When should PSA‑based prostate cancer screening begin for average‑risk men, for higher‑risk men (African‑American or first‑degree relative diagnosed before age 65), and for very high‑risk men (BRCA1/2 carriers or strong family history)?

When to Start Prostate Cancer Screening

Begin shared decision-making conversations about PSA screening at age 50 for average-risk men, age 45 for African-American men or those with a first-degree relative diagnosed before age 65, and age 40 for men with multiple affected first-degree relatives or BRCA1/2 mutations—all requiring at least 10-15 years life expectancy. 1, 2

Risk-Stratified Screening Initiation

Average-Risk Men

• Start discussions at age 50 for men with at least 10-15 years of life expectancy 1
• Consider obtaining a baseline PSA at age 40-45 to establish future risk stratification, as this single measurement predicts prostate cancer risk up to 30 years later with robust accuracy (AUC 0.72-0.75) 2, 3
• A baseline PSA above the median at age 40 is a stronger predictor of future prostate cancer risk than family history or race alone 2, 3

Higher-Risk Men (African-American or First-Degree Relative Diagnosed Before Age 65)

• Begin screening discussions at age 45 1, 2
• African-American men face 75% higher incidence rates and more than double the mortality compared to non-Hispanic white men 1
• Men with one first-degree relative diagnosed with prostate cancer before age 65 should also start at age 45 1, 2

Very High-Risk Men (Multiple Family Members or BRCA1/2 Carriers)

• Start screening at age 40 for men with multiple first-degree relatives diagnosed before age 65 1, 2
• BRCA1/2 mutation carriers should begin screening at age 40, as they have increased risk of more aggressive prostate cancer 4
• For men starting at age 40 with PSA <1.0 ng/mL, no additional testing is needed until age 45 1

Rationale for Early Baseline Testing

• PSA measurement in men aged 40-49 is more specific for cancer because benign prostatic enlargement is uncommon at this age, reducing false-positive results 2
• Baseline PSA levels in men aged 45-49 strongly predict future prostate cancer death, with 44% of deaths occurring in men in the highest tenth of PSA distribution 2
• Establishing baseline values before age 50 helps identify men with life-threatening prostate cancer when cure is still possible 2

Mandatory Shared Decision-Making Process

PSA screening must never occur without an informed decision-making conversation. 1, 3 This discussion should cover:

• Potential benefits: 25% relative reduction in prostate cancer mortality after 16 years, with approximately 1.3 fewer deaths per 1,000 men screened 2, 3
• Potential harms: High false-positive rates (12.9% cumulative risk after 4 tests), overdiagnosis of indolent cancers, unnecessary biopsies (5.5% risk), and treatment complications affecting urinary, sexual, and bowel function 3, 5
• Uncertainties: No demonstrated effect on overall survival despite reducing cancer-specific mortality 3

Screening Intervals After Initiation

Once screening begins, use risk-stratified intervals based on PSA results rather than uniform annual testing: 2, 3

• 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
• PSA ≥2.5 ng/mL: Screen annually and consider further evaluation 1, 2
• PSA ≥4.0 ng/mL: Repeat the test; if elevation persists, proceed to additional work-up such as biopsy 1, 2

Screening every 2 years reduces advanced prostate cancer diagnosis by 43% compared to every 4 years, while minimizing overdiagnosis 2

When to Stop Screening

• Discontinue routine screening at age 70 in most men 2, 3, 6
• Continue beyond age 70 only in very healthy men with minimal comorbidity, prior elevated PSA values, and documented life expectancy >10-15 years 2, 3, 6
• Men aged 75 or older with PSA <3.0 ng/mL have only 0.2% risk of prostate cancer death and may safely discontinue screening 2, 3
• Men aged 60 with PSA <1.0 ng/mL have only 0.5% risk of metastases and 0.2% risk of death, suggesting screening can safely stop 2, 3

Common Pitfalls to Avoid

• Delaying baseline PSA until after age 50 forfeits the opportunity to risk-stratify men when PSA is most predictive of long-term cancer risk 2
• Applying uniform annual screening to all men regardless of PSA level leads to unnecessary testing, higher false-positive rates, and increased patient anxiety 2, 3
• Proceeding directly to testing without informed consent violates guideline recommendations and may lead to unwanted downstream consequences including overtreatment 2, 5
• Screening men with <10 years life expectancy provides no benefit and only causes harm through unnecessary interventions 2, 3
• Continuing routine screening beyond age 70 without considering health status and prior PSA values increases harms without clear benefit 2, 6
• Not accounting for race and family history when determining screening initiation age may miss opportunities to identify aggressive cancers when still curable 1, 2