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Possible prostate cancer — MSRA MCQ

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ModeratePSAPossible prostate cancerMSRA

A 58-year-old man presents to his GP with 5 months of nocturia, hesitancy and a reduced urinary stream. He also reports erectile dysfunction. Urinalysis and midstream urine culture are negative. He has no dysuria, fever, pelvic pain, visible haematuria, recent urinary retention, catheterisation or other urinary instrumentation. He has avoided ejaculation and vigorous cycling for 48 hours before testing. Digital rectal examination finds a smooth, symmetrically enlarged prostate. His PSA is 3.8 micrograms/L. He is otherwise fit, has no major comorbidity and wishes to undergo investigation if clinically indicated. What is the most appropriate next management step?

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

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

This man has lower urinary tract symptoms and erectile dysfunction, both of which are indications to assess for possible prostate cancer with PSA testing and digital rectal examination. His PSA is 3.8 micrograms/L. For a symptomatic man aged 50 to 59 years, the NICE age-specific PSA threshold for considering suspected cancer pathway referral is greater than 3.5 micrograms/L. He has no identified transient cause of PSA elevation, such as urinary infection or recent instrumentation, and he wishes to proceed with investigation. A benign digital rectal examination does not negate referral when the age-specific PSA threshold is exceeded. A is initially attractive because PSA can fluctuate, but repeat testing is not the recommended primary-care next step here where a symptomatic patient has a PSA above the relevant threshold without a reversible confounder. B and E inappropriately delay cancer assessment; lower urinary tract symptoms commonly arise from benign prostatic enlargement but do not explain away an above-threshold PSA. D is less appropriate because NICE specifies a suspected cancer pathway referral, rather than a routine referral, in this clinical context. Subsequent specialist investigation may include multiparametric MRI, but this does not replace the indicated referral.

Reference: NICE NG12: Suspected cancer: recognition and referral — Recommendations organised by site of cancer (2021) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer