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Possible prostate cancer — MSRA MCQ

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HardPSAPossible prostate cancerMSRA

A 48-year-old man presents with 4 months of nocturia, hesitancy and reduced urinary stream, and reports new erectile dysfunction. Urinalysis and midstream urine culture are negative. He has no fever, pelvic pain, visible haematuria, recent urinary instrumentation or acute urinary retention. Digital rectal examination is benign. He takes finasteride 1 mg daily for androgenetic alopecia and has done so consistently for 18 months. He has not ejaculated, cycled or undertaken vigorous exercise during the preceding 48 hours. His PSA is 2.1 micrograms/L. He is fit, would accept investigation and treatment if indicated, and wishes to proceed. What is the most appropriate next management step?

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

Reveal the answer and explanation

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

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

Finasteride lowers PSA, including when prescribed at 1 mg for androgenetic alopecia. In men taking finasteride, the measured PSA should be interpreted with consideration of an approximate doubling. This patient’s PSA of 2.1 micrograms/L therefore corresponds to an untreated-equivalent value of approximately 4.2 micrograms/L. He has possible prostate-cancer symptoms (lower urinary tract symptoms and erectile dysfunction), no urinary infection or other identified transient cause of PSA elevation, and is aged 48 years. NICE advises considering a suspected cancer pathway referral in symptomatic people aged 40 to 49 years when PSA is above 2.5 micrograms/L. A benign DRE does not override an elevated appropriately interpreted PSA. A is inappropriate because stopping finasteride to obtain an unadjusted result delays assessment and is unnecessary: the SmPC provides the adjustment needed for interpretation. B wrongly treats presumed benign prostatic enlargement without addressing a PSA level above the referral threshold. C under-triages a person who meets criteria for a suspected cancer pathway referral. D may be reasonable where a transient cause or an equivocal unadjusted result needs clarification, but here the result is interpretable, pre-test confounders have been excluded and the adjusted PSA exceeds the age-specific threshold.

Reference: NICE NG12: Suspected cancer: recognition and referral — Prostate cancer recommendations (Updated April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer Propecia 1 mg Film-Coated Tablets — Summary of Product Characteristics, section 4.4 (Updated 14 July 2026) — https://www.medicines.org.uk/emc/product/2194/smpc NHS: PSA test — Preparing for a PSA test (2024) — https://www.nhs.uk/tests-and-treatments/psa-test/