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Suspected prostate cancer — MSRA MCQ

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HardPSASuspected prostate cancerMSRA

A 57-year-old man reports 6 months of nocturia, hesitancy and reduced urinary flow. He also reports erectile dysfunction. He has taken finasteride 5 mg daily for benign prostatic enlargement for 10 months, with good adherence. He has no dysuria, fever, pelvic pain, visible haematuria, urinary retention, recent urinary instrumentation or urinary infection. He avoided ejaculation and vigorous cycling for 48 hours before testing. Digital rectal examination shows a smooth, symmetrically enlarged prostate. Urine culture is negative. PSA is 1.9 micrograms/L. He is fit, wishes to pursue investigation if indicated, and would accept treatment for clinically significant prostate cancer. 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: C — Discuss and make a suspected cancer pathway referral for prostate cancer

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

Finasteride 5 mg reduces PSA by about 50% after at least 6 months of treatment; therefore, this PSA of 1.9 micrograms/L should be interpreted as approximately 3.8 micrograms/L when compared with thresholds for untreated men. He has symptoms for which NICE advises PSA testing and DRE, and at age 57 the NICE suspected-cancer threshold is a PSA greater than 3.5 micrograms/L. His adjusted PSA exceeds this threshold. His preference for investigation and fitness for treatment further support referral. A smooth DRE does not exclude prostate cancer, and benign enlargement may coexist with cancer. Starting an alpha-blocker (A) may be reasonable for symptom relief after the cancer pathway decision, but it must not replace appropriate referral. Stopping finasteride (B) is unnecessary: the SmPC provides a validated adjustment for PSA interpretation and a sustained rise or concerning adjusted value requires evaluation. Repeating PSA after 3 months (C) may seem attractive for a borderline result, but there are no transient PSA confounders here and the adjusted result already exceeds the age-specific referral threshold. Routine urology referral (E) under-prioritises a presentation meeting criteria for a suspected cancer pathway referral.

Reference: NICE NG12: Suspected cancer: recognition and referral — Prostate cancer recommendations (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