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CPG1 localised prostate cancer managed with active surveillance — MSRA MCQ

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HardProstate CancerCPG1 localised prostate cancer managed with active surveillanceMSRA

A 62-year-old man is followed in primary care under an agreed shared-care active surveillance protocol for CPG1 localised prostate adenocarcinoma. Initial MRI was Likert 2; systematic biopsy showed Gleason score 3+3=6 (grade group 1) cancer in 2 of 14 cores. His baseline PSA was 4.0 micrograms/L and clinical stage was cT1c. Using the same assay, PSA results at 3, 6 and 9 months are 4.1, 4.9 and 6.2 micrograms/L respectively. He has no urinary infection, retention, catheterisation, ejaculation or vigorous cycling before testing. He is asymptomatic, DRE remains unchanged, and he would accept radical treatment if disease progression were confirmed. What is the most appropriate next management step?

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Correct answer: B — Arrange early urology reassessment with multiparametric MRI and consideration of repeat prostate biopsy before deciding on radical treatment

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

This PSA pattern is concerning during active surveillance: it represents a greater than 20% rise between consecutive measurements and a confirmed rise of more than 50% within 12 months. Transient causes of PSA elevation have been excluded. However, a PSA rise alone does not establish pathological progression requiring immediate radical treatment. NICE advises reassessment with multiparametric MRI and/or repeat biopsy whenever there is concern about PSA or clinical change during active surveillance. This distinguishes true grade or volume progression from PSA variation due to benign prostatic enlargement or other non-malignant causes, and retains the patient within the window for curative treatment. B is premature because radical prostatectomy should follow confirmation of progression or an informed preference for treatment, not PSA kinetics alone. C fails to respond to a clearly concerning kinetic change. D is not appropriate for CPG1 localised disease under surveillance and would not be a curative strategy. E is disproportionate in an asymptomatic man with low-risk localised cancer; metastatic imaging is not the immediate investigation for an isolated PSA rise in this setting.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Table 2: Protocol for active surveillance (2019, amended 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management — Box 2 and recommendations 1.3.15 to 1.3.16 (2019, amended 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations