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Suspected metastatic prostate cancer — MSRA MCQ

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HardPSASuspected metastatic prostate cancerMSRA

A 76-year-old man presents with 4 months of worsening lower back pain, nocturia and unintentional weight loss. He has no leg weakness, saddle sensory disturbance, bladder or bowel dysfunction, fever, or features of acute urinary retention. Digital rectal examination finds a hard, irregular prostate. PSA is 146 micrograms/L and alkaline phosphatase is raised. A pelvic radiograph, requested for persistent hip pain, shows multiple sclerotic bone lesions. He is fit enough for systemic treatment. What is the most appropriate immediate diagnostic management plan?

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

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Correct answer: D — Arrange urgent urology or uro-oncology assessment without obtaining a prostate biopsy

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

This presentation gives a very high clinical suspicion of metastatic prostate cancer: a malignant-feeling prostate on DRE, markedly elevated PSA and sclerotic bone lesions. NICE recommends suspected-cancer-pathway referral when the prostate feels malignant on DRE. In the specific situation of a high PSA with radiological evidence of bone metastases, NICE advises against prostate biopsy for histological confirmation unless required for a clinical trial. Urgent specialist assessment is therefore appropriate to coordinate staging, treatment planning and symptom management. A is inappropriate because prostate MRI is not required before referral and does not supersede the biopsy exception where metastatic disease is already evident. B is the key error: biopsy can cause harm and is not routinely required in this high-suspicion metastatic presentation. D would inappropriately delay assessment; repeat testing is useful where PSA elevation may be transient or diagnostic uncertainty remains, neither of which applies here. E would be indicated urgently if there were symptoms or signs suggesting metastatic spinal cord compression, but he has no neurological deficit, sphincter disturbance or saddle sensory change.

Reference: NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy recommendations (Last updated 15 December 2021; last reviewed 13 August 2025) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral — Prostate cancer recommendation 1.6.1 (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer