skip to main content

Possible prostate cancer — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

ModeratePSAPossible prostate cancerMSRA

A 74-year-old man presents with 5 months of nocturia, hesitancy and reduced urinary flow. He also reports erectile dysfunction. Urinalysis and midstream urine culture are negative. He has no dysuria, fever, pelvic pain, visible haematuria, urinary retention or recent urinary instrumentation. Digital rectal examination shows a smooth, symmetrically enlarged prostate. PSA is 6.6 micrograms/L. He is otherwise fit, has no important comorbidity, and would accept investigation and treatment for clinically significant prostate cancer if indicated. What is the most appropriate next management step?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

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

This man has lower urinary tract symptoms and erectile dysfunction, both of which are possible symptoms of prostate cancer for which PSA testing and DRE are appropriate. In symptomatic people aged 70 to 79 years, NICE uses a PSA referral threshold of more than 6.5 micrograms/L. His PSA of 6.6 micrograms/L is therefore above the age-specific threshold. He is fit and wishes to pursue investigation, supporting referral on the suspected cancer pathway despite a benign-feeling prostate. A routine referral is less appropriate because he meets the NICE threshold for suspected cancer pathway referral. Starting an alpha-blocker may improve presumed benign prostatic enlargement symptoms, but must not defer cancer-pathway assessment in this setting. Repeating PSA before referral is attractive because the result is borderline, but there is no active infection, retention or instrumentation to explain a transient elevation, and the PSA already exceeds the referral threshold. Annual PSA surveillance is appropriate only after risk assessment where referral is not indicated or following specialist advice; it is not appropriate here.

Reference: Suspected cancer: recognition and referral (NG12), recommendations organised by site of cancer (Recommendation amended 2021; page crawled July 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer