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Suspected prostate cancer — MSRA MCQ

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HardPSASuspected prostate cancerMSRA

A 68-year-old man presents with 5 months of nocturia, hesitancy and a weak urinary stream. Urine dipstick and midstream urine culture are negative. He has no fever, dysuria, recent catheterisation or urinary instrumentation. He is otherwise fit and would accept investigation and treatment if indicated. His PSA is 4.2 micrograms/L. Digital rectal examination identifies a hard, irregular area in the right lobe of the prostate. What is the most appropriate next management step?

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Correct answer: B — Make a suspected cancer pathway referral for prostate cancer now

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

The correct action is a suspected cancer pathway referral now. NICE recommends referral for prostate cancer when the prostate feels malignant on digital rectal examination (DRE). This is an independent referral criterion and is not negated by a PSA below the age-specific PSA threshold. For symptomatic people aged 60 to 69 years, the PSA threshold for considering referral on the basis of PSA is more than 4.5 micrograms/L; this patient’s PSA of 4.2 micrograms/L does not meet that separate criterion. However, the hard, irregular DRE finding takes priority. The negative urine assessment and absence of recent infection remove a reason to defer interpretation of the PSA. A is inappropriate because repeating PSA would delay referral despite a malignant-feeling prostate. C is plausible because his symptoms are compatible with benign prostatic enlargement, but treatment of presumed benign disease must not replace cancer referral. D under-triages a finding requiring the suspected cancer pathway. E is inappropriate because MRI-based diagnostic assessment is normally organised within the specialist prostate-cancer pathway rather than used in primary care to decide whether a malignant DRE warrants referral.

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