At what ages should PSA (prostate‑specific antigen) screening for prostate cancer be started and stopped in men, including recommendations for average‑risk and higher‑risk individuals?

PSA Screening Age Recommendations

For average-risk men, begin shared decision-making about PSA screening at age 50, but start earlier at age 45 for African American men or those with a first-degree relative diagnosed before age 65, and at age 40 for men with multiple affected first-degree relatives; discontinue routine screening at age 70 unless the patient is exceptionally healthy with minimal comorbidity and life expectancy exceeding 10-15 years. 1, 2

Starting Ages by Risk Category

Average-Risk Men

• Initiate screening discussions 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 1, 3
• Starting at ages 50-54 can reduce prostate cancer mortality with a number needed to invite of 176 and number needed to diagnose of 16 to prevent one death at 17 years 4

High-Risk Populations

African American men:

• Begin screening at age 45 due to 75-80% higher incidence and more than double the mortality compared to non-Hispanic White men 1, 2

Family history considerations:

• One first-degree relative diagnosed before age 65: start at age 45 1, 2
• Multiple first-degree relatives diagnosed before age 65: start at age 40 1, 2

Baseline PSA Strategy

• Consider obtaining a baseline PSA at age 40 for all men to establish future risk stratification, as baseline PSA above the median is a stronger predictor of future prostate cancer risk than family history or race alone 1
• Men with baseline PSA <1.0 ng/mL at age 40 require no further testing until age 45 1

Screening Intervals After Initiation

Use risk-stratified intervals based on PSA results rather than fixed annual testing 1:

PSA Level	Screening Interval	Additional Actions
<1.0 ng/mL	Every 2-4 years [1]	Continue routine monitoring
1.0-2.5 ng/mL	Every 1-2 years [1,2]	Annual DRE recommended
≥2.5 ng/mL	Annually [1,2]	Consider further evaluation (imaging, referral)
≥4.0 ng/mL	Repeat promptly [1]	If persistent elevation, proceed to biopsy

• 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% 1

When to Stop Screening

Age 70 is the recommended stopping point for most men 1, 2, 3:

• Randomized trials demonstrated mortality benefits only in men up to age 70 1
• The USPSTF recommends against PSA screening in men aged 70 years and older 1, 3

Continue screening beyond age 70 only if ALL of the following apply:

• Exceptionally healthy with minimal comorbidity 1, 2
• Prior elevated PSA values 1
• Life expectancy >10-15 years 1, 2

Additional stopping criteria:

• Men aged 60 with PSA <1 ng/mL have only 0.5% risk of metastases and 0.2% risk of prostate cancer death—screening can safely stop in this group 1
• Men aged 75 or older with PSA <3.0 ng/mL are unlikely to die from prostate cancer and may safely discontinue screening 1

Mandatory Shared Decision-Making

PSA screening must never occur without an informed decision-making conversation 1, 2, 3:

Benefits to discuss:

• Approximately 1.3 fewer prostate cancer deaths per 1,000 men screened over 13 years (modest absolute benefit) 1, 3
• 21-25% relative reduction in prostate cancer mortality 2, 3
• Prevention of approximately 3 cases of metastatic disease per 1,000 men screened 3

Harms to discuss:

• High false-positive rate leading to unnecessary biopsies 1, 2
• Overdiagnosis: approximately 48 men need treatment to save one life 1
• Treatment complications: 1 in 5 men develop long-term urinary incontinence after radical prostatectomy, and 2 in 3 experience long-term erectile dysfunction 3
• Biopsy risks: pain, infection, and bleeding 2

Common Pitfalls to Avoid

• Starting screening too late (after age 55) may miss opportunities to identify aggressive cancers when still curable 1
• Not accounting for risk factors (race, family history) when determining screening initiation age 1
• Using fixed annual screening intervals for all men rather than risk-stratifying based on baseline PSA results leads to unnecessary testing and false-positives 1
• Continuing screening beyond age 70 in men with limited life expectancy increases harms without clear benefit 1, 3
• Proceeding directly to testing without informed consent violates guideline recommendations and may lead to unwanted downstream consequences 1
• Never screen men with <10 years life expectancy regardless of age, as the mortality benefit requires more than a decade to manifest 1, 2