American Cancer Society Updates Prostate Cancer Screening Guidelines

The American Cancer Society (ACS) has issued updated prostate cancer screening guidelines recommending routine prostate-specific antigen (PSA) testing beginning at age 50 for average-risk men and age 45 for Black men and those with a family history of prostate cancer, marking the organization's first major update to its screening recommendations since 2010.¹

Published in CA: A Cancer Journal for Clinicians, the 2026 guidelines recommend PSA-based screening every 2 years for average-risk men aged 50 to 69 years and annual screening for Black men aged 45 to 69 years. Screening should also begin at age 45 for non-Black men with a first-degree relative diagnosed with prostate cancer, with screening frequency determined by family history.¹

The updated recommendations also introduce age-specific PSA thresholds for further evaluation, emphasize repeat testing before additional diagnostic procedures, and recommend magnetic resonance imaging (MRI) or validated biomarkers to help guide prostate biopsy decisions.

The changes reflect accumulating evidence that PSA-based screening reduces prostate cancer mortality and advanced-stage diagnoses, alongside advances in diagnostic testing and active surveillance that may help mitigate the harms of overdiagnosis and overtreatment.

Investigators led by Richard M. Hoffman, MD, MPH, and Andrew M. D. Wolf, MD, developed the updated recommendations following a systematic evidence review and modeling analyses conducted through the Cancer Intervention and Surveillance Modeling Network (CISNET).¹

The ACS concluded that the benefits of PSA-based screening outweigh the associated harms for appropriately selected patients, while maintaining that informed decision-making should occur before screening begins.

When Should Men Start PSA Screening for Prostate Cancer?

The updated guidelines provide specific recommendations based on age, race, and family history, with different screening intervals for average-risk and higher-risk men.

For men at average risk, defined as non-Black men without a family history of prostate cancer or known hereditary predisposition, the ACS recommends PSA testing every 2 years from ages 50 through 69 years (grade B recommendation; moderate certainty of evidence).¹

For men at increased risk, the recommendations include:

• Black men: Annual PSA screening from ages 45 through 69 years (grade B recommendation for starting age; consensus statement for interval).
• Non-Black men with a strong family history: Annual screening from ages 45 through 69 years if they have multiple first-degree relatives diagnosed with prostate cancer at any age or 1 first-degree relative diagnosed before age 65 years (consensus statement).
• Non-Black men with a single first-degree relative diagnosed at age 65 years or older: PSA screening every 2 years from ages 45 through 69 years (consensus statement).

For men aged 70 to 74 years, the ACS recommends individualized decisions based on overall health, life expectancy, and patient preferences because the balance between screening benefits and harms remains uncertain (grade C recommendation).

Men in this age group who elect to continue screening should undergo PSA testing every 2 years through age 74. Screening may be discontinued after any PSA result below 3 ng/mL.¹

The ACS recommends against prostate cancer screening in men aged 75 years and older or those of any age with a life expectancy of less than 10 years (grade D recommendation).

The guidelines also emphasize that men with known or suspected hereditary cancer syndromes, including BRCA2 mutations, require individualized risk assessment and should follow relevant specialty screening recommendations.

What PSA Levels Require Further Evaluation Under the New Guidelines?

The ACS also updated recommendations for evaluating abnormal PSA results, an important consideration for primary care physicians who frequently initiate prostate cancer screening.

Under the new guidelines, a PSA level of at least 3.0 ng/mL is considered abnormal in men aged 69 years and younger, while the threshold increases to 6.5 ng/mL for men aged 70 to 74 years.¹

Rather than proceeding directly to biopsy or other diagnostic evaluation, the ACS recommends repeating an abnormal PSA test, preferably within 2 weeks to 3 months after the initial result.

For most men with a persistently elevated PSA level, the guidelines recommend further evaluation using prostate MRI and/or a validated biomarker test with high sensitivity for clinically significant prostate cancer to help determine whether a biopsy is warranted.

The recommendations reflect efforts to reduce unnecessary biopsies and distinguish clinically significant cancers from lower-risk disease that may not require immediate treatment.

The ACS also recommends against using digital rectal examination as a primary screening test for prostate cancer (grade D recommendation; high certainty of evidence).

When Is Active Surveillance Recommended for Prostate Cancer?

Another major component of the updated guidelines is the emphasis on reducing overtreatment following prostate cancer diagnosis.

The ACS recommends that men diagnosed with low-risk prostate cancer initially be offered active surveillance rather than immediate definitive treatment.¹

Active surveillance typically involves monitoring with serial PSA testing, prostate MRI, and repeat biopsies, with treatment considered if there is evidence of disease progression or if the patient elects intervention.

This approach is intended to reduce unnecessary treatment-related complications, including urinary incontinence, erectile dysfunction, and bowel dysfunction, among men whose cancers may never become clinically significant.

The guideline authors emphasized that advances in secondary testing and surveillance strategies have changed the balance of benefits and harms associated with prostate cancer screening since the organization's previous recommendations were published in 2010.

How Does PSA Screening Affect Prostate Cancer Mortality?

The updated recommendations were informed in part by extended follow-up from major randomized prostate cancer screening trials.

In the European Randomized Study of Screening for Prostate Cancer (ERSPC), PSA-based screening was associated with a 13% reduction in prostate cancer mortality after 23 years of follow-up among men aged 55 to 69 years (rate ratio, 0.87; 95% CI, 0.80-0.95).¹

Although the relative mortality benefit was smaller than that observed in earlier analyses, the absolute reduction in prostate cancer mortality increased from 0.07% at 9 years to 0.22% at 23 years.

The number of men who needed to be invited for screening to prevent 1 prostate cancer death declined from 1410 to 456 over the same period.

Additional evidence from the ERSPC demonstrated that screening was associated with fewer metastatic prostate cancer diagnoses, while long-term population-based studies have documented changes in advanced-stage disease associated with screening practices.

The ACS also considered evidence of persistent disparities in prostate cancer outcomes. According to the guideline, Black men have approximately 67% higher prostate cancer incidence and nearly twice the prostate cancer mortality of White men, supporting more intensive screening recommendations for this population.¹

What Do the New Prostate Cancer Screening Guidelines Mean for Primary Care?

The updated guidelines provide primary care physicians with more specific recommendations for identifying screening-eligible patients, determining PSA testing intervals, and managing abnormal results.

Rather than relying on a uniform screening approach, the ACS recommends incorporating race, family history, age, life expectancy, and patient preferences into screening decisions.

For clinicians, this includes discussing the potential mortality benefits of PSA testing alongside the risks of false-positive results, unnecessary biopsies, overdiagnosis, and treatment-related complications.

Importantly, the recommendations recognize that the clinical value of screening depends not only on detecting elevated PSA levels but also on appropriate follow-up testing and management decisions.

The ACS noted that more widespread use of MRI, validated biomarkers, and active surveillance may reduce some of the harms historically associated with PSA-based screening.

However, the guidelines maintain that screening decisions should be informed by individual patient circumstances, particularly among men aged 70 to 74 years, for whom the net benefit remains uncertain.

The authors concluded that accumulating evidence supports PSA-based screening to reduce prostate cancer mortality and advanced-stage diagnoses, with risk-stratified screening and modern diagnostic strategies offering opportunities to improve outcomes while minimizing unnecessary interventions.

Reference

1. Hoffman RM, Wolf AMD, Etzioni RD, et al. American Cancer Society guideline for the early detection of prostate cancer, 2026. CA Cancer J Clin. 2026;e70112. doi:10.3322/caac.70112