When should a man start prostate‑specific antigen (PSA) screening and how often should it be repeated, considering average risk and risk factors such as African‑American ethnicity or a family history of prostate cancer?

When to Start PSA Screening

For average-risk men, begin shared decision-making discussions about PSA screening at age 50, but obtain a baseline PSA at age 45 to establish future risk stratification and screening intervals. 1, 2, 3

Risk-Stratified Screening Initiation

The timing of PSA screening depends critically on your risk factors:

Average-Risk Men

• Start screening discussions at age 50 for men with at least 10-15 years life expectancy 1, 2
• However, obtain a baseline PSA at age 45 to establish future risk stratification, as this single measurement powerfully predicts prostate cancer risk for the next 30 years 2, 3, 4
• A baseline PSA above the median at age 40-49 is a stronger predictor of future prostate cancer risk than family history or race 1, 2, 3

High-Risk Men (Start Earlier)

• African American men: Begin at age 45 due to 75% higher incidence rates and more than double the mortality rates compared to non-Hispanic white men 1, 2, 3
• Men with one first-degree relative diagnosed before age 65: Begin at age 45 1, 2, 3
• Men with multiple first-degree relatives diagnosed before age 65: Begin at age 40 1, 2, 3

The rationale for earlier screening in younger men is compelling: PSA testing is more specific in men in their 40s because prostatic enlargement is less likely to confound interpretation 1, 3. Additionally, 44% of prostate cancer deaths occur in men in the highest tenth of PSA distribution at ages 45-49 2, 3.

How Often to Repeat PSA Testing

Screening intervals should be risk-stratified based on your PSA result, not fixed at annual testing for everyone. 1, 2, 3

Interval Algorithm Based on PSA Level

• PSA <1.0 ng/mL: Repeat every 2-4 years 2, 3
• PSA 1.0-2.5 ng/mL: Repeat every 1-2 years 1, 2, 3
• PSA ≥2.5 ng/mL: Screen annually with consideration for further evaluation 1, 2, 3
• PSA ≥4.0 ng/mL: Repeat the test, and if still elevated, proceed to further evaluation including possible biopsy 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% 2, 3. This represents a reasonable balance between benefit and harm.

When to Stop PSA Screening

Discontinue routine PSA screening at age 70 in most men. 2, 3, 6

Age-Based Stopping Algorithm

• Age <70 with life expectancy >10 years: Continue screening 2, 3
• Age 70-74 with PSA <3.0 ng/mL and average health: Stop screening 2
• Age ≥75: Stop screening in all men except those with exceptional health, minimal comorbidity, prior elevated PSA values, and documented >10-15 year life expectancy 2, 3, 6

The evidence supporting cessation at age 70 is strong: men aged 60 with PSA <1 ng/mL have only 0.5% risk of metastases and 0.2% risk of prostate cancer death 2, 3. Men aged 75 or older with PSA <3.0 ng/mL are unlikely to die from prostate cancer (0.2% risk) 2.

Mandatory Shared Decision-Making

PSA screening should never occur without an informed decision-making process. 1, 3, 5

Before any testing, discuss:

• Potential benefits: Approximately 1.3 fewer prostate cancer deaths per 1,000 men screened over 13 years 2, 6
• Potential harms: High false-positive rates (12.9% cumulative risk after 4 tests), unnecessary biopsies (5.5% risk), overdiagnosis, and treatment complications including erectile dysfunction (67% of men after radical prostatectomy) and urinary incontinence (20% of men) 3, 6
• No reduction in all-cause mortality despite reducing prostate cancer-specific mortality 5, 6

Common Pitfalls to Avoid

• Starting screening too late (after age 50) without a baseline PSA misses the opportunity to risk-stratify men in their 40s when PSA is most predictive 1, 2, 3
• Using fixed annual screening for all men rather than risk-stratifying based on PSA results leads to unnecessary testing and false-positives 1, 3
• Continuing screening beyond age 70 in men with limited life expectancy increases harms without clear benefit 2, 3, 6
• Proceeding directly to testing without informed consent violates guideline recommendations and may lead to unwanted downstream consequences 2, 3
• Screening men with <10 years life expectancy provides no benefit and only causes harm 2, 3