Age, prostate-specific antigen, screening frequency, and metastatic prostate cancer in U.S. Veterans

ImportanceMetastatic prostate cancer (PCa) incidence has increased in U.S. men, partly due to changes in prostate-specific antigen (PSA) screening recommendations. However, few studies have examined contemporary PSA screening practices in large U.S. healthcare systems. ObjectiveDescribe and examine contemporary PSA testing practices associated with metastatic PCa incidence. DesignCohort study. SettingVeterans Health Administration. ParticipantsVeterans diagnosed with prostate needle biopsy (PNBx) between 2015 and 2023 with follow-up through 2024, excluding those with a history of PCa. ExposuresPSA tests were retrieved from the VA corporate data warehouse and categorized by age at first VA PSA (<50, 50-59, [&ge;]60 years) and by longest interval between consecutive VA PSA tests in the 5 years before PNBx ([&le;]24 , >24 months). Clinical, laboratory, pathological, demographic, and Census Block Group-level socioeconomic status data were obtained from the VA Multi-OMICS Analysis Platform for Prostate Cancer (VA-MAPP) database. Main Outcomes and MeasuresMultivariable Cox models estimated hazard ratios (HR) from time of first VA PSA to first PNBx, evaluated risk of metastatic (regional or distant) versus localized PCa, or benign diagnosis, adjusted for sociodemographic and clinical covariates. Data were analyzed between July 1, 2023 and November 6, 2025. ResultsThere were 103,067 participants of whom 20% were <50 years old at first PSA, 31% non-Hispanic Black, 57% non-Hispanic White, and 13% other racial and ethnic groups. Of these, 22% had first PSA value [&le;]1, 51% had a screening interval [&le;]24 months, and 4% were diagnosed with metastatic PCa at time of PNBx. Compared to men aged <50 years at first PSA, those 50-59 (aHR 1.08, 95% CI: 1.06-1.11) and [&ge;]60 years (aHR 1.79, 95% CI: 1.74-1.84) had higher metastatic PCa. Men with longer screening intervals had higher metastatic PCa (aHR 1.09, 95% CI: 1.07-1.11). Men aged <50 years with shorter screening intervals had lower metastatic PCa (aHR: 0.10, 95% CI: 0.09-0.12) compared to men aged [&ge;]60 years with longer screening intervals. Conclusions and RelevanceFew male veterans were observed to have the most favorable combinations of age, PSA value, and PSA screening interval in relation to metastatic PCa, suggesting potential for further screening optimization.