At what age does Prostate-Specific Antigen (PSA) screening typically start?

PSA Screening Initiation Age

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

Risk-Stratified Starting Ages

The timing of PSA screening initiation depends on individual risk factors:

Average-Risk Men

• Start at age 45 for baseline PSA testing according to the National Comprehensive Cancer Network 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, 2

High-Risk Men: Earlier Initiation Required

• African American men: Start at age 45 due to higher incidence and mortality rates 1, 5, 2
• Men with one first-degree relative diagnosed before age 65: Start at age 45 1, 5, 2
• Men with multiple first-degree relatives diagnosed before age 65: Start at age 40 1, 5, 2

Evidence Supporting Earlier Baseline Testing

A compelling rationale exists for obtaining baseline PSA at age 40, even in average-risk men:

• A 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, 2
• A single PSA test before age 50 predicts subsequent prostate cancer up to 30 years later with robust accuracy (AUC 0.72-0.75 for all cancers, 0.75 for advanced cancer) 3, 1, 2, 6
• Early PSA measurement provides a more specific test in younger men because benign prostatic hyperplasia is less likely to confound interpretation 3, 2
• The American Urological Association recommends obtaining a baseline PSA at age 40 to establish future risk stratification 1, 2

Screening Intervals After Initiation

Once screening begins, tailor the frequency based on PSA results rather than using fixed annual testing:

• PSA <1.0 ng/mL: Repeat every 2-4 years 3, 1, 2
• PSA 1.0-2.5 ng/mL: Repeat annually to every 2 years 1, 5, 2
• PSA ≥2.5 ng/mL: Screen annually with consideration for further evaluation 1, 2

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% 1, 2

When to Stop Screening

Discontinue routine PSA screening at age 70 in most men 1, 5, 2

Continue beyond age 70 only in very healthy men with:

• Minimal comorbidity 1, 2
• Prior elevated PSA values 1, 2
• Life expectancy >10-15 years 1, 5, 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 in this group 1, 2

Mandatory Shared Decision-Making

PSA screening should never occur without an informed decision-making process 5, 2

Essential discussion points include:

• Small potential benefit (1.3 deaths prevented per 1,000 men screened) 4
• High false-positive rate requiring additional testing 5, 4
• Overdiagnosis risk (many cancers would never cause symptoms) 5, 4
• Biopsy complications 5
• Treatment harms: 1 in 5 men develop long-term urinary incontinence and 2 in 3 experience long-term erectile dysfunction after radical prostatectomy 4

Pre-Test Preparation

To optimize PSA accuracy:

• Avoid ejaculation for 48 hours before testing 2
• Refrain from vigorous exercise (particularly cycling) for 48 hours 2
• Be aware that 5-alpha reductase inhibitors (finasteride, dutasteride) lower PSA levels by approximately 50% 2

Common Pitfalls to Avoid

• Starting screening too late may miss opportunities to identify aggressive cancers when still curable, particularly in younger men who present with advanced disease 7
• Not accounting for risk factors (race, family history) when determining screening initiation age leads to missed opportunities in high-risk populations 1
• Continuing screening beyond age 70 in men with limited life expectancy increases harms without clear benefit 1, 4
• Using fixed annual screening intervals for all men rather than risk-stratifying based on baseline PSA results leads to unnecessary testing and false-positives 2
• Proceeding directly to testing without informed consent violates guideline recommendations and may lead to unwanted downstream consequences 5