At What Age Should You Start Prostate Cancer Screening?

Age is a main risk factor for prostate cancer, and prostate-specific antigen (PSA) screening has proved effective in the early diagnosis of this common cancer. Because of the potential harms of a PSA test, there is no consensus about the start and stop ages for prostate cancer screening, but experts have age-based screening recommendations.

Age Is a Main Risk Factor for Prostate Cancer

Prostate cancer is the second most common cancer in American men, after skin cancer. Prostate cancer is also the second leading cause of cancer-related death in American men, behind only lung cancer.¹

Among the main risk factors for prostate cancer, age is the best-established risk factor—older men are more likely than young men to be diagnosed with prostate cancer and have lower overall survival. Almost 6 of 10 cases of prostate cancer are diagnosed at age 65 or older, and the average age at the time of diagnosis is about 66.¹

Prostate cancer is rare before age 40, but the risk increases rapidly after age 50. Research shows that²:

• About 0.6% (less than 1%) of prostate cancer cases were diagnosed between ages 35 and 44
• 9.7% between ages 45 and 54
• 32.7% (almost one-third) between ages 55 and 64
• 36.3% (more than one-third) between ages 65 and 74
• 16.8% (almost one-quarter) between ages 75 and 84
• And 3.8% at 85 years of age or older.

Overall, men aged 55 or older had an almost 17-fold higher risk for prostate cancer compared with those younger than 55.²

Benefits and Harms of Prostate Cancer Screening

The PSA test has been frequently used in prostate cancer screening. PSA is a particular protein produced by the prostate, and a PSA test measures the level of PSA in the blood, which is often higher in men who have prostate cancer.

Early diagnosis and treatment are the main benefits of prostate cancer screening, because it helps to reduce cancer death. For example, in a study of more than 160,000 men aged 55 to 69, researchers found that PSA testing led to a substantial reduction in prostate cancer mortality. After 13-year follow-up, there was a significant 21% relative mortality reduction in favor of screening.³

However, the mortality reduction benefits need to be weighed against the potential harms of PSA screening, which include identifying the slow-growing (or indolent) tumors, which can exist without symptoms for many years, and some may never show symptoms or contribute to death. In such cases, a positive PSA test (showing elevated PSA levels) can lead to overdiagnosis and overtreatment, which are harmful rather than helpful.

Adverse events, such as urinary incontinence and erectile dysfunction, may come with the cascade of treatments administered as a result of a positive PSA test. In addition, men undergoing radiation therapy are at risk for rectal bleeding from radiation proctitis, as well as for secondary cancers caused by the radiation. Men who receive prostate cancer treatment and then have a rising PSA without evidence of metastatic cancer may then receive hormonal therapy, which may also result in side effects and harms.⁴

Recommended Screening Strategies

Although there is no consensus about the ages at which PSA screening for prostate cancer should start and stop, some age-specific screening recommendations, such as those by the U.S. Preventive Services Task Force (USPSTF), have been followed in clinical practices.

The USPSTF is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. In the area of prostate cancer, the USPSTF recommends periodic PSA-based screening for men aged 55 to 69 and recommends against such screenings in men aged 70 and older. The USPSTF also recommends that the screening decision should be individual and should be shared with the patient. Before deciding whether to be screened, men should have an opportunity to discuss the potential benefits and harms of screening with their clinician and incorporate their values and preferences in the decision.⁵

In addition to the start and stop ages, researchers say an optimum strategy would be screening with 3-year intervals between ages 55 and 64. Research shows that this strategy could result in a 27% mortality reduction from prostate cancer and 28 life-years gained per 1,000 men.⁶

Whether to screen for prostate cancer should be an individualized, informed, and shared decision-making process, because men may weigh the harms and benefits in different ways. The best path forward, as one researcher suggests, is not more screening or less screening, but rather to continue to develop better screening tests and algorithms for prostate cancer to decide who would benefit from early diagnosis and treatment.⁴

References:

1. American Cancer Society. Key statistics for prostate cancer. www.cancer.org/cancer/prostate-cancer/about/key-statistics.html. Accessed July 29, 2022.
2. Bashir MN. Epidemiology of prostate cancer. Asian Pacific Journal of Cancer Prevention. 2015;16(13):5137-5141. http://journal.waocp.org/article_31224.html.
3. Schröder FH, Hugosson J, Roobol MJ, et al; for the ERSPC investigators. Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. Lancet. 2014;384(9959):2027-2035. www.ncbi.nlm.nih.gov/pmc/articles/PMC4427906/pdf/nihms683906.pdf.
4. Gilligan T. Prostate cancer: to screen or not to screen? The question is complicated. Cleveland Clinic Journal of Medicine. 2021;88(1):17-18. www.ccjm.org/content/88/1/17.long.
5. U.S. Preventive Services Task Force. Prostate cancer: screening. Final recommendation statement. May 8, 2018. www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening. Accessed July 29, 2022.
6. Getaneh AM, Heijnsdijk EAM, Roobol MJ, de Koning HJ. Assessment of harms, benefits, and cost-effectiveness of prostate cancer screening: a micro-simulation study of 230 scenarios. Cancer Medicine. 2020;9(20):7742-7750. https://onlinelibrary.wiley.com/doi/10.1002/cam4.3395.