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

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HardPSAPersistently raised PSA after low-risk MRI and negative prostate biopsyMSRA

A 68-year-old man is reviewed in urology after investigation for a persistently raised PSA. Six months ago, his PSA was 4.9 micrograms/L, multiparametric MRI showed a Likert score of 2 and prostate volume was 38 mL. He underwent systematic prostate biopsy, which showed no malignancy. His PSA is now 5.5 micrograms/L using the same assay. He has no urinary infection, recent instrumentation, ejaculation or vigorous cycling before either PSA measurement. Digital rectal examination is benign. He is fit for radical treatment, has an estimated life expectancy of more than 10 years and wishes to pursue further investigation if indicated. What is the most appropriate next management plan?

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Correct answer: C — Offer a repeat prostate biopsy after discussion of risks and benefits

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

The appropriate next step is to offer repeat prostate biopsy. Although the MRI was low risk (Likert 2) and PSA density is below the example threshold for strong suspicion (5.5/38 = 0.145 ng/mL/mL), his PSA has increased by 0.6 micrograms/L over 6 months: a PSA velocity of 1.2 ng/mL/year. This exceeds NICE's example threshold of 0.75 ng/mL/year for strong suspicion of prostate cancer after a negative MRI and negative biopsy. His fitness, life expectancy and willingness to accept radical treatment support further diagnostic investigation. A is appropriate only where suspicion is low after reassessment. B would be reasonable if the planned 3- to 6-month reassessment had not yet occurred, or if PSA kinetics were not concerning. D may appear attractive because MRI can be repeated in selected circumstances, but NICE specifically advises offering biopsy when suspicion remains strong after a low-risk MRI and negative biopsy. E is incorrect because NICE does not recommend Prostate Health Index testing in people being investigated for suspected prostate cancer after a negative or inconclusive biopsy.

Reference: NICE NG131: Prostate cancer: diagnosis and management — recommendations 1.2.12 and 1.2.13 (Published 2019; last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations