From the Guidelines
Prostate specific antigen (PSA) levels should be drawn when screening for prostate cancer in men after a thorough discussion of the potential benefits and harms, starting at age 50 for men at average risk, age 45 for men at higher risk, and age 40 for men at appreciably higher risk.
Key Considerations
- The decision to screen for prostate cancer should be made after an informed discussion between the patient and their healthcare provider, taking into account the patient's general health, preferences, and values 1.
- Men at average risk should receive information about prostate cancer screening starting at age 50, while men at higher risk, including African American men and those with a family history of prostate cancer, should receive this information starting at age 45 1.
- For men who choose to be screened, the PSA test is recommended, with or without a digital rectal examination (DRE), and screening intervals can be extended to every 2 years for men with a PSA level less than 2.5 ng/mL 1.
Important Details
- 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 who are at average risk for prostate cancer 1.
- The American Cancer Society guideline for the early detection of prostate cancer emphasizes the importance of informed decision-making and recommends that men who have at least a 10-year life expectancy should have an opportunity to make an informed decision about whether to be screened for prostate cancer 1.
- Asymptomatic men with less than a 10-year life expectancy based on age and health status should not be offered prostate cancer screening 1.
Additional Considerations
- PSA testing is also indicated when monitoring patients with known prostate cancer, evaluating treatment response, and detecting recurrence after treatment 1.
- Additionally, PSA should be measured when evaluating men with symptoms suggestive of prostate disorders such as difficulty urinating, frequent urination, or pelvic pain 1.
- The test is valuable because elevated PSA levels may indicate prostate cancer, though other conditions like benign prostatic hyperplasia, prostatitis, or recent ejaculation can also cause elevations 1.
- PSA testing should be performed before digital rectal examination and patients should avoid ejaculation for 48 hours before testing to prevent false elevations 1.
From the Research
Prostate Specific Antigen Levels
Prostate specific antigen (PSA) levels should be drawn when:
- The PSA level is greater than 4 micrograms/l 2
- Digital rectal examination is suspicious for cancer, even in the absence of abnormal transrectal ultrasonography findings 2
- Considering the combination of PSA and digital rectal examination for early prostate cancer detection 2
Digital Rectal Examination
Digital rectal examination (DRE) may not be a useful screening test for prostate cancer at serum PSA level 3.0-3.9 ng/ml 3
- The cancer detection rate of DRE is lower than that of PSA 4
- DRE may cause a modest increase in total and percentage of free PSA 5
- Performing DRE immediately before PSA measurement might change the clinical decision-making on a significant number of occasions 6
Biopsy Triggers
Biopsy triggers may include:
- PSA level greater than 4 micrograms/l 2
- Increase in PSA level greater than 0.75 ng/ml 6
- PSA density greater than 0.15 6
- Free/total PSA ratio less than 0.18 6
Clinical Decision-Making
Clinical decision-making for prostate cancer screening and diagnosis may be influenced by: