Recommended Age for Prostate Exam
For average-risk men, begin shared decision-making discussions about prostate cancer screening at age 50, while African American men and those with a first-degree relative diagnosed before age 65 should start these conversations at age 45. 1
Risk-Stratified Screening Initiation
Average-Risk Men
- Begin screening discussions at age 50 for men with at least 10 years life expectancy 1, 2
- Screening should include PSA testing with or without digital rectal examination (DRE) 1
- The decision to screen must involve informed/shared decision-making about benefits, harms, and uncertainties—screening should never occur without this process 1, 2
High-Risk Men: Start at Age 45
Men at higher risk should begin screening discussions at age 45 and include: 1, 3
- African American men (who have 75% higher incidence rates and more than double the mortality rates compared to non-Hispanic white men) 1
- Men with a first-degree relative (father or brother) diagnosed with prostate cancer before age 65 1, 3
Very High-Risk Men: Start at Age 40
- Men with multiple first-degree relatives diagnosed with prostate cancer before age 65 should begin screening discussions at age 40 1, 3
- Some guidelines recommend 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 3, 4
Screening Methodology and Intervals
Initial Testing
- PSA blood test is the primary screening tool, with or without DRE 1
- DRE is specifically recommended for men with hypogonadism due to reduced PSA sensitivity in this population 1
Follow-Up Intervals Based on PSA Results
The screening interval should be risk-stratified based on initial PSA values: 1
- PSA < 2.5 ng/mL: Screen every 2 years 1
- PSA ≥ 2.5 ng/mL: Screen annually 1
- PSA ≥ 4.0 ng/mL: Consider referral for further evaluation or biopsy 1
When to Stop Screening
- Discontinue screening at age 70 for most men 3, 2, 4
- Continue beyond age 70 only in very healthy men with minimal comorbidity, prior elevated PSA values, and life expectancy >10-15 years 3, 4
- Never screen men with less than 10 years life expectancy, regardless of age, as harms outweigh benefits 1, 5
Critical Context: The Informed Decision-Making Requirement
The evidence supporting PSA screening shows modest benefits with real harms that must be discussed: 1, 5
Potential Benefits
- May prevent approximately 1.3 prostate cancer deaths per 1,000 men screened over 13 years 5
- May prevent approximately 3 cases of metastatic prostate cancer per 1,000 men screened 5
Potential Harms That Must Be Discussed
- Frequent false-positive results requiring additional testing and biopsies 1, 5
- Overdiagnosis and overtreatment of cancers that would never cause symptoms 1, 5
- Treatment complications: About 1 in 5 men develop long-term urinary incontinence after radical prostatectomy, and 2 in 3 experience long-term erectile dysfunction 5
- Biopsy complications including pain, infection, and bleeding 1
Common Pitfalls to Avoid
- Starting screening without informed consent violates guideline recommendations and may lead to unwanted downstream consequences 3, 2
- Not accounting for race and family history when determining screening age misses opportunities to identify aggressive cancers when still curable 3
- Continuing screening beyond age 70 in men with limited life expectancy increases harms without clear benefit 3, 4
- Using fixed annual screening for all men rather than risk-stratifying based on PSA results leads to unnecessary testing 3
- Screening men with less than 10 years life expectancy provides no benefit and only causes harm 3