At what ages should prostate-specific antigen (PSA) screening be initiated and discontinued for men of average risk versus higher risk (e.g., African‑American or family history)?

PSA Screening Initiation Ages

For average-risk men, begin PSA screening discussions at age 50; for African-American men or those with a first-degree relative diagnosed before age 65, start at age 45; and for men with multiple affected first-degree relatives, begin at age 40. 1

Risk-Stratified Screening Initiation

Average-Risk Men

• Start shared decision-making conversations at age 50 for men with at least 10-15 years life expectancy 1, 2
• The American Urological Association recommends obtaining a baseline PSA at age 40 to establish future risk stratification, even if formal screening discussions begin later 1, 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 1, 2

Higher-Risk Populations

African-American Men:

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

Men with Family History:

• 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

Screening Intervals After Initiation

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

PSA Level	Screening Interval	Action
<1.0 ng/mL	Every 2-4 years [1,2]	Routine monitoring
1.0-2.5 ng/mL	Every 1-2 years [1,2]	Continue surveillance
≥2.5 ng/mL	Annually [1,2]	Consider further evaluation (imaging, urology referral)
≥4.0 ng/mL	Repeat promptly [1]	If persistent elevation, proceed to biopsy

• Biennial screening 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

Discontinue routine PSA screening at age 70 for most men 1, 2, 3

Continue screening beyond age 70 only in men who meet all of the following criteria:

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

Men aged 60 with PSA <1 ng/mL have only 0.5% risk of metastases and 0.2% risk of prostate cancer death, suggesting screening can safely stop in this low-risk group 1

Mandatory Shared Decision-Making

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

Discuss with patients:

• Small absolute mortality benefit (approximately 1.3 fewer deaths per 1,000 men screened over 13 years) 1
• High false-positive rate (12.9% cumulative risk after 4 tests) 2
• Risk of overdiagnosis and overtreatment 1, 2
• Biopsy complications (infection, bleeding, pain) 1
• Treatment-related harms (erectile dysfunction, urinary incontinence, bowel dysfunction) 1

Common Pitfalls to Avoid

• Starting screening too late may miss opportunities to identify aggressive cancers when still curable 1
• Not accounting for race or family history when determining screening initiation age leads to delayed detection in high-risk populations 1
• Using fixed annual screening intervals for all men rather than risk-stratifying based on baseline PSA results increases unnecessary testing and false-positives 1, 2
• Continuing screening beyond age 70 in men with limited life expectancy (<10 years) increases harms without clear benefit 1, 2
• Failing to have informed discussions about benefits and limitations violates all major guideline recommendations 1, 2

Pre-Test Preparation

To optimize PSA accuracy:

• Avoid ejaculation for 48 hours before testing 2, 3
• Refrain from vigorous exercise (particularly cycling) for 48 hours before testing 2, 3
• Be aware that 5-alpha reductase inhibitors (finasteride, dutasteride) lower PSA levels by approximately 50% 2, 3