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Benign prostatic enlargement treated with finasteride, with a rising PSA requiring prostate cancer assessment

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ModerateBPHBenign prostatic enlargement treated with finasteride, with a rising PSA requiring prostate cancer assessmentMSRA

A 64-year-old man is reviewed 18 months after starting tamsulosin MR 400 micrograms daily and finasteride 5 mg daily for bothersome voiding LUTS due to benign prostatic enlargement (prostate volume 54 mL). His symptoms have improved and he wishes to continue treatment. Before treatment, his PSA was 3.0 micrograms/L and DRE was benign. PSA at 6 months was 1.4 micrograms/L. At routine review his PSA is 2.7 micrograms/L; a repeat sample 4 weeks later is 2.8 micrograms/L. He has no urinary infection, recent catheterisation, ejaculation or vigorous cycling. DRE remains smooth and benign. He is fit for investigation and treatment if indicated. What is the most appropriate next management step?

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Correct answer: D — Make a suspected cancer pathway referral for prostate cancer while continuing current treatment

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

Finasteride reduces serum PSA by approximately 50%. After at least 6 months of treatment, the measured PSA should therefore be doubled when comparing it with reference values for untreated men. His repeated PSA of 2.8 micrograms/L equates to an adjusted PSA of approximately 5.6 micrograms/L. For a man aged 60–69 years with LUTS, NICE recommends considering a suspected cancer pathway referral when PSA exceeds 4.5 micrograms/L. This patient has a confirmed rise from his finasteride-associated nadir, no recognised reversible cause of PSA elevation, and an adjusted result above the age-specific threshold. A benign DRE does not remove the indication for referral. Finasteride and tamsulosin can be continued because they are controlling his LUTS; stopping finasteride is not required to interpret PSA once the appropriate adjustment has been made. A is insufficient because the PSA already meets criteria for expedited assessment. C would delay evaluation without improving interpretation. D is inappropriate: 5 mg daily is the licensed finasteride dose. E is unsupported because he has no symptoms or microbiological evidence of infection.

Reference: Finasteride 5 mg film-coated tablets - Summary of Product Characteristics (Updated 2025) — https://www.medicines.org.uk/emc/product/13543/smpc NICE NG12: Suspected cancer: recognition and referral — prostate cancer recommendations (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE CG97: Lower urinary tract symptoms in men: management (Last updated 3 June 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations