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Localised prostate cancer on active surveillance — MSRA MCQ

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HardPSALocalised prostate cancer on active surveillanceMSRA

A 63-year-old man is on active surveillance for Cambridge Prognostic Group 1 localised prostate cancer. His diagnostic MRI was Likert 2 and systematic biopsy showed ISUP Grade Group 1 disease in 2 of 12 cores. He has chosen active surveillance because he wishes to avoid treatment-related adverse effects. During year 1 of surveillance, PSA values using the same assay have risen from 3.8 ng/mL at enrolment, to 4.7 ng/mL after 4 months, and 5.1 ng/mL after a further 6 weeks. He had no urinary infection, retention, instrumentation, ejaculation or vigorous exercise in the 48 hours before either repeat test. Digital rectal examination remains benign. He is fit for radical treatment if progression is confirmed. 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 — Reassess with multiparametric MRI and consider repeat MRI-influenced biopsy

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

The confirmed, clinically meaningful PSA rise during active surveillance is a trigger for reassessment, not an automatic indication for radical treatment. He has had serial measurements with the same assay, relevant transient causes of PSA elevation have been excluded, and the increase from 3.8 to 5.1 ng/mL over approximately 5.5 months gives concerning PSA kinetics. NICE advises reassessment with multiparametric MRI and/or re-biopsy whenever there is concern about PSA or clinical change during active surveillance. This determines whether there is radiological or histological progression before changing management. B is inappropriate because this is not a stable PSA pattern suitable for simply continuing routine surveillance. C and D are premature: a PSA rise alone does not establish pathological progression, and treatment choice should follow reassessment and shared decision-making if progression is demonstrated. E is incorrect because androgen-deprivation therapy is not treatment for a PSA rise during active surveillance of localised disease; biochemical relapse terminology applies after radical treatment.

Reference: NICE NG131: Prostate cancer: diagnosis and management, active surveillance protocol (Last updated December 2021; checked August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management, active surveillance and radical treatment (Last updated December 2021; checked August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management, managing relapse after radical treatment (Last updated December 2021; checked August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations