PSA (Prostate-Specific Antigen), including free PSA and PSA ratio

Pick Ordered or Not ordered to see the note.

Indicated when

• —Diagnosed, treated, or followed prostate cancer, or clinician-suspected prostate cancer based on symptoms or exam findings [1]
• —Shared decision-making screening in an asymptomatic man aged 55-69 who, after a discussion of the potential benefits and harms, expresses a preference for testing [2]
• —Shared decision-making screening from about age 50 (or age 45 with a first- or second-degree family history of prostate cancer), for a man who wants to discuss screening and has a life expectancy over 10 years [4]

Not indicated when

• —Routine, unprompted screening added to general bloodwork without a prior discussion of benefits and harms [4, 2]
• —Men 70 and older, in whom the USPSTF found the potential benefits don't outweigh the expected harms [2]
• —Men under 50 without an increased-risk factor [4]. The CTFPHC 2014 recommends against screening at every age it reviewed [3].

Why not

PSA screening in average-risk men carries real, well-documented harms: false-positive results that lead to biopsy, and overdiagnosis and overtreatment of cancers that might never have caused symptoms, with treatment complications such as incontinence and erectile dysfunction [2]. This is a genuinely unsettled, values-sensitive question rather than a clear-cut 'don't order': the Canadian Task Force on Preventive Health Care's 2014 guideline recommends against PSA screening for men of every age it reviewed (weakly for ages 55-69, strongly outside that range) [3], while the Canadian Urological Association's 2022 update recommends offering screening via shared decision-making from age 50 [4]. Reasonable, well-informed guidelines disagree here.

Better first step

Have the shared decision-making conversation itself before ordering: explain that PSA screening may modestly reduce the chance of dying from prostate cancer, but at the cost of a real risk of a false alarm, biopsy, and overdiagnosis or overtreatment of a cancer that might never have caused problems, then order PSA if the informed patient wants it. For a man with lower urinary tract symptoms alone (nocturia, urgency, frequency, poor stream) and a benign exam, these are usually from benign prostatic hyperplasia, not something that alone requires PSA testing; the CTFPHC's 2014 recommendations were written specifically to apply to this group as well [3].

Typical ND rationale

An ND may recommend PSA as a well-established cancer marker, particularly for a man in his 50s or 60s or with a family history, reasoning that most men have heard of it and that checking it is a reasonable part of general men's health screening.

Ontario coverage & CONO orderability

OHIP status

insured_conditional

Under the 2026 Schedule, PSA is insured for men who have been diagnosed with, are being treated for, or are being followed after prostate cancer, or 'whose health care practitioner suspects prostate cancer because of their history, race, and/or the results of their physical examination' [1]. Screening an average-risk man with no such suspicion falls outside that wording and is patient-paid, and community labs list it as 'PSA (uninsured)'. The April 2026 requisition revision (INFOBulletin 260405) spells the insured criterion out as suspected prostate cancer '(family history, race, physical examination, symptoms)', relabels the uninsured option 'Asymptomatic screening', and states there is no change to PSA's insured status [7]. ND-ordered testing is patient-paid regardless (Reg. 552 s. 22).

CONO orderable

Yes — CONO list #106

CONO list item 106, blood: 'PSA, Ratio.' The CONO list entry covers the free/total PSA ratio (requiring both free and total PSA); a stand-alone total PSA is not separately numbered on the CONO list but is inherent in obtaining the ratio.

Linked conditions

• Tumour markers to check for 'hidden' cancer ↗

Counselling script

“If you've been diagnosed with or treated for prostate cancer, PSA is standard, covered follow-up. Without a diagnosis, screening is a genuine choice: it might lower your chance of dying from prostate cancer, but it can also lead to biopsies or treatment for a cancer that would never have caused problems. Guidelines disagree, so I'd like us to decide together, and I'll tell you whether OHIP covers it in your situation.”

Revisit if

• —Urinary or other symptoms suggestive of prostate cancer develop, such as new voiding symptoms with an abnormal exam
• —A patient who previously declined screening reconsiders after further discussion
• —A diagnosis of prostate cancer is made, requiring follow-up PSA testing

References

1. [1]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkOHIP insures PSA only for diagnosed, treated, or followed prostate cancer, or clinician-suspected cancer; not asymptomatic screening
2. [2]US Preventive Services Task Force (2018). Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement. linkShared decision-making for men 55-69 (Grade C); against routine screening for men 70 and older (Grade D); overview of screening benefits and harms
3. [3]Canadian Task Force on Preventive Health Care (2014). Recommendations on screening for prostate cancer with the prostate-specific antigen test. linkolder guidelineCTFPHC recommends against PSA screening at every age it reviewed (2014)
4. [4]Canadian Urological Association (2022). UPDATE – 2022 Canadian Urological Association recommendations on prostate cancer screening and early diagnosis. linkCUA recommends offering PSA screening via shared decision-making starting at age 50, or 45 with an increased risk factor such as family history, for men with life expectancy over 10 years
5. [5]Government of Ontario (e-Laws) (2026). Health Insurance Act, R.R.O. 1990, Reg. 552: General, s. 22 (insured laboratory services). linkA lab test is insured only when ordered by a physician, midwife, or NP who has clinically assessed the patient
6. [6]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkTests ordered by anyone other than an authorized provider, including NDs, are not insured services
7. [7]Ontario Ministry of Health (2026). Bulletin 260405 — Revision to PSA test on lab requisition effective April 16, 2026. linkPSA requisition (Apr 2026): insured for suspected prostate cancer (family history, race, physical examination, symptoms) or diagnosed cancer; uninsured option relabelled 'Asymptomatic screening'; no change to insured status