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If <40 yo, life expectancy ≥10y
Don’t screen for prostate CA - Screening not recommended by ACP.1
- AAFP,2 USPSTF,3 and the BMJ Rapid Recs team4 don’t recommend PSA screening in asymptomatic pts.
- NCI says inadequate evidence for benefit and solid evidence of harms (over-dx, over-tx, urinary and erectile dysfxn due to tx).5
Footnotes 1 ACP 2013. Qaseem A, et al. Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2013 May 21;158(10):761-769. Full-text article
2 AAFP 2022 [C]. Clinical Preventive Service Recommendation: Prostate Cancer. American Academy of Family Physicians. Accessed January 6, 2022
3 USPSTF 2018. There are limited data on the benefit of screening younger pts (<50 yo).
Final Recommendation Statement: Prostate Cancer: Screening. U.S. Preventive Services Task Force. Updated May 8, 2018. Accessed September 4, 2018
4 Tikkinen KAO, et al. Prostate cancer screening with prostate-specific antigen (PSA) test: a clinical practice guideline. BMJ. 2018 Sep 5:362:k3581. Free, full-text article at PubMed® Central
5 NCI 2024. Prostate Cancer Screening (PDQ®)–Health Professional Version. National Cancer Institute. Updated March 7, 2024. Accessed July 19, 2024
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If 40-49 yo, life expectancy ≥10y
If average risk, screening not recommended for most;1-6 inadequate evidence for benefit and solid evidence of harms (over-dx, over-tx, urinary and erectile dysfxn due to tx).7 AAFP3 and USPSTF4 don’t recommend PSA screening. NCCN says start risk/benefit discussion, check baseline PSA, and consider DRE at 45 yo.8 AUA says may begin offering screening and baseline PSA at 45 yo [CR][AUA-B].2 If high risk, guidance varies. Per ACS, discuss possible benefits, risks, and uncertainties of screening.1 Black pts—who are more likely to be diagnosed at a younger age, w/ more-aggressive dz, and are >2x as likely to die of prostate CA—should engage in shared decision-making w/ clinicians, but benefits of screening generally outweigh risks.9 If pt desires screen, use PSA8-10 (may include DRE;7-9 do not screen w/ DRE alone8). AUA and NCCN say begin screening at 40-45 yo [SR][AUA-B];2,8 PCF says baseline PSA should be done at 40-45 yo for Black pts who choose screening.9 Per ASCO and ACP, no evidence that higher-prevalence groups have different degrees of benefit/risk or better outcomes w/ PSA screening vs. general population.11,12 High risk if: - Age >50 yo; ~6/10 prostate CAs are found in pts >65 yo.13
- African American; Caribbean of African ancestry8,9,13
- FHx of prostate CA, esp. sibling.13 Even higher risk if ≥2 first-deg relatives w/ prostate CA before age 65.5
- Known gene variants/mutations: BRCA1/BRCA2, CHEK2, ATM, PALB2, Lynch syndrome (HNPCC), HOXB13; refer to genetics specialist.8,13
- Agent orange exposure8
Less certain risk factors:13 - Diet high in dairy, animal fats7
- Arsenic exposure13
- Firefighter chemical exposure13
- EtOH use7
- Conflicting evidence: prostatitis, STIs, vasectomy.13
- Other possible dietary factors:7 selenium, vitamin E, vitamin D, lycopene, and isoflavones.
Main benefit of screening is detecting CA at earlier stage, when it may be easier to treat. Risks/cons to screening include:14 - False-positive or false-negative PSA results14
- Over-dx. Many prostate CAs grow so slowly that they won’t cause problems during pt’s lifetime.14
- Over-tx. Tx has many negative side effects7,14 (urinary incontinence, bowel, erectile dysfxn) that ↓ QOL.
- Tests can cause anxiety; risks of pain, infxn, bleeding; time, cost assoc w/ dx of inconsequential dz.7,14
- Unclear mortality benefit7
- Misdirection of research focus and resources7
If proceeding w/ decision to screen, base timing on baseline risk: - If higher risk (i.e., ≥1 first-deg relative w/ early-age prostate CA;1 Black w/ strong FHx or who carries high-risk genetic variant9), begin screening at 40 yo.1,9
- If high risk, begin screening at 45 yo.1,11
- Screen at 40-45 yo if Black ancestry, germline mutations, FHx [SR][AUA-B].2,8,9
Factors that might raise PSA levels:10 older age, BPH, prostatitis, ejaculation, bike riding, urological procedures, meds (testosterone or meds that raise testosterone levels). Factors that might lower PSA levels:8,10 meds (5α-reductase inhibitors), herbal mixtures/dietary supplements (but not saw palmetto), aspirin, statins, thiazides. DRE has no effect on PSA levels.7 Rescreen interval or d/c of screening based on pt preference, age, PSA, prostate CA risk, life expectancy, and general health, following shared decision-making [CR][AUA-B].2 - Per ACP, no evidence that screening more often than q4y offers additional benefit.11
- Per ACS, if PSA <2.5 ng/mL, retest q2y; if ≥2.5 ng/mL, retest q1y.1
- Per NCCN, if average risk w/ PSA <1 ng/mL, retest q2-4y.8
- Per NCCN, if normal DRE and high risk w/ PSA ≤3, or average risk w/ PSA 1-3 ng/mL, retest q1-2y.8
- Consider annual screening for Black pts, depending on PSA value and health status, and esp. for those w/ strong FHx or who carry high-risk genetic variant.9
- If very suspicious DRE and/or PSA ≥3 ng/mL, bx indicated.8 Validated risk calculators may be used to inform shared decision-making process for prostate bx [CR][AUA-B].2
Follow same guidance in transgender women, regardless of hormone tx or gender-affirming surgery;15,16 if digital exam indicated, neovaginal approach may be more effective than rectal.16
Footnotes 1 ACS 2023. American Cancer Society Recommendations for Prostate Cancer Early Detection. American Cancer Society. Updated November 22, 2023. Accessed July 17, 2024
2 AUA 2023. Wei JT, et al. Early Detection of Prostate Cancer: AUA/SUO Guideline Part I: Prostate Cancer Screening. J Urol. 2023 Jul;210(1):46-53. Full-text article
3 AAFP 2022 [C]. Clinical Preventive Service Recommendation: Prostate Cancer. American Academy of Family Physicians. Accessed January 6, 2022
4 USPSTF 2018. There are limited data on the benefit of screening younger pts (<50 yo).
Final Recommendation Statement: Prostate Cancer: Screening. U.S. Preventive Services Task Force. Updated May 8, 2018. Accessed September 4, 2018
5 ACP 2015. Wilt TJ, et al. Screening for cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2015 May 19;162(10):718-25. Full-text article
6 Tikkinen KAO, et al. Prostate cancer screening with prostate-specific antigen (PSA) test: a clinical practice guideline. BMJ. 2018 Sep 5:362:k3581. Free, full-text article at PubMed® Central
7 NCI 2024. Prostate Cancer Screening (PDQ®)–Health Professional Version. National Cancer Institute. Updated March 7, 2024. Accessed July 19, 2024
8 NCCN 2024 [2A]. Prostate Cancer Early Detection (Version 2.2024). National Comprehensive Cancer Network. March 6, 2024. Accessed July 23, 2024
9 PCF 2024. Prostate Cancer Foundation Highlights Evidence-Based Prostate Cancer Screening Guidelines for Black Men. Prostate Cancer Foundation. June 18, 2024. Accessed August 20, 2024
10 ACS 2023. Screening Tests for Prostate Cancer. American Cancer Society. Updated November 22, 2023. Accessed July 17, 2024
11 ACP 2013. Qaseem A, et al. Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2013 May 21;158(10):761-769. Full-text article
12 ASCO 2012. Evidence-based; strong strength of recommendation; moderate strength of evidence.
Basch E, et al. Screening for prostate cancer with prostate-specific antigen testing: American Society of Clinical Oncology Provisional Clinical Opinion. J Clin Oncol. 2012 Aug 20;30(24):3020-5. PDF
13 ACS 2023. Prostate Cancer Risk Factors. American Cancer Society. Updated November 22, 2023. Accessed July 17, 2024
14 ACS 2023. Can Prostate Cancer Be Found Early? American Cancer Society. Updated November 22, 2023. Accessed July 17, 2024
15 ACOG 2021. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. Accessed June 3, 2021
16 UCSF 2016. Wesp L. Prostate and Testicular Cancer Considerations in Transgender Women. UCSF Transgender Care. Publication date: June 17, 2016. Accessed May 4, 2021
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If 50-69 yo, life expectancy ≥10y
ACP,1 ACS,2 NCCN,3 and USPSTF4 recommend discussion in light of FHx, race, other risk factors. Discuss possible benefits, risks, and uncertainties of screening.2 Black pts—who are more likely to be diagnosed at a younger age, w/ more-aggressive dz, and are >2x as likely to die of prostate CA—should engage in shared decision-making w/ clinicians, but benefits of screening generally outweigh risks.5 AAFP6 and the BMJ Rapid Recs team7 don’t recommend routine PSA screening in asymptomatic pts, but if the pt is 55-69 yo and considering periodic prostate CA screening, discuss risks/benefits and engage in shared decision-making that enables an informed choice. NCI says inadequate evidence for benefit and solid evidence of harms (over-dx, over-tx, urinary and erectile dysfxn due to tx).8 If pt desires screen, use PSA3,5,9 (may include DRE;3,5,8 do not screen w/ DRE alone3). NCCN says start risk/benefit discussion, check baseline PSA, and consider DRE.3 High risk if: - Age >50 yo; ~6/10 prostate CAs are found in pts >65 yo.10
- African American; Caribbean of African ancestry3,5,10
- FHx of prostate CA, esp. sibling.10 Even higher risk if ≥2 first-deg relatives w/ prostate CA before age 65.1
- Known gene variants/mutations: BRCA1/BRCA2, CHEK2, ATM, PALB2, Lynch syndrome (HNPCC), HOXB13; refer to genetics specialist.3,10
- Agent orange exposure3
Less certain risk factors:10 - Diet high in dairy, animal fats8
- Arsenic exposure10
- Firefighter chemical exposure10
- EtOH use8
- Conflicting evidence: prostatitis, STIs, vasectomy.10
- Other possible dietary factors:8 selenium, vitamin E, vitamin D, lycopene, and isoflavones.
Main benefit of screening is detecting CA at earlier stage, when it may be easier to treat. Risks/cons to screening include:11 - False-positive or false-negative PSA results11
- Over-dx. Many prostate CAs grow so slowly that they won’t cause problems during pt’s lifetime.11
- Over-tx. Tx has many negative side effects8,11 (urinary incontinence, bowel, erectile dysfxn) that ↓ QOL.
- Tests can cause anxiety; risks of pain, infxn, bleeding; time, cost assoc w/ dx of inconsequential dz.8,11
- Unclear mortality benefit8
- Misdirection of research focus and resources8
Screening considerations - If pt can’t decide, clinician can decide based on pt’s general health, preferences, and values.2
- ACP says don’t screen if pt doesn’t express clear preference.12
- If average-risk pt inquires about PSA screening and is 50-69 yo: Offer one-time discussion on limited potential benefit and substantial harms (have more discussions if pt requests them).1
- AUA13 strongly recommends offering pts 50-69 yo regular screening q2-4y [SR][AUA-A].
- USPSTF4 recommends individualized decision-making in pts ages 55-69 yo. Discuss potential benefits and harms of screening and consider pt’s values and preferences. Don’t screen pts who don’t express preference for screening.
- If Black/African American, reasonable to begin discussing PSA screening at age 40 and consider screening q1y,3,5 although no current evidence shows that testing at an earlier age will ↓ morbidity and mortality vs. testing at age 45, and earlier screening may ↑ over-dx.3
- The BMJ Rapid Recs team notes that pts who place more value on avoiding complications from bx and CA tx are likely to decline screening. In contrast, pts who put more value in even a small reduction of prostate CA mortality (i.e., those at high baseline risk because of FHx or African descent, or who want to r/o dx) may opt for screening.7
- If known/suspected germline mutation (e.g., BRCA2, BRCA1, ATM, CHEK2, PALB2, HOXB13, MLH1, MSH2, MSH6, PMS2, EPCAM, and TP53), refer to CA-genetics specialist.3
- Factors that might raise PSA levels:9 older age, BPH, prostatitis, ejaculation, bike riding, urological procedures, meds (testosterone or meds that raise testosterone levels).
- Factors that might lower PSA levels:3,9 meds (5α-reductase inhibitors), herbal mixtures/dietary supplements (but not saw palmetto), aspirin, statins, thiazides.
- DRE has no effect on PSA levels.8
Rescreen interval or d/c of screening based on pt preference, age, PSA, prostate CA risk, life expectancy, and general health, following shared decision-making [CR][AUA-B].13 - Per ACP, no evidence that screening more often than q4y offers additional benefit.12
- Per ACS, if PSA <2.5 ng/mL, retest q2y; if ≥2.5 ng/mL, retest q1y.2
- Per NCCN, if average risk w/ PSA <1 ng/mL, retest q2-4y.3
- Per NCCN, if normal DRE and high risk w/ PSA ≤3, or average risk w/ PSA 1-3 ng/mL, retest q1-2y.3
- Consider annual screening for Black pts, depending on PSA value and health status, and esp. for those w/ strong FHx or who carry high-risk genetic variant.5
- If very suspicious DRE and/or PSA ≥3 ng/mL, bx indicated.3 Validated risk calculators may be used to inform shared decision-making process for prostate bx [CR][AUA-B].13
Follow same guidance in transgender women, regardless of hormone tx or gender-affirming surgery;14,15 if digital exam indicated, neovaginal approach may be more effective than rectal.15
Footnotes 1 ACP 2015. Wilt TJ, et al. Screening for cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2015 May 19;162(10):718-25. Full-text article
2 ACS 2023. American Cancer Society Recommendations for Prostate Cancer Early Detection. American Cancer Society. Updated November 22, 2023. Accessed July 17, 2024
3 NCCN 2024 [2A]. Prostate Cancer Early Detection (Version 2.2024). National Comprehensive Cancer Network. March 6, 2024. Accessed July 23, 2024
4 USPSTF 2018 [C]. Final Recommendation Statement: Prostate Cancer: Screening. U.S. Preventive Services Task Force. Updated May 8, 2018. Accessed September 4, 2018
5 PCF 2024. Prostate Cancer Foundation Highlights Evidence-Based Prostate Cancer Screening Guidelines for Black Men. Prostate Cancer Foundation. June 18, 2024. Accessed August 20, 2024
6 AAFP 2022 [C]. Clinical Preventive Service Recommendation: Prostate Cancer. American Academy of Family Physicians. Accessed January 6, 2022
7 Tikkinen KAO, et al. Prostate cancer screening with prostate-specific antigen (PSA) test: a clinical practice guideline. BMJ. 2018 Sep 5:362:k3581. Free, full-text article at PubMed® Central
8 NCI 2024. Prostate Cancer Screening (PDQ®)–Health Professional Version. National Cancer Institute. Updated March 7, 2024. Accessed July 19, 2024
9 ACS 2023. Screening Tests for Prostate Cancer. American Cancer Society. Updated November 22, 2023. Accessed July 17, 2024
10 ACS 2023. Prostate Cancer Risk Factors. American Cancer Society. Updated November 22, 2023. Accessed July 17, 2024
11 ACS 2023. Can Prostate Cancer Be Found Early? American Cancer Society. Updated November 22, 2023. Accessed July 17, 2024
12 ACP 2013. Qaseem A, et al. Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2013 May 21;158(10):761-769. Full-text article
13 AUA 2023. Wei JT, et al. Early Detection of Prostate Cancer: AUA/SUO Guideline Part I: Prostate Cancer Screening. J Urol. 2023 Jul;210(1):46-53. Full-text article
14 ACOG 2021. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. Accessed June 3, 2021
15 UCSF 2016. Wesp L. Prostate and Testicular Cancer Considerations in Transgender Women. UCSF Transgender Care. Publication date: June 17, 2016. Accessed May 4, 2021
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If ≥70 yo or life expectancy <10y
Don’t offer prostate CA screening to asymptomatic pts1,2 or those who aren’t expected to live 10+ years [CR][AUA-B];3-7 consider overall health status, not just age.3 Black pts who’ve been undergoing prostate CA screening should discuss w/ a clinician whether to continue screening and make an informed decision based on age, life expectancy, health status, FHx, and prior PSA levels.8 Main benefit of screening is detecting CA at earlier stage, when it may be easier to treat. Risks/cons to screening include:9 - False-positive or false-negative PSA results9
- Over-dx. Many prostate CAs grow so slowly that they won’t cause problems during pt’s lifetime.9
- Over-tx. Tx has many negative side effects9,10 (urinary incontinence, bowel, erectile dysfxn) that ↓ QOL.
- Tests can cause anxiety; risks of pain, infxn, bleeding; time, cost assoc w/ dx of inconsequential dz.9,10
- Unclear mortality benefit10
- Misdirection of research focus and resources10
Screening considerations - Consider individual risks/benefits, race, FHx, comorbidities, risks of dx/tx,9 etc.
◦ High risk if: age >50 yo (~6/10 prostate CAs are found in pts >65 yo);11 African American, or Caribbean of African ancestry [2A];8,11,12 FHx of prostate CA, esp. sibling11 (even higher risk if ≥2 first-deg relatives w/ prostate CA before age 655); known gene variants/mutations—BRCA1/BRCA2, CHEK2, ATM, PALB2, Lynch syndrome (HNPCC), HOXB13 (refer to genetics specialist) [2A];11,12 agent orange exposure [2A].12
◦ Less certain risk factors:11 diet high in dairy, animal fats;10 arsenic exposure;11 firefighter chemical exposure;11 EtOH use.10 Conflicting evidence: prostatitis, STIs, vasectomy.11 Other possible dietary factors:10 selenium, vitamin E, vitamin D, lycopene, and isoflavones. - AUA6 and ASCO7 discourage screening in pts w/ <10-year life expectancy [CR][AUA-B].
- NCCN:12 Testing after 75 yo should be done only in very healthy people w/ little or no comorbidity (esp. if they’ve never had PSA testing or their PSA is rising) [2B] to detect the small number of aggressive CAs that would pose significant risk if left undetected until s/sx develop.
- USPSTF:2 Counsel pts >70 yo who request screening of its ↓likelihood of benefit, ↑risk of false-positive test results, and potential dx and tx complications.
- Follow same guidance in transgender women, regardless of hormone tx or gender-affirming surgery;13,14 if digital exam indicated, neovaginal approach may be more effective than rectal.14
If older pts are screened, identify those more likely to benefit from tx: - Offer PSA as 1st screening test [SR][AUA-A].8,9
- Use PSA w/ ↑bx threshold [2A];6,12 may include DRE but do not screen w/ DRE alone [2A].12
- Factors that might raise PSA levels:15 older age, BPH, prostatitis, ejaculation, bike riding, urological procedures, meds (testosterone or meds that raise testosterone levels).
- Factors that might lower PSA levels:12,15 meds (5α-reductase inhibitors), herbal mixtures/dietary supplements (but not saw palmetto), aspirin, statins, thiazides.
- DRE has no effect on PSA levels.10
If screened at age >75 yo, rescreen interval and bx guidance: - Individuals ≥60 yo w/ PSA <1.0 ng/mL and those >75 yo w/ PSA <3.0 ng/mL have a very low lifetime risk of prostate CA metastases [2A].12
- NCCN says very healthy pts >75 yo w/ little or no comorbidity (esp. if they’ve never had PSA testing or if their PSA is rising) [2B], PSA <4 ng/mL, normal DRE (if done), and no other indications for bx can repeat testing q1-3y, or consider d/c’ing screening if clinically appropriate [2A].12
- AUA: May d/c screening or substantially lengthen rescreening interval for pts ≥75 yo if PSA <3 ng/mL [CR][AUA-B].6
- If PSA >4 ng/mL or very suspicious DRE, bx and further w/u indicated [2A].12 Validated risk calculators may be used to inform shared decision-making process for prostate bx [CR][AUA-B].6
- AUA: Use age-specific cut thresholds:6
◦ Age 40-49 yo: 2.5 ng/mL
◦ Age 50-59 yo: 3.5 ng/mL
◦ Age 60-69 yo: 4.5 ng/mL
◦ Age 70-79 yo: 6.5 ng/mL - Rescreen interval or d/c of screening based on pt preference, age, PSA, prostate CA risk, life expectancy, and general health, following shared decision-making [CR][AUA-B].6
Footnotes 1 AAFP 2022 [D]. Clinical Preventive Service Recommendation: Prostate Cancer. American Academy of Family Physicians. Accessed January 6, 2022
2 USPSTF 2018 [D]. Final Recommendation Statement: Prostate Cancer: Screening. U.S. Preventive Services Task Force. Updated May 8, 2018. Accessed September 4, 2018
3 ACS 2023. American Cancer Society Recommendations for Prostate Cancer Early Detection. American Cancer Society. Updated November 22, 2023. Accessed July 17, 2024
4 ACP 2013. Qaseem A, et al. Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2013 May 21;158(10):761-769. Full-text article
5 ACP 2015. Wilt TJ, et al. Screening for cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2015 May 19;162(10):718-25. Full-text article
6 AUA 2023. Wei JT, et al. Early Detection of Prostate Cancer: AUA/SUO Guideline Part I: Prostate Cancer Screening. J Urol. 2023 Jul;210(1):46-53. Full-text article
7 ASCO 2012. Evidence-based; strong strength of recommendation; moderate strength of evidence.
Basch E, et al. Screening for prostate cancer with prostate-specific antigen testing: American Society of Clinical Oncology Provisional Clinical Opinion. J Clin Oncol. 2012 Aug 20;30(24):3020-5. PDF
8 PCF 2024. Prostate Cancer Foundation Highlights Evidence-Based Prostate Cancer Screening Guidelines for Black Men. Prostate Cancer Foundation. June 18, 2024. Accessed August 20, 2024
9 ACS 2023. Can Prostate Cancer Be Found Early? American Cancer Society. Updated November 22, 2023. Accessed July 17, 2024
10 NCI 2024. Prostate Cancer Screening (PDQ®)–Health Professional Version. National Cancer Institute. Updated March 7, 2024. Accessed July 19, 2024
11 ACS 2023. Prostate Cancer Risk Factors. American Cancer Society. Updated November 22, 2023. Accessed July 17, 2024
12 NCCN 2024. Prostate Cancer Early Detection (Version 2.2024). National Comprehensive Cancer Network. March 6, 2024. Accessed July 23, 2024
13 ACOG 2021. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. Accessed June 3, 2021
14 UCSF 2016. Wesp L. Prostate and Testicular Cancer Considerations in Transgender Women. UCSF Transgender Care. Publication date: June 17, 2016. Accessed May 4, 2021
15 ACS 2023. Screening Tests for Prostate Cancer. American Cancer Society. Updated November 22, 2023. Accessed July 17, 2024
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