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Localised prostate cancer on active surveillance — MSRA MCQ

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HardPSALocalised prostate cancer on active surveillanceMSRA

A 64-year-old man is followed in primary care under an agreed active-surveillance protocol for CPG 1 localised prostate cancer (ISUP Grade Group 1, cT1c). His baseline PSA at enrolment was 4.0 ng/mL. PSA values using the same assay were 4.8 ng/mL 6 months ago, 6.1 ng/mL this month and 6.2 ng/mL on repeat testing 4 weeks later. He has no urinary symptoms, bone pain, weight loss or neurological symptoms. Urine culture is negative, he has had no recent urinary instrumentation, and he avoided ejaculation and vigorous cycling before both recent tests. He remains fit for radical treatment if needed. What is the most appropriate next management plan?

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Correct answer: D — Refer for active-surveillance reassessment with multiparametric MRI and/or repeat biopsy before deciding on radical treatment

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

This PSA pattern requires reassessment of active surveillance rather than simple continuation or immediate treatment. The PSA has risen by more than 20% between consecutive measurements and by more than 50% over 12 months; the latter rise has been confirmed on repeat testing. Infection, recent instrumentation and avoidable transient PSA influences have been excluded, making the change clinically meaningful. NICE advises reassessment with multiparametric MRI and/or re-biopsy if there is concern about PSA or clinical change during active surveillance. PSA kinetics can indicate possible progression but do not, alone, establish pathological progression or mandate radical treatment. The reassessment findings, alongside the patient's preferences, comorbidity and life expectancy, should guide whether continued surveillance or radical treatment is appropriate. A is inappropriate because the confirmed PSA kinetics warrant earlier reassessment. B is not indicated for an asymptomatic man with localised disease and no proven metastases. C is not the next routine investigation in an otherwise asymptomatic man with PSA progression on surveillance. E is premature because evidence of disease progression should be established and treatment chosen through shared decision-making after reassessment.

Reference: NICE NG131: Prostate cancer: diagnosis and management — active surveillance protocol and treatment recommendations (2019, amended 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management — Box 2, treatment options for localised prostate cancer (2019, amended 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations