At what age is a Prostate-Specific Antigen (PSA) blood test recommended for men?

PSA Screening Age Recommendations

For average-risk men, begin PSA screening discussions at age 50, but initiate testing at age 45 for African American men and those with a first-degree relative diagnosed with prostate cancer before age 65. 1, 2

Risk-Stratified Screening Initiation

Average-Risk Men

• Start screening at age 50 for men with at least 10 years life expectancy 1, 2
• The strongest randomized trial evidence (ERSPC) supports testing starting at age 55, showing approximately 1.3 fewer prostate cancer deaths per 1,000 men screened over 13 years 3, 4
• However, NCCN guidelines recommend starting at age 45 for all men to capture aggressive cancers earlier 1, 2

High-Risk Men

• African American men should begin at age 45 due to increased prostate cancer risk 1, 2
• Men with one first-degree relative diagnosed before age 65 should start at age 45 1, 2
• Men with multiple first-degree relatives diagnosed before age 65 should begin at age 40 2

Baseline PSA Strategy

• Consider obtaining a baseline PSA at age 40 for all men to establish future risk stratification, as baseline PSA above the median is a stronger predictor of future prostate cancer risk than family history or race alone 2
• A single PSA test before age 50 predicts subsequent prostate cancer up to 30 years later with robust accuracy 2

Screening Components

What to Test

• PSA blood test is the primary screening tool 1
• Digital rectal examination (DRE) should be performed alongside PSA, as it may identify high-risk cancers even when PSA values appear "normal" 1, 2
• DRE should not be used as a stand-alone test 1

Screening Intervals After Initiation

• For PSA ≥1.0 ng/mL: repeat every 1-2 years 1, 2
• For PSA <1.0 ng/mL: repeat every 2-4 years 2
• Men with PSA 1-2.5 ng/mL should undergo annual testing 2
• Men with PSA ≥2.5 ng/mL should undergo further evaluation with biopsy 2

When to Stop Screening

Age 70 and Beyond

• Discontinue routine PSA screening at age 70 in most men 1, 2, 3
• 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
• The USPSTF recommends against PSA screening in men aged 70 years and older, as potential benefits do not outweigh expected harms 3

Risk-Based Discontinuation

• Men aged 60 with PSA <1.0 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 2
• Men aged 75 years or older with PSA <3.0 ng/mL are unlikely to die from prostate cancer and may safely discontinue screening 2

Shared Decision-Making Requirements

Before any PSA testing, engage in informed discussion about both benefits and harms 1, 2, 3

Benefits to Discuss

• Reduced risk of advanced disease and prostate cancer mortality 5
• Screening every 2 years reduces advanced prostate cancer diagnosis by 43% compared to every 4 years 2
• May prevent approximately 3 cases of metastatic prostate cancer per 1,000 men screened 3

Harms to Discuss

• False-positive results requiring additional testing and possible prostate biopsy 3
• Overdiagnosis and overtreatment of indolent cancers 3
• Treatment complications: approximately 1 in 5 men who undergo radical prostatectomy develop long-term urinary incontinence, and 2 in 3 men experience long-term erectile dysfunction 3
• Bowel symptoms from treatment 3

Common Pitfalls to Avoid

• Starting screening too late may miss opportunities to identify aggressive cancers when still curable 2
• Not accounting for race and family history when determining screening initiation age leads to missed early detection in high-risk populations 2
• Continuing screening beyond age 70 in men with limited life expectancy increases harms without clear benefit, as evidenced by data showing PSA screening is most common in men aged 70 or older despite recommendations against it 6, 7
• Failing to discuss both benefits AND harms before testing—studies show most discussions focus only on benefits, not both 6
• 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 2