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Possible prostate cancer in a man taking finasteride for benign prostatic enlargement — MSRA MCQ

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ModeratePSAPossible prostate cancer in a man taking finasteride for benign prostatic enlargementMSRA

A 61-year-old man presents with persistent nocturia, hesitancy and reduced urinary flow, and has recently developed erectile dysfunction. He has taken finasteride 5 mg daily for benign prostatic enlargement for 10 months and reports good adherence. Urinalysis and midstream urine culture are negative. He has no dysuria, fever, pelvic pain, visible haematuria, urinary retention, recent urinary instrumentation, ejaculation or vigorous cycling within 48 hours. Digital rectal examination shows a smooth, symmetrically enlarged prostate. His PSA is 2.6 micrograms/L. He is fit for radical treatment should clinically significant prostate cancer be diagnosed. What is the most appropriate next management step?

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

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Correct answer: C — Refer using a suspected cancer pathway for prostate cancer

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

This man has possible symptoms of prostate cancer: lower urinary tract symptoms and erectile dysfunction. Although his measured PSA is 2.6 micrograms/L, finasteride 5 mg lowers PSA by approximately 50%. After at least 6 months of treatment, the SmPC advises doubling the measured PSA for comparison with reference ranges. His adjusted PSA is therefore approximately 5.2 micrograms/L. For a symptomatic man aged 60 to 69 years, NICE advises considering suspected cancer pathway referral when PSA is greater than 4.5 micrograms/L. His adjusted value exceeds this threshold, so referral is appropriate despite a benign digital rectal examination. B is appropriate in selected specialist-led pathways after a low-suspicion MRI assessment, but not for an initial PSA result above the referral threshold. C underestimates the cancer risk and delays the indicated pathway. D may be appropriate for benign LUTS only after appropriate cancer assessment; it does not address the raised adjusted PSA. E is inappropriate because finasteride should not be stopped to interpret PSA: its established effect is accounted for by doubling the result.

Reference: Suspected cancer: recognition and referral (NG12), recommendations organised by site of cancer (2021) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer Finasteride 5 mg Tablets - Summary of Product Characteristics, section 4.4 (2025) — https://www.medicines.org.uk/emc/product/547/smpc