When should prostate‑specific antigen (PSA) testing be started and how often repeated in average‑risk men versus higher‑risk men (e.g., African‑American or with a first‑degree relative with prostate cancer)?

When to Start PSA Testing

Men at average risk should begin shared decision-making about PSA screening at age 50, African American men and those with a first-degree relative diagnosed before age 65 should start at age 45, and men with multiple affected first-degree relatives should begin at age 40—all requiring at least 10 years of life expectancy. 1

Risk-Stratified Screening Initiation

Average-Risk Men

• Begin informed discussions about PSA testing at age 50 for men with at least 10-15 years of life expectancy 1, 2
• The strongest randomized trial evidence (ERSPC) supports screening starting at age 55, showing approximately 1.3 fewer prostate cancer deaths per 1,000 men screened over 13 years 2, 3
• Obtaining a baseline PSA at age 40-45 enables future risk stratification, as a single PSA measurement before age 50 predicts prostate cancer risk up to 30 years later with robust accuracy (AUC 0.72-0.75) 2, 4

African American Men

• Start screening discussions at age 45 due to 75% higher incidence and more than double the mortality compared to non-Hispanic White men 1, 2, 5
• This population experiences significantly elevated risk that justifies earlier detection efforts 6

Men with Family History

• One first-degree relative diagnosed before age 65: Begin screening at age 45 1, 2
• Multiple first-degree relatives diagnosed before age 65: Begin screening at age 40 1, 2
• If PSA is <1.0 ng/mL at age 40, no additional testing is needed until age 45 1, 2
• Baseline PSA above the median at age 40 is a stronger predictor of future prostate cancer risk than family history or race alone 2

Screening Intervals After Initiation

The frequency of repeat testing should be risk-stratified based on PSA results, not fixed annual intervals:

• PSA <1.0 ng/mL: Repeat every 2-4 years 2, 5
• 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 biopsy or additional work-up 1, 2

Biennial screening (every 2 years) reduces advanced prostate cancer diagnosis by 43% compared to every 4 years, while reducing total tests by 59% and false-positives by 50% compared to annual screening 2

When to Stop PSA Screening

• Discontinue routine screening at age 70 in most men 1, 2, 5
• Continue beyond age 70 only in very healthy men with minimal comorbidity, prior elevated PSA values, and documented life expectancy >10-15 years 1, 2, 5
• Men aged 75 or older with PSA <3.0 ng/mL are unlikely to die from prostate cancer (0.2% risk) and may safely discontinue screening 2
• Men aged 60 with PSA <1.0 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 2
• Never screen men with <10 years life expectancy, regardless of age, as the mortality benefit requires more than a decade to accrue 1, 5, 6

Mandatory Shared Decision-Making

PSA screening must never occur without an informed decision-making conversation covering benefits, harms, and uncertainties 1, 2, 5. This is not optional—it is a core requirement of all major guidelines.

Key Points to Discuss:

• Small absolute mortality benefit (approximately 1 fewer death per 1,000 men screened over 10-13 years) 6, 3
• High false-positive rate leading to unnecessary biopsies 1, 5
• Substantial overdiagnosis risk: 37 additional men need diagnosis through screening for every 1 prostate cancer death prevented 3
• Biopsy complications (infection, bleeding) 1
• Treatment harms including erectile dysfunction and urinary incontinence 1, 5

Rationale for Early Baseline PSA

• PSA measurement in men aged 40-49 is more specific for cancer because benign prostatic enlargement is uncommon at this age 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 identifies men with life-threatening prostate cancer at a time when cure is still possible 2

Common Pitfalls to Avoid

• Delaying baseline PSA until after age 50 forfeits the opportunity to risk-stratify men when PSA is most predictive 2
• Applying uniform annual screening to all men regardless of PSA level leads to unnecessary testing and higher false-positive rates 2
• Starting screening too late may miss opportunities to identify aggressive cancers when still curable 2
• Not accounting for risk factors (race, family history) when determining screening initiation age 2
• Continuing screening beyond age 70 in men with limited life expectancy increases harms without clear benefit 1, 2
• Proceeding directly to testing without informed consent violates guideline recommendations and may lead to unwanted downstream consequences 5

Testing Methodology

• The PSA blood test is the primary screening tool 1, 5
• Digital rectal examination (DRE) may be performed in conjunction with PSA, particularly for men with hypogonadism where PSA sensitivity is reduced 1, 5
• Pre-test preparation: avoid ejaculation and vigorous exercise for 48 hours before testing 5
• Be aware that 5-alpha reductase inhibitors (finasteride, dutasteride) lower PSA levels by approximately 50% 5