Recent studies have caused me to believe that men should have an initial PSA test earlier than I previously recommended. All men should have an annual PSA test and a digital rectal exam beginning at age 40 to assess their risk of having prostate cancer or developing prostate cancer in the future. And if men have a family history of early age-at-onset prostate cancer, then the PSA should be tested at 35. I recommend biopsy for a suspicious DRE or a PSA of more than 2.5. Also, I recommend that PSA velocity be considered in biopsy decisions. Some doctors do not recommend a biopsy if the PSA is over 2.5 or even if it is over 4. (Again, my recommendation is biopsy with a PSA 2.5 or over.) However, if the PSA velocity is higher than 0.5 ng/ml/year in a man whose total PSA is below four or if the PSA velocity is higher than 0.75 in a man with a PSA higher than 4, it is even more important to have a prostate biopsy. An important caveat is that very dramatic increases in PSA (more than 2 ng/ml/year) are more likely to be caused by prostatitis rather than prostate cancer. Also, in patients who have had a prior biopsy for a PSA over 2.5 or over 4.0 and the biopsy was negative for cancer, a rising PSA makes a case for repeating the biopsy procedure. These recommendations are similar to the 2004 National Comprehensive Cancer Center Network guidelines.