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Biochemical relapse after radical prostatectomy — MSRA MCQ

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HardPSABiochemical relapse after radical prostatectomyMSRA

A 67-year-old man has PSA monitoring in primary care after radical prostatectomy 2 years ago for CPG 3 localised prostate cancer. His postoperative PSA was undetectable. Using the same assay, his PSA has subsequently risen from 0.18 ng/mL 8 months ago, to 0.26 ng/mL 4 months ago, and 0.37 ng/mL today. He has no bone pain, weight loss, neurological symptoms or troublesome urinary symptoms. He is fit for further radical treatment and wishes to pursue treatment if recurrence 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: A — Arrange specialist assessment for salvage prostatic-bed radiotherapy with PSA-doubling-time calculation

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

This is biochemical relapse after radical prostatectomy: PSA should be undetectable after surgery, and he has two PSA results of at least 0.2 ng/mL with a sustained rise. He is fit for radical salvage treatment and has no features suggesting metastatic disease. He should therefore be referred to the specialist prostate cancer team for consideration of salvage radiotherapy to the prostatic bed. PSA doubling time should also be estimated, as there are three measurements spanning more than 6 months. A is incorrect because NICE advises against biopsy of the prostatic bed after radical prostatectomy. B is inappropriate because androgen-deprivation therapy is not routinely indicated for biochemical relapse alone; it is reserved for symptomatic local progression, proven metastases, or a PSA doubling time below 3 months. C is incorrect because routine MRI is not recommended before salvage radiotherapy in this setting. E inappropriately delays salvage assessment despite confirmed biochemical relapse in a man suitable for radical treatment.

Reference: NICE NG131: Prostate cancer: diagnosis and management, Managing relapse after radical treatment (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management, recommendation 1.3.59 (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NHS Scotland Cancer Collaborative Clinical Management Pathway: Prostate cancer surgery (2025) — https://www.rightdecisions.scot.nhs.uk/nhs-scotland-cancer-collaborative-clinical-management-pathways/prostate-cancer/surgery/