What are the guidelines for prostate cancer screening in men?

Prostate Cancer Screening Guidelines

For average-risk men, begin shared decision-making discussions about PSA screening at age 50, but initiate these conversations earlier at age 45 for African American men and men with a first-degree relative diagnosed with prostate cancer before age 65, and at age 40 for men with multiple affected first-degree relatives. 1

Age-Based Screening Initiation

The most recent guidelines emphasize risk-stratified approaches to screening initiation:

• Average-risk men: Begin screening discussions at age 50 with at least 10-year life expectancy 1, 2
• African American men: Start discussions at age 45 due to 75% higher incidence rates and more than double the mortality compared to White men 1, 3, 4
• Men with one first-degree relative diagnosed before age 65: Begin at age 45 1, 3, 5
• Men with multiple first-degree relatives diagnosed before age 65: Start at age 40 1, 3, 5

Consider obtaining a baseline PSA at age 40-45 for all men to establish future risk stratification, as baseline PSA above the median at age 40 is a stronger predictor of future prostate cancer risk than family history or race. 3, 5, 6

When to Stop Screening

Discontinue PSA screening at age 70 in most men. 1, 3, 5, 2

Continue screening beyond age 70 only in very healthy men with minimal comorbidity, prior elevated PSA values, and life expectancy greater than 10-15 years. 1, 3, 5 The USPSTF specifically recommends against screening in men 70 years and older because harms outweigh benefits due to increased false-positive results, biopsy complications, and treatment-related adverse effects. 2

Men aged 60 with PSA less than 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. 5

Screening Intervals

After initiating screening, adjust intervals based on PSA levels:

• PSA less than 1.0 ng/mL: Repeat every 2-4 years 5, 6
• PSA 1.0-2.5 ng/mL: Screen annually to every 2 years 1, 5, 6
• PSA 2.5 ng/mL or higher: Screen annually with consideration for further evaluation 1, 5

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%. 5

Mandatory Shared Decision-Making

PSA screening should never occur without an informed decision-making process. 1, 5, 2

The discussion must include:

• Small potential mortality benefit: approximately 1.3 deaths prevented per 1,000 men screened over 13 years 3, 2
• High false-positive rate and psychological distress 1, 3, 2
• Overdiagnosis risk: 37 additional men receive diagnoses for every 1 prostate cancer death prevented 7
• Biopsy complications including infection, bleeding, and pain 1, 3
• Treatment harms: 1 in 5 men develop long-term urinary incontinence and 2 in 3 experience long-term erectile dysfunction after radical prostatectomy 2

Despite guideline recommendations, two-thirds of men report no past discussion with physicians about advantages, disadvantages, or scientific uncertainty regarding screening. 1 Most screening decisions do not meet criteria for shared decision-making because patients receive unbalanced discussions emphasizing benefits (71.4%) over harms (32.0%), have limited knowledge, and are not routinely asked for their preferences. 8

Evidence Supporting Screening

The European Randomized Study of Screening for Prostate Cancer (ERSPC) demonstrated:

• 21% reduction in prostate cancer mortality (29% when adjusted for non-compliance) 3
• 781 men need to be invited for screening and 27 patients need treatment to prevent one death 3
• Relative risk of prostate cancer death of 0.79 (95% CI, 0.68-0.91) after 11 years 7

The Prostate, Lung, Colorectal and Ovarian (PLCO) trial showed no cancer-specific mortality benefit (RR 1.09; 95% CI, 0.87-1.36) after 13 years, though this trial had significant contamination with 52% of control group receiving PSA testing. 7

Pre-Test Preparation

To optimize PSA accuracy:

• Avoid ejaculation for 48 hours before testing 5, 6
• Refrain from vigorous exercise, particularly cycling, for 48 hours 5, 6
• Account for 5-alpha reductase inhibitors (finasteride, dutasteride), which lower PSA levels by approximately 50% 3, 5, 6

Management of Elevated PSA

After a positive PSA test result (greater than 4 ng/mL), repeat the test before proceeding to biopsy. 3, 9

If PSA remains elevated, next steps include:

• Multiparametric MRI before biopsy to improve diagnostic accuracy 3, 9
• Assessment of urine or blood biomarkers 9
• Referral to urology 9
• Consider multiple factors including DRE findings, ethnicity, age, comorbidities, free/total PSA ratio, and previous biopsy history 3

Common Pitfalls to Avoid

• Starting screening too late may miss opportunities to identify aggressive cancers when still curable 3
• Not accounting for risk factors (race, family history) when determining screening initiation age 3
• Continuing screening beyond age 70 in men with limited life expectancy increases harms without clear benefit 3, 2
• Proceeding to biopsy based on a single elevated PSA without confirmation 3
• Failing to have informed discussions about benefits and limitations before initiating screening 1, 5, 8

Guideline Variations

While most guidelines converge on shared decision-making, there are notable differences:

• The US Preventive Services Task Force (2018) recommends providing information for men aged 55-69 years and recommends against screening for men 70 years and older 1, 2
• The Canadian Task Force (2014) recommends against routine screening with weak recommendation for ages 55-69 and strong recommendation against for other ages 1
• The American Cancer Society (2016) emphasizes informed decision-making starting at age 50 for average-risk men, age 45 for high-risk men 1
• The National Comprehensive Cancer Network (2018) recommends offering screening to men aged 45-75 years 1, 5
• The European Association of Urology (2018) recommends screening for men over 50 years (or over 45 for high-risk) with life expectancy 10-15 years 1

Approximately 75% of patients present with localized prostate cancer, which has a 5-year survival rate of nearly 100%, while 10% present with metastatic disease with a 5-year survival rate of 37%. 4