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Possible prostate cancer — MSRA MCQ

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ModerateUrologyPossible prostate cancerMSRA

A 53-year-old man presents with 4 months of nocturia, hesitancy and reduced urinary flow. He has also developed erectile dysfunction. He has no dysuria, fever, perineal pain, visible haematuria or bone pain. Urine dipstick is negative for blood, nitrites and leucocytes. Digital rectal examination shows a smooth, symmetrically enlarged prostate. Following discussion of the limitations of PSA testing, his PSA is 3.8 micrograms/L. He has no major comorbidity and would accept investigation if indicated. What is the most appropriate next management step?

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Correct answer: C — Discuss and arrange a suspected cancer pathway referral for prostate cancer

This man has possible symptoms of prostate cancer: lower urinary tract symptoms and erectile dysfunction. For men aged 50 to 59 years, NICE uses an age-specific PSA threshold of more than 3.5 micrograms/L when considering suspected cancer pathway referral. His PSA of 3.8 micrograms/L therefore exceeds the relevant threshold. A smooth prostate on digital rectal examination does not exclude cancer and should not override an elevated age-specific PSA result. In a fit man who would accept investigation, the appropriate action is to discuss and arrange suspected cancer pathway referral. Starting an alpha-blocker may improve symptoms from coexistent benign prostatic enlargement, but it must not delay cancer referral in this setting. Repeating PSA before referral may be appropriate where there is a plausible transient cause of elevation or uncertainty about test validity, but none is provided here. A routine referral is insufficient because the PSA exceeds the NICE threshold for this symptomatic age group. Reassurance alone incorrectly applies a fixed PSA threshold of 4 micrograms/L and disregards the age-specific threshold.

Reference: NICE NG12: Suspected cancer: recognition and referral — Recommendations organised by site of cancer (2015, updated 2025) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer