From the Guidelines
Prostate-specific antigen (PSA) screening should begin at age 50 for men at average risk, but may start as early as age 45 for those at higher risk, including African American men and those with a family history of prostate cancer, as recommended by the American Cancer Society guidelines published in 2010 and reviewed in 2018 1.
Key Considerations for PSA Screening
- Men at average risk should receive information about the benefits, risks, and uncertainties associated with prostate cancer screening starting at age 50 years.
- Men at higher risk, including African American men and men with a family member (father or brother) diagnosed with prostate cancer before age 65 years, should receive this information beginning at age 45 years.
- Men at appreciably higher risk (multiple family members diagnosed with prostate cancer before age 65 years) should receive this information beginning at age 40 years.
Screening Recommendations
- Screening is recommended with a PSA test, with or without DRE (DRE is recommended along with PSA for men with hypogonadism, because of reduced sensitivity of PSA) 1.
- For men who choose to be screened for prostate cancer after a process of shared or informed decision making, screening intervals can be extended to every 2 years for men with PSA levels less than 2.5 ng/mL, and screening should be conducted yearly for men with PSA levels of 2.5 ng/mL or higher 1.
Individualized Risk Assessment
- A PSA level of 4.0 ng/mL or higher has historically been used to recommend referral for further evaluation or biopsy, which remains a reasonable approach for men at average risk for prostate cancer 1.
- For PSA levels between 2.5 and 4.0 ng/mL, health care providers should consider an individualized risk assessment that incorporates other risk factors for prostate cancer, particularly for high-grade cancer, which may be used for a referral recommendation 1.
From the Research
Age for Monitoring Prostate Specific Antigen
The age at which to start monitoring prostate specific antigen (PSA) levels is a topic of debate among medical professionals.
- For 'average-risk' men, the recommended age for PSA screening varies from 50-55 to 70 years, considering life expectancy and other factors 2.
- Some studies suggest that men at average risk of prostate cancer should discuss the pros and cons of PSA screening with their clinicians, starting at age 55-69 years 3.
- For high-risk men, such as those of African descent or with a family history of prostate cancer, the earliest age for screening is 40 years, although recommendations often defer to clinical judgement 2.
- Other studies have investigated the effectiveness of PSA testing in men over 50 years of age, with some finding that the combination of PSA and digital rectal examination (DRE) can improve the stage of diagnosis of patients with prostate cancer 4.
Screening Guidelines
- Population-based PSA testing of asymptomatic men is not widely recommended, and guidelines emphasize shared patient-clinician decision making 2.
- Screening intervals, when specified, are biennial, annual, or determined from baseline PSA 2.
- The development of clinical decision aids and international consensus on guidelines may help reduce national and international variation on how men are counselled about PSA screening 2.
Evidence and Recommendations
- Available evidence favors clinician discussion of the pros and cons of PSA screening with average-risk men aged 55 to 69 years, with only men who express a definite preference for screening undergoing PSA testing 3.
- Other strategies to mitigate the potential harms of screening include considering biennial screening, a higher PSA threshold for biopsy, and conservative therapy for men receiving a new diagnosis of prostate cancer 3.
- Men should decide for themselves whether to be tested, based on their own values, and support men's autonomy to make their own decisions 5.