ACS Updates Prostate Cancer Screening Guideline With Risk-Based PSA Intervals

The American Cancer Society (ACS) has issued its first update to its prostate cancer screening guideline since 2010, now recommending prostate-specific antigen (PSA)–based screening every 2 years from ages 50 through 69 years for men at average risk, according to the guideline update published in CA: A Cancer Journal for Clinicians.¹ The update also recommends earlier and more frequent screening for Black men and men with a family history of prostate cancer, along with secondary testing with MRI or validated biomarkers and active surveillance to reduce overdiagnosis and overtreatment.

“Previously, the American Cancer Society did not recommend a specific prostate cancer screening schedule,” William L. Dahut, MD, chief scientific officer of the ACS and a coauthor of the guideline, stated in a release by the ACS.²

What does the updated ACS prostate cancer screening guideline recommend?

The ACS recommends PSA-based screening every 2 years from ages 50 through 69 years for men at average risk (grade B; moderate certainty of evidence). Annual screening from ages 45 through 69 years is recommended for Black men (grade B for starting age; low certainty of evidence) and for non-Black men with a first-degree relative diagnosed before age 65 years or multiple first-degree relatives diagnosed at any age. Non-Black men with a single first-degree relative diagnosed at 65 years or older should be screened every 2 years from ages 45 through 69 years.

For men aged 70 through 74 years, the guideline recommends individualized decision-making because the balance of benefits and harms is uncertain (grade C). Screening is not recommended for men aged 75 years and older or for men of any age with a life expectancy of less than 10 years (grade D), and digital rectal examination is not recommended as a primary screening test (grade D; high certainty of evidence). The recommendations do not apply to men with hereditary cancer syndromes, such as BRCA2 mutations.

What evidence supports PSA-based screening?

At 23 years of follow-up, the European Randomized Study of Screening for Prostate Cancer (ERSPC) reported a 13% reduction in prostate cancer mortality among men aged 55 to 69 years (rate ratio [RR], 0.87; 95% CI, 0.80-0.95). Although the RR attenuated from 0.80 at 9 years, the absolute risk reduction increased from 0.07% to 0.22%, and the number needed to invite to prevent 1 prostate cancer death fell from 1410 to 456. Data from 4 ERSPC centers showed a 42% reduction in metastatic prostate cancer at 12 years.

In the Göteborg trial, screening reduced prostate cancer mortality by 29% after 22 years (RR, 0.71; 95% CI, 0.55-0.91).³ The Cluster-Randomized Trial of PSA Testing for Prostate Cancer (CAP), which offered a single PSA test, showed a smaller reduction at 15 years (RR, 0.92; 95% CI, 0.85-0.99).

Why does the guideline recommend earlier screening for Black men?

Modeling from 3 Cancer Intervention and Surveillance Modeling Network (CISNET) teams projected that Black men have a 28% to 56% higher lifetime risk of prostate cancer by age 85 years and a 44% to 75% higher risk of progression to metastasis by clinical diagnosis than the general population. With MRI-aided biennial screening from ages 50 to 69 years, the models projected 28 to 36 lives saved per 1000 Black men vs 14 to 16 per 1000 men in the general population, alongside 22 to 65 vs 17 to 41 overdiagnoses, respectively.

“By making a direct recommendation for men to engage in screening and advocating for earlier and more frequent screening for Black men, our aim is also to help reduce prostate cancer disparities and ease the disease burden,” Dahut said in a news release.⁴

How does the guideline address overdiagnosis and overtreatment?

The guideline defines an abnormal PSA level as 3.0 ng/mL or higher for men aged 69 years and younger and 6.5 ng/mL or higher for men aged 70 through 74 years, with retesting recommended 2 weeks to 3 months later before further evaluation. Most men with a confirmed elevated PSA level should be offered MRI and/or a validated biomarker test to guide biopsy decisions, and men diagnosed with low-risk disease should initially be offered active surveillance.

In CISNET modeling, keeping the PSA threshold at 3.0 ng/mL but using MRI to guide biopsy decisions reduced biopsies by 30% to 34% and overdiagnoses by 8% to 14% while increasing lives saved by 1% to 9%. The guideline also notes that validated biomarkers generally have negative predictive values above 90% and can avoid 35% to 40% of biopsies.

References

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;76(6):e70112. doi:10.3322/caac.70112
2. What you need to know about the updated prostate cancer screening guideline. American Cancer Society. November 12, 2026. Accessed November 13, 2026. https://tinyurl.com/3zxp3epf
3. Frånlund M, Månsson M, Godtman RA, et al. Results from 22 years of followup in the Göteborg Randomized Population-Based Prostate Cancer Screening Trial. J Urol. 2022;208(2):292-300. doi:10.1097/JU.0000000000002696
4. American Cancer Society updates prostate cancer screening guideline. News release. American Cancer Society. November 12, 2026. Accessed November 13, 2026. https://tinyurl.com/4xz3dhbb