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Suspected prostate cancer — MSRA MCQ

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ModeratePSASuspected prostate cancerMSRA

A 56-year-old man presents with 4 months of nocturia, hesitancy and reduced urinary stream. He also reports erectile dysfunction. Urinalysis and midstream urine culture are negative. He has no fever, pelvic pain, visible haematuria, urinary retention, recent urinary instrumentation, ejaculation or vigorous cycling within 48 hours. His PSA is 3.2 micrograms/L. Digital rectal examination identifies a discrete hard, irregular nodule in the right lobe of the prostate. He is fit for radical treatment should clinically significant prostate cancer be diagnosed. What is the most appropriate next management step?

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

This man requires a suspected cancer pathway referral because his prostate feels malignant on digital rectal examination (DRE). NICE recommends referral on this basis irrespective of the PSA result. His PSA of 3.2 micrograms/L is below the age-specific referral threshold for symptomatic men aged 50 to 59 years (>3.5 micrograms/L), but this threshold applies to referral decisions based on PSA; it does not negate a suspicious DRE finding. A repeat PSA is appropriate when a result may have been transiently elevated by factors such as urinary infection, ejaculation or vigorous exercise, or where a raised PSA needs confirmation. Here, these confounders have been excluded and the decisive finding is the hard irregular nodule. Starting an alpha-blocker may eventually help coexisting lower urinary tract symptoms, but must not delay cancer referral. Multiparametric MRI is the first-line diagnostic investigation in secondary care for suspected localised prostate cancer, rather than an investigation that should delay an urgent referral from general practice. Surveillance based on repeat PSA alone is inappropriate because a malignant-feeling prostate warrants urgent specialist assessment even when PSA is below the age-specific threshold.

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 NHS: PSA test (02 September 2024) — https://www.nhs.uk/tests-and-treatments/psa-test/?wpmobileexternal=true