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Possible prostate cancer — MSRA MCQ

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ModeratePSAPossible prostate cancerMSRA

A 49-year-old man presents with 6 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, 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 and wishes to pursue investigation if indicated. What is the most appropriate next management step?

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

This man has symptoms for which NICE recommends PSA testing and digital rectal examination, including lower urinary tract symptoms and erectile dysfunction. For symptomatic people aged 40–49 years, the NICE PSA threshold for considering a suspected cancer pathway referral is a PSA concentration of more than 2.5 micrograms/L. His PSA of 2.6 micrograms/L therefore exceeds the relevant age-specific threshold. His fitness for radical treatment and preference for investigation support referral. A repeat PSA is appropriate when there is a likely transient cause of elevation, such as urinary infection, recent retention, instrumentation, ejaculation or vigorous cycling; these have been excluded here. Starting an alpha-blocker may improve LUTS but should not delay investigation of a PSA above the age-specific threshold. A routine urology referral does not reflect the suspected-cancer referral pathway indicated by the PSA result. A PSA below 4 micrograms/L is not reassuring in this age group because NICE uses age-specific rather than a universal 4 micrograms/L threshold. A benign DRE does not negate an elevated age-specific PSA result.

Reference: Suspected cancer: recognition and referral (NG12) – Recommendations organised by site of cancer (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer