Click to Enlarge: PSA indicates prostate-specific antigen. To convert PSA to micrograms per liter, multiply by 1.
Source: JAMA Network Open
ANN ARBOR, MI — In men over 70 years old, prostate-specific antigen (PSA) screening history could be a highly informative predictor of long-term risk of prostate cancer by identifying individuals with certain PSA values as very low risk, according to a recent study.
The study published in JAMA Network Open examined the value of PSA levels, race and ethnicity and competing mortality in risk stratification for prostate cancer-specific mortality (PCSM) and metastatic prostate cancer (mPCa) in men after 70 years old.1
Study authors are affiliated with the University of Michigan, VA Center for Clinical Management Research and Ann Arbor (MI) VAHS, each in Ann Arbor, MI; University of California, San Diego in La Jolla, CA; and Fred Hutchinson Cancer Center in Seattle.
“Older men frequently undergo PSA screening, yet they have been largely understudied,” Dana Chung, first author of the study and a medical student at University of Michigan Medical School, told U.S. Medicine. “Current guidelines provide inconsistent recommendations regarding screening past age 70, creating uncertainty among clinicians. We aimed to clarify whether PSA levels, race and ethnicity, and competing mortality risk could effectively stratify older men’s risk, guiding informed decisions about continuing or discontinuing PSA screening.”
Currently, practice guidelines vary for the recommended upper age limit of PSA screening, depending on general health, prior PSA values and patient preferences after shared decision-making. Black men, known to be at significantly higher risk of PCSM compared to other racial and ethnic groups, could possibly benefit from continued screening past age 70 years, but supporting data is lacking, the authors suggested.
In this cohort study, the researchers used clinical data of all men receiving healthcare through the VHA who turned 70 years old between 2008 and 2020 and had a normal screening PSA value between age 65 and 69 years (<4 ng/mL [baseline PSA]). These men also had no prior history of prostate cancer or biopsy examined. The cutoff date for study data was Dec. 26, 2023. The analysis involved 921,609 men, 11% who self-reported as Black and 82% who self-reported as white race, the study reported.
“Our study found that PSA values between ages 65 to 69 are highly informative predictors of prostate cancer-specific mortality (PCSM) and metastatic prostate cancer (mPCa) in men aged over 70,” Chung said. “Men with PSA levels less than 1 ng/mL had very low risk of PCSM and metastatic prostate cancer, suggesting that discontinuing screening is safe in this subgroup, regardless of race, ethnicity or competing mortality.”
The investigators determined that, between 65 and 70 years old, 45% of patients had a baseline PSA of less than 1 ng/mL, and 32% had a baseline PSA of 1 to 1.99 ng/mL. Most patients (87%) continued to undergo screening past 70 years old, with little variation by competing mortality risk or race and ethnicity.
PSA values from age 65 to 69 years old were associated with 10-year PCSM and mPCa, regardless of race and ethnicity or competing mortality. The 10-year cumulative incidence of PCSM was 0.26% overall, and 95% of men had a 10-year risk less than 0.73%. Higher baseline PSA level between age 65 and 69 years old was associated with 10-year PCSM risk (0.79% for 3.00-3.99 ng/mL vs. 0.10% for 0.20-0.99 ng/mL), race and ethnicity (0.36% for Black vs. 0.25% for white) and competing mortality (0.24% for the highest quintile vs. 0.21% for the lowest quintile). Similar results were found for mPCa, according to the study authors.
Low PSA values (0.20-0.99 ng/mL) from age 65 to 69 years old were associated with very low PCSM and mPCa risk, even among the healthiest Black men who would otherwise represent a high-risk subgroup, the researchers pointed out.
The study’s most important finding is that PSA levels measured before age 70 strongly predict the risk of significant prostate cancer outcomes later in life. Specifically, a PSA level below 1 ng/mL identifies men with an extremely low 10-year risk of metastatic disease and prostate cancer-specific death, supporting discontinuation of screening in this subgroup irrespective of their race, ethnicity or overall health, Chung explained.
“Our findings highlight an opportunity for healthcare systems to reduce unnecessary screenings in older adults without compromising patient safety, potentially minimizing overdiagnosis and overtreatment,” Chung explained.
She noted that healthcare providers should recognize that continued PSA screening after age 70 is widespread but often unnecessary.
“PSA levels measured between ages 65 to 69 can effectively guide decisions about discontinuing screening safely, especially for those with low PSA levels who face minimal long-term risk,” Chung suggested.
Overall, this study suggests that assessing personal risk based on PSA values before age 70 can result in predictive information concerning risk for PCSM and mPCa. This data may inform shared decision-making regarding the potential benefits of continuing PSA screening past 70 years old among healthy men with high-normal PSA values. It could also support the safety of discontinuing screening in men with low PSA values regardless of race and ethnicity or competing mortality risk, study authors concluded.
- Chung DH, Caverly TJ, Schipper MJ, Hofer TP, et. Al. Prostate Cancer Mortality in Men Aged 70 Years Who Recently Underwent Prostate-Specific Antigen Screening. JAMA Netw Open. 2025 Feb 3;8(2):e2459766. doi: 10.1001/jamanetworkopen.2024.59766. PMID: 39951264; PMCID: PMC11829239.