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Benign prostatic hyperplasia — MSRA MCQ

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HardBPHBenign prostatic hyperplasiaMSRA

A 69-year-old man is reviewed 14 months after starting tamsulosin MR 400 micrograms daily and finasteride 5 mg daily for bothersome LUTS due to BPH (prostate volume 56 mL; baseline PSA 2.8 micrograms/L). His urinary symptoms are now well controlled. He reports noticing a painless lump beneath his left nipple 5 weeks ago. Examination confirms a discrete 2 cm unilateral subareolar breast lump. There is no contralateral breast enlargement, skin inflammation or recent chest trauma. He has no fever or weight loss. What is the most appropriate next management step?

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Correct answer: B — Make a suspected cancer pathway referral for breast cancer

This man requires a suspected cancer pathway referral for breast cancer. NICE recommends this for any person aged 30 years or over with an unexplained breast lump, whether or not it is painful. A discrete new unilateral lump in a 69-year-old man meets this criterion. The absence of constitutional symptoms does not reduce the need for referral. Finasteride can cause breast symptoms, including gynaecomastia, and male breast cancer has been reported during clinical trials and post-marketing surveillance. However, possible drug causation must not be assumed before malignancy has been excluded. Stopping finasteride and observing the lump would therefore inappropriately delay investigation. Endocrine testing may be appropriate later if specialist assessment supports gynaecomastia, but it is not the priority now. Switching to dutasteride is also inappropriate because it is another 5-alpha-reductase inhibitor and does not address the cancer risk. A routine referral fails to use the indicated cancer pathway. His well-controlled LUTS do not alter the priority of investigating the breast lump.

Reference: Suspected cancer: recognition and referral (NG12) — Recommendations organised by site of cancer, section 1.4 Breast cancer (2015 (updated 2025)) — 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 (19 July 2024) — https://www.medicines.org.uk/emc/product/9958/smpc