When to Stop PSA Screening for Prostate Cancer
PSA screening should be discontinued at age 70 years for most men, and absolutely stopped at age 75 years, with the critical exception that screening should only occur in men with at least a 10-year life expectancy regardless of age. 1, 2
Primary Age-Based Stopping Points
Stop at age 70 years for the majority of men, as this represents the upper age limit where benefits have been demonstrated in major randomized controlled trials (ERSPC, PLCO, Göteborg). 1, 2
- The USPSTF explicitly recommends against PSA screening in men 70 years and older (Grade D recommendation), meaning the harms outweigh benefits. 2, 3
- The American College of Physicians and multiple other guidelines recommend against screening in men ≥70 years. 2
- Screening beyond age 70 substantially increases overdiagnosis rates while providing minimal mortality benefit. 1, 2
Life Expectancy Threshold (Overrides Age)
The 10-year life expectancy rule supersedes chronological age - if a man has less than 10 years of estimated life expectancy, PSA screening should not be performed regardless of his actual age. 1, 4
- Men with significant comorbidities face all the harms of screening (false positives, unnecessary biopsies, overtreatment complications) without realistic benefit from early detection. 2, 5
- Physicians often overvalue age and undervalue comorbidity when estimating life expectancy - use validated tools like life insurance tables or Charlson comorbidity scores. 1
Age 70-75: Highly Selective Continuation Only
For men aged 70-74 years, screening may be individualized but should be approached with extreme caution (Category 2B recommendation reflecting non-uniform consensus). 1, 2
Criteria for considering continuation in this age group:
- Excellent health with minimal to no comorbidities 1
- Strong patient preference after informed discussion 1
- Consider increasing the PSA threshold for biopsy (rather than the standard 4.0 ng/mL cutoff) to reduce overdiagnosis while maintaining detection of clinically significant cancers 1, 2
A microsimulation model demonstrated that decreasing the stopping age from 74 to 69 years would reduce lives saved by 27% but decrease overdiagnosis by nearly 50%, highlighting the trade-off in this age range. 1, 2
Age 75+: PSA Level-Based Discontinuation Strategy
For men 75-80 years old with PSA <3.0 ng/mL, screening can be safely discontinued as they are extremely unlikely to die from prostate cancer. 1, 2
- In the Baltimore Longitudinal Study of Aging, zero men aged 75-80 years with PSA <3.0 ng/mL died of prostate cancer. 1, 2
- The time to death or diagnosis of aggressive prostate cancer was significantly longer in men with PSA <3.0 ng/mL versus >3.0 ng/mL. 1
- Men with PSA below median (<1 ng/mL) at age 60 have only 0.5% risk of metastases and 0.2% risk of prostate cancer death. 1, 2
Very few men older than 75 years benefit from PSA testing under any circumstances. 1, 2
Key Harms of Continued Screening in Elderly Men
The balance shifts decisively toward harm in older populations:
- Overdiagnosis is particularly problematic - many elderly men harbor indolent cancers that would never affect their life expectancy. 1, 2, 3
- Treatment complications (erectile dysfunction in 2/3 of men, urinary incontinence in 1/5 after radical prostatectomy) have greater impact on quality of life in older men. 3
- False-positive rates increase with age, leading to unnecessary anxiety and invasive biopsies. 2, 3
- Older men have increased risk of complications from prostate biopsies. 2
Common Pitfalls to Avoid
Do not continue screening based solely on "good health for age" - actual life expectancy calculation is essential. 1, 5
Avoid the trap of "one more test" - studies show PSA screening rates among men in worst health (Charlson score ≥4) aged 85+ were nearly identical to those in best health (36% vs 34%), representing inappropriate screening. 5
Do not screen men who have not expressed a preference for screening after informed discussion of harms and benefits. 3