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Suspected clinically localised prostate cancer with low-suspicion MRI but high PSA density and PSA velocity —

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HardProstate CancerSuspected clinically localised prostate cancer with low-suspicion MRI but high PSA density and PSA velocityMSRA

A 65-year-old man is reviewed in urology after investigation for a persistently raised PSA. Four months ago, his PSA was 5.2 micrograms/L, DRE was benign, and multiparametric MRI showed a Likert score of 2 with a prostate volume of 28 mL. After discussion, he initially chose PSA surveillance rather than biopsy. His repeat PSA is now 6.1 micrograms/L. He has had no urinary infection, catheterisation, ejaculation or vigorous cycling in the preceding 48 hours. He is well, has no significant comorbidity, and would accept radical treatment if clinically significant cancer were found. What is the most appropriate next management step?

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Correct answer: E — Offer a systematic prostate biopsy after discussing its risks and benefits

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

This man has a low-suspicion MRI (Likert 2), for which biopsy can often be omitted after shared decision-making. However, his subsequent risk assessment is no longer low. His PSA density is 6.1/28 = 0.22 ng/mL/mL, exceeding the NICE example threshold of 0.15 ng/mL/mL. His PSA velocity is also approximately 2.7 ng/mL/year over 4 months, well above the NICE example threshold of 0.75 ng/mL/year. He is fit for, and would consider, radical treatment. He should therefore be offered biopsy. A is inappropriate because discharge with PSA follow-up is for low clinical suspicion after low-risk MRI. B delays diagnosis despite both PSA density and velocity indicating strong suspicion. C is not the recommended next step: the decision to biopsy after a Likert 1–2 MRI should be guided by repeat PSA and clinical risk factors, which are already concerning here. D is best; where biopsy is undertaken after a Likert 1–2 MRI, NICE advises systematic biopsy. E is inappropriate because there is no MRI-visible suspicious lesion to target; targeted-only sampling risks missing clinically significant disease.

Reference: NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy; management after negative/low-suspicion MRI (Updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy (Updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations