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Suspected prostate cancer — MSRA MCQ

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HardPSASuspected prostate cancerMSRA

A 68-year-old man presents for review 10 days after completing antibiotics for a culture-confirmed Escherichia coli urinary tract infection. Before the infection he had reported 4 months of nocturia, reduced urinary flow and hesitancy. At the acute presentation, digital rectal examination found a hard, irregular area in the left lobe of the prostate. PSA taken on the same day was 7.2 micrograms/L. His dysuria and fever have resolved, and repeat urine culture is now negative. What is the most appropriate next step?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Make a suspected cancer pathway referral now, documenting that the PSA was taken during a proven urinary infection

Explanation lettering: C = shown as B · B = shown as C · E = shown as D · D = shown as E

A hard, irregular prostate on digital rectal examination is suspicious for prostate cancer and independently warrants a suspected cancer pathway referral. This takes priority over interpreting the PSA result. The PSA of 7.2 micrograms/L was measured during a microbiologically confirmed urinary infection, so it may be falsely elevated and should not be used alone to quantify cancer risk or determine whether referral is needed. However, waiting 4–6 weeks for a valid repeat PSA would inappropriately delay referral in a person with a malignant-feeling prostate. B is appropriate for an isolated raised PSA obtained during or soon after urinary infection when rectal examination is not suspicious. C is similarly inappropriate because the examination finding requires an urgent, rather than routine, referral. D is tempting because prostatitis can elevate PSA, but the stem describes resolved infection and a focal hard irregular lesion rather than a tender, diffusely boggy prostate; empiric additional antibiotics must not delay cancer assessment. E ignores both persistent lower urinary tract symptoms and the abnormal rectal examination.

Reference: NICE NG12: Suspected cancer: recognition and referral — recommendations organised by site of cancer (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer NHS: PSA test (Last reviewed 2 September 2024) — https://www.nhs.uk/tests-and-treatments/psa-test/