American Cancer Society now recommends PSA tests for most men starting at 50

The American Cancer Society is telling most men to stop treating prostate cancer screening as optional. Under guidelines published Thursday in CA: A Cancer Journal for Clinicians, men ages 50 to 69 at average risk should get a prostate-specific antigen, or PSA, blood test every other year.

Men at higher risk, including Black men and men with close relatives who have had the disease, should start sooner and test more often: every year beginning at age 45. For men 70 to 74, the society recommends a conversation with a healthcare provider about whether testing makes sense, weighing their overall health and how long they are likely to live.

The shift is one of tone as much as timing. The society's previous guidance, issued in 2010, framed PSA testing as a matter of "shared decision-making" between doctor and patient for men with at least a decade of life expectancy, and it tied repeat testing to a PSA-level threshold. ACS experts concluded that this looser approach left too many men skipping the test altogether. The new version asks doctors to recommend screening outright.

Why the cancer society changed course

The timing reflects a troubling trend. Advanced prostate cancer has been rising, and prostate cancer remains the second-leading cause of cancer death among American men, behind only lung cancer. An ACS study published last year found prostate cancer diagnoses grew about 3% a year from 2014 to 2021, and that metastatic cases among men 55 and older climbed roughly 6% a year over a decade of data. Dr. William L. Dahut, the society's chief scientific officer and a co-author of that study, said the increase has continued in recent years.

Death rates tell a related story. Prostate cancer mortality fell by half over the past three decades, but that progress has slowed overall and has leveled off for men ages 55 to 69. The stakes of catching the disease late are stark: only about a third of men diagnosed with late-stage prostate cancer survive five more years.

Dahut said he hoped the guidelines would raise screening rates among average-risk men and ultimately reduce the number who develop metastatic disease or die of it, while limiting harm.

The scientific case also got stronger. The authors leaned heavily on a large randomized screening trial in Europe that now has more than 20 years of follow-up and found that testing middle-aged men did reduce prostate cancer deaths. For years, the central knock on PSA screening was that nobody could show it saved lives. That evidence, along with other newer research, gave the authors enough confidence to call the test beneficial and to spell out who should get it and how often.

That is the most persuasive part of the update. Guidelines built on decades of randomized follow-up deserve more weight than ones built on worry about a test's downsides, and the long European data address the weakest point in the old argument for screening.

A test that has swung in and out of favor

PSA screening has been through several reversals. The Food and Drug Administration approved the test for cancer surveillance in 1986. As it came into wide use for screening, late-stage diagnoses fell by more than half, and the death rate dropped 7% by the mid-1990s.

In the 2000s, health authorities grew uneasy about overdiagnosis and narrowed their recommendations. In 2012, the U.S. Preventive Services Task Force went furthest, advising against PSA screening for men of any age. Late-stage diagnoses then began rising, fueling concern that reduced testing was partly to blame and prompting campaigns to bring screening back. The task force softened its position in 2018, recommending an individual decision for men 55 to 69 while continuing to advise against routine screening for older men.

The ACS guidance now goes further than that federal framework in two notable ways: it starts routine testing at 50 rather than leaving it to individual choice, and it leaves room for testing in the early 70s. Dahut said the revised guidelines recognize that many men in their 70s can expect to live more than another decade, which means treatment may extend their lives. That is a reasonable update to reflect longer life expectancy, though the decision for that age group is still left to patients and their doctors rather than made routine.

The trade-offs that have not gone away

The concerns that pushed screening out of favor are real, and the new guidelines do not make them disappear. PSA testing often finds cancers that are unlikely to cause serious illness or death, at least in the near term. Many older men die with prostate cancer rather than from it, which is why the ACS and other groups do not recommend the test for men unlikely to live another 10 years.

False positives can lead to anxiety and unnecessary treatment. The biopsy needed to confirm a diagnosis carries its own risks. Treatment itself, typically surgery or radiation, can cause sexual dysfunction, urinary incontinence and bowel problems. Dahut said recent improvements in medical practice have helped reduce those effects.

What has changed most is what doctors do after a positive result. Physicians are better at separating aggressive cancers that need prompt treatment from slow-growing ones that can be watched over time. That distinction is the hinge of the whole policy. A more aggressive screening schedule only pays off if a high PSA reading no longer leads almost automatically to surgery or radiation. If clinicians lean on monitoring for low-risk cases, more testing should mean more lives saved without a matching rise in harm. If they do not, the old overtreatment problem could return.

Dr. Daniel George, a Duke Health medical oncologist who specializes in urological cancers and was not involved in the guidelines, argued that fear of a cancer diagnosis is often out of proportion to the actual risk. "There are more cancer survivors in the United States than ever before in history," he said, crediting more effective therapies rather than overdiagnosis for that growth.

The practical effect will depend on how primary care doctors respond, since they are the ones who order the test. The 2010 guidance put the burden of the decision partly on patients, and the ACS believes that left many men untested. By turning a conversation into a recommendation, the society is betting that clearer advice will move more men in their 50s and 60s to get a simple blood test, and that better follow-up care can keep the downsides in check.