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Suspected clinically localised prostate cancer — MSRA MCQ

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ModerateMRISuspected clinically localised prostate cancerMSRA

A 62-year-old man consults his GP with 8 months of nocturia, urinary frequency and reduced urinary stream. He has no dysuria, fever, pelvic pain, visible haematuria or recent urinary tract infection. Digital rectal examination finds a smooth, symmetrically enlarged prostate with no nodules or induration. His PSA is 5.4 micrograms/L, confirmed on a repeat sample taken 2 weeks later. He is fit, with an estimated life expectancy of more than 10 years. What is the most appropriate next step?

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Correct answer: C — Arrange a suspected cancer pathway referral for secondary-care multiparametric MRI before any biopsy decision

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

This man has lower urinary tract symptoms and a PSA of 5.4 micrograms/L. For men aged 60 to 69 years, the NICE age-specific PSA threshold for suspected prostate cancer pathway referral is greater than 4.5 micrograms/L. A benign-feeling prostate does not negate that referral indication. Following referral with suspected clinically localised prostate cancer, NICE recommends multiparametric MRI (mpMRI) as the first-line investigation; biopsy is then guided by the MRI result, with MRI-influenced biopsy offered for a Likert score of 3 or more. A is inappropriate because delaying for a further PSA is not the recommended primary-care action once symptomatic PSA exceeds the age-specific threshold. B under-triages a possible cancer presentation. D is attractive because mpMRI is the appropriate diagnostic test, but NICE locates this investigation after referral to secondary care rather than as a strategy to determine whether referral is needed in primary care. E reverses the recommended sequence: routine pre-MRI systematic biopsy may expose the patient to avoidable biopsy and can be less informative than an MRI-directed approach.

Reference: NICE NG12: Suspected cancer: recognition and referral — Prostate cancer (2015; updated 2021) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy (2019) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations