Summary

USPSTF 2018 recommendation on PSA-based screening for prostate cancer in asymptomatic men. For men 55-69, screening is an individualized decision after shared decision-making about benefits and harms (Grade C, upgraded from D in 2012 based on longer ERSPC follow-up showing reduced prostate cancer mortality and metastatic disease, plus increased use of active surveillance). For men ≥70 years, routine PSA screening is not recommended (Grade D).

Key Recommendations

Men aged 55-69: offer shared decision-making about PSA screening; do not screen men who do not express a preference (Grade C).
Do not screen men aged 70 years or older for prostate cancer with PSA (Grade D).
Do not use digital rectal exam as a screening modality (insufficient evidence of benefit).
Inform African American men of their increased risk and offer individualized shared decision-making; insufficient evidence to make a separate recommendation or to screen before age 55.
Inform men with a family history of prostate cancer (especially multiple first-degree relatives) of their increased risk and engage in shared decision-making; do not screen if ≥70 regardless of family history.
Do not screen men who are unable or unwilling to undergo treatment if cancer is detected.
Discuss treatment options including active surveillance, radical prostatectomy, and radiation therapy, including harms (erectile dysfunction, urinary incontinence, bowel symptoms) before screening.
Screening every 2-4 years (rather than annually) provides a reasonable trade-off between mortality benefit and overdiagnosis.
Do not obtain a baseline PSA in men younger than 55 (inadequate evidence of benefit).

Thresholds & Doses

Age 55-69 years: shared decision-making for PSA screening (Grade C).
Age ≥70 years: do not screen (Grade D).
PSA biopsy thresholds used in trials: 2.5-10.0 ng/mL; >4.0 ng/mL was the PLCO threshold; ERSPC sites commonly used 3.0 ng/mL.
Screening interval in trials: every 2-4 years (every 2 years at Göteborg site with greatest benefit).
Lifetime risk of prostate cancer diagnosis: ~11%; lifetime risk of death from prostate cancer: 2.5%.
Lifetime risk of prostate cancer death by race: 4.2% African American, 2.9% Hispanic, 2.3% white, 2.1% Asian/Pacific Islander.
ERSPC: NNS = 781 men aged 55-69 over 13 years to prevent 1 prostate cancer death.
Per 1000 men screened over 13 years: ~1.3 prostate cancer deaths prevented and ~3 metastatic cases prevented.
Overdiagnosis rate: 20-50% of screen-detected cancers.
False-positive rate: >15% over 10 years with biopsy threshold ~3 ng/mL; up to 45% with repeated screening at low thresholds.
Treatment harms: ~1 in 5 develop long-term urinary incontinence and ~2 in 3 develop long-term erectile dysfunction after radical prostatectomy; >50% erectile dysfunction and up to 1 in 6 bowel symptoms after radiation.
Radical prostatectomy perioperative mortality: ~3 per 1000; serious surgical complications: ~50 per 1000.

Citations

Recommendation Summary table — Grade C for ages 55-69 and Grade D for ≥70.
Clinical Considerations: Screening — PSA thresholds, trial intervals, and biopsy approach.
Clinical Considerations: African American Men — risk and advising approach.
Clinical Considerations: Family History — risk and advising approach.
Discussion: Potential Harms of Treatment — incontinence, ED, and bowel complication rates.
Update of Previous USPSTF Recommendation — rationale for change from D (2012) to C for ages 55-69.
Table: Estimated Effects After 13 Years of PSA Screening in Men Aged 55-69 — per-1000 outcomes.
Rationale: Benefits of Early Detection — ERSPC, PLCO, CAP trial summary.