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Benign prostatic enlargement with rising PSA during finasteride treatment — MSRA MCQ

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HardLUTSBenign prostatic enlargement with rising PSA during finasteride treatmentMSRA

A 66-year-old man is reviewed for benign prostatic enlargement. Eighteen months ago he started finasteride 5 mg once daily plus tamsulosin after assessment for bothersome moderate LUTS; his pre-treatment PSA was 2.6 micrograms/L and DRE was benign. His urinary symptoms have improved and he confirms adherence. PSA at 6 months was 1.2 micrograms/L. At routine review today it is 2.4 micrograms/L, and a repeat sample 6 weeks later is 2.5 micrograms/L. He has no dysuria, fever, haematuria, perineal pain or recent urinary instrumentation. Urine culture is negative. DRE remains smoothly enlarged with no focal abnormality. He is fit for investigation and treatment if required. What is the most appropriate next management step?

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Correct answer: E — Make a suspected cancer pathway referral for prostate cancer while continuing current treatment

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

This man requires suspected cancer pathway referral. After at least 6 months of finasteride, measured PSA should be doubled when compared with reference ranges in untreated men. His repeat PSA of 2.5 micrograms/L therefore corresponds approximately to 5.0 micrograms/L. In a man aged 60–69 years with LUTS, this exceeds the NICE age-specific referral threshold of 4.5 micrograms/L. Additionally, the PSA has shown a confirmed increase from the finasteride-treated nadir (1.2 to 2.5 micrograms/L), which the SmPC states should be carefully evaluated because it may indicate prostate cancer, even where an unadjusted value appears unremarkable. A is inappropriate because the abnormality has already been confirmed and delaying referral risks missed clinically significant cancer. B is unnecessary: stopping finasteride delays assessment and PSA interpretation remains valid when adjusted. D under-triages a patient meeting suspected-cancer referral criteria; a benign DRE does not negate the PSA-based indication. E has no role: 5 mg daily is the licensed finasteride dose for BPH, and dose escalation would not address the cancer concern.

Reference: NICE NG12: Suspected cancer: recognition and referral, recommendations 1.6.2–1.6.3 and Table 2 (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, section 4.4 (17 September 2025) — https://www.medicines.org.uk/emc/product/13543/smpc