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Suspected prostate cancer — MSRA MCQ

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ModerateProstate CancerSuspected prostate cancerMSRA

A 62-year-old man presents with 3 months of nocturia, urinary hesitancy and reduced urinary stream. He has no dysuria, fever, perineal pain, visible haematuria, bone pain or unintentional weight loss. Urine dipstick is negative for blood, leucocytes and nitrites. His PSA is 3.9 micrograms/L, measured before digital rectal examination; he has had no recent urinary tract infection, catheterisation, ejaculation or vigorous cycling. Digital rectal examination identifies a focal hard, irregular area in the right lobe of the prostate. He is fit for radical treatment should clinically significant cancer be diagnosed. What is the most appropriate next management step?

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Correct answer: A — Refer using the suspected cancer pathway for prostate cancer

The hard, irregular focal abnormality on digital rectal examination is the discriminating feature. NICE recommends suspected cancer pathway referral when the prostate feels malignant on DRE; this recommendation does not depend on PSA exceeding the age-specific threshold. Although his PSA of 3.9 micrograms/L is below the NICE referral threshold of more than 4.5 micrograms/L for symptomatic men aged 60 to 69 years, a non-elevated PSA does not negate a clinically malignant-feeling prostate. A repeat PSA at either 6 weeks or 3 to 6 months would be reasonable where DRE is benign and the decision depends on a borderline or potentially transient PSA elevation, but would inappropriately delay assessment here. An alpha-blocker may improve coexisting benign outlet symptoms, but should not substitute for urgent cancer referral when examination is suspicious. Routine urology referral also fails to reflect the cancer risk sign identified on DRE. The appropriate action is suspected cancer pathway referral, alongside clear explanation that referral is precautionary and that benign pathology remains possible.

Reference: NICE NG12: Suspected cancer: recognition and referral — recommendations organised by site of cancer (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer