Prostate specific antigen (PSA) testing – New conditions apply

From 1 November 2023, conditions have changed for PSA items in the Medicare Benefits Schedule (MBS) which affect the frequency of PSA assessment and the performance of follow-up testing that will be eligible for a Medicare rebate. These changes reflect the recommendations made in the NHMRC-approved Clinical Practice Guidelines (CPG) for ‘PSA testing and early management of test-detected prostate cancer’ published in 2016.¹

Routine assessment of men for prostate cancer

For men who have no previously diagnosed prostate disease and who are not at increased risk of prostate cancer based upon family history, the interval between routine PSA tests has been extended from 12 months to 23 months (MBS Item 66655).

For men who have an increased relative risk of prostate cancer, as shown in the table overleaf, the interval between successive routine PSA tests has been reduced from 12 months to 11 months (MBS Item 66654).

Follow-up of an abnormal total PSA in men undergoing routine assessment

If a total PSA result obtained on routine assessment falls within the ranges specified in the three patient categories listed below, then follow-up testing that includes both total and free PSA measurement should be carried out after one to three months. The following MBS criteria, which are dependent upon the patient’s initial total PSA result in conjunction with their relative risk or age, apply to eligibility for free PSA testing (MBS Item 66659):

• PSA >2.0 ug/L but ≤5.5 ug/L for patients with a family history of prostate cancer; or
• PSA >3.0 ug/L but ≤5.5 ug/L for patients who are ≥50 years of age but <70 years of age; or
• PSA >5.5 ug/L but ≤10.0 ug/L for patients who are at least 70 years of age.

Free PSA testing is limited to one episode within a period of 11 months.

In the absence of identified causes for an elevated total PSA, such as urinary tract infection or prostatitis, referral for specialist management must be considered for any men whose total PSA is greater than the upper limits specified in the three patient categories above.

Testing of men with previously diagnosed prostate disease

Under the new MBS items, previously diagnosed prostate disease includes prostate cancer, prostatitis and premalignant conditions, such as atypical small acinar proliferation, but excludes benign prostatic hyperplasia. For patients who are undergoing monitoring of previously diagnosed prostate disease, there are no specific intervals that apply between successive total PSA tests (MBS Item 66656).

If free PSA testing is required, then the same conditions that apply in the three separate patient categories listed above must be satisfied with respect to the patient’s current total PSA result in conjunction with their relative risk or age. For monitoring purposes, there is a limit of four episodes of free PSA testing within a period of 11 months (MBS Item 66660). It also should be noted that there is limited clinical utility in performing a free PSA test for patients who already have a history of treated prostate cancer.

MBS conditions applying to PSA testing and multi-parametric MRI scan of the prostate

The current MBS descriptor for a multi-parametric MRI scan of the prostate specifies that for men aged 70 years or older, there must be at least two PSA tests performed within an interval of 1 to 3 months, with a total PSA concentration greater than 5.5 ug/L and a free to total PSA ratio that is less than 25% (MBS Item 63541). Satisfying the latter condition presents a problem when the total PSA concentration is greater than 10 ug/L, as this would exceed the limit that applies for free PSA testing to be eligible for a Medicare rebate. Referral for specialist management, however, would be advised for any patient who has a persistently elevated total PSA concentration that is over 10.0 ug/L.

Review of CPG

The need to update the CPG published in 2016 is well recognised and, as such, a review of this document is presently being undertaken in order to evaluate more recent evidence, including the role of MRI assessment and parameters such as PSA density in detecting the presence of prostate cancer. This, in turn, will inform further refinements to the various conditions specified in the MBS items that currently apply to both free and total PSA testing.

From Table 1.1 of CPG