75-80 years with PSA <3.0 ng/mL died of prostate cancer. 3, 2
• 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. 1
• PSA testing should end at age 60 for men with PSA ≤1 ng/mL. 4

Age 70-74 Special Considerations

• For men aged 70-74 years who are very healthy with minimal comorbidities, consider increasing the PSA threshold for biopsy (rather than routine screening) to reduce overdiagnosis. 3, 2
• Continue screening beyond age 70 only in very healthy men with minimal comorbidity, prior elevated PSA values, and life expectancy >10-15 years. 1, 2

Life Expectancy Requirement

PSA screening should only be offered to men with a life expectancy of at least 10 years, regardless of chronological age. 1, 2

• Men with significant comorbidities and reduced life expectancy are unlikely to benefit from PSA screening but still face all potential harms. 2
• The NCCN uniformly discourages PSA testing in men unlikely to benefit from prostate cancer diagnosis based on age and/or comorbidity. 3

Rationale for Stopping

Harms Outweigh Benefits in Older Men

• Overdiagnosis is particularly problematic in older men, as many harbor cancers that would never affect their life expectancy. 2
• Routine screening in men over 70 substantially increases rates of overdetection without corresponding mortality benefit. 3, 2
• Approximately 33% of older men with high likelihood of 9-year mortality continue to be screened despite minimal clinical benefit. 5

Balancing Mortality Reduction vs. Overdiagnosis

• A microsimulation model showed that decreasing the screening stopping age from 74 to 69 years would lead to a 27% reduction in lives saved but an almost 50% reduction in overdiagnosis. 2
• The goal of refined testing beyond age 70 should be to maximize reduction in overdiagnosis while minimizing impact on cancer-specific mortality. 2

Common Pitfalls to Avoid

• Continuing routine screening beyond age 70 without considering health status and prior PSA values leads to substantial overdiagnosis. 1, 2
• Screening men with <10 years life expectancy provides no benefit and only causes harm. 1
• Up to a third of men older than 75 years undergo PSA testing despite an average life expectancy of less than 10 years. 6
• Failing to discuss both benefits and harms before continuing screening in older men. 1