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Persistently raised PSA after negative MRI and negative prostate biopsy — MSRA MCQ

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HardProstate CancerPersistently raised PSA after negative MRI and negative prostate biopsyMSRA

A 66-year-old man was referred with a PSA of 5.0 micrograms/L. Digital rectal examination was benign and multiparametric MRI showed a Likert score of 2 with a prostate volume of 40 mL. After counselling, he elected to undergo a systematic transperineal biopsy, which showed no malignancy. Four months later, repeat PSA is 5.2 micrograms/L, measured using the same assay. He has had no urinary infection, retention, catheterisation, ejaculation or vigorous cycling before either PSA test. He has no first-degree relative with prostate cancer, is fit for radical treatment if needed, and remains asymptomatic. What is the most appropriate next management plan?

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Correct answer: E — Discharge to primary care with PSA measurement every 2 years and a re-referral threshold based on PSA density or PSA velocity

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

This man has both a low-risk MRI (Likert 2) and a negative biopsy. His repeat PSA should now be interpreted using PSA density and kinetics rather than the absolute PSA alone. PSA density is 5.2/40 = 0.13 ng/mL/mL, below the NICE threshold of greater than 0.15. PSA velocity is 0.2 ng/mL over 4 months, equivalent to 0.6 ng/mL/year, below the threshold of greater than 0.75 ng/mL/year. He also has no strong family history or other stated reason for persistent high clinical suspicion. NICE therefore advises discharge to primary care after repeat PSA at 3–6 months in people with a raised PSA, MRI Likert 1–2 and a negative biopsy when suspicion is low. The follow-up interval is every 2 years. This differs from the pathway for a low-risk MRI without a previous biopsy, for which PSA follow-up is at 6 months and then annually. A and B are appropriate when suspicion remains high; MDT discussion with possible repeat biopsy is specifically relevant after a negative biopsy with MRI Likert 3 or more. C applies to low-risk MRI without a biopsy, not after a negative biopsy. E adds intensive surveillance without a guideline-based trigger.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations, section 1.2 Assessment and diagnosis (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations