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Possible prostate cancer in a man taking finasteride for benign prostatic hyperplasia — MSRA MCQ

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HardProstate CancerPossible prostate cancer in a man taking finasteride for benign prostatic hyperplasiaMSRA

A 68-year-old man attends for review of worsening nocturia and urinary frequency. He has taken finasteride 5 mg daily for benign prostatic hyperplasia for 18 months and reports good adherence. His PSA before finasteride was 4.8 micrograms/L; after 6 months of treatment it was 2.1 micrograms/L. PSA measured today is 2.9 micrograms/L. Digital rectal examination shows a smoothly enlarged prostate without nodularity or induration. He has no dysuria, fever, perineal pain, urinary retention, recent catheterisation, ejaculation or vigorous cycling. Urine dipstick is negative for blood, leucocytes and nitrites. What is the most appropriate next management step?

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Correct answer: D — Refer using a suspected cancer pathway referral for prostate cancer

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

This man requires a suspected cancer pathway referral. NICE advises considering such referral in men with lower urinary tract symptoms whose PSA exceeds the age-specific threshold; for men aged 60–69 years, this is more than 4.5 micrograms/L. Finasteride lowers PSA by about 50%; after at least 6 months of treatment, the measured PSA should therefore be doubled when comparing it with usual reference ranges. His PSA of 2.9 micrograms/L is equivalent to approximately 5.8 micrograms/L, above the referral threshold. It has also risen substantially from his finasteride-treated nadir, which the SmPC states should be evaluated. A routine referral in A is insufficiently urgent given the adjusted PSA. B is initially attractive because PSA can be transiently elevated, but the stem excludes common reversible causes and the adjusted result already meets NICE referral criteria. D is inappropriate because there are no clinical or laboratory features of urinary infection or prostatitis; empirical antibiotics should not be used to defer cancer assessment. E is unsafe because stopping finasteride delays assessment and is unnecessary for interpreting PSA: adjustment is valid after 6 months of treatment.

Reference: NICE NG12: Suspected cancer: recognition and referral — Prostate cancer recommendations (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer Finasteride 5 mg film-coated tablets — Summary of Product Characteristics (2025) — https://www.medicines.org.uk/emc/product/13543/smpc