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Persistently raised PSA after negative MRI and negative prostate biopsy — MSRA MCQ

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HardPSAPersistently raised PSA after negative MRI and negative prostate biopsyMSRA

A 66-year-old man is reviewed in urology following investigation of a raised PSA. Eight months ago, his PSA was 5.2 micrograms/L, digital rectal examination was benign, multiparametric MRI showed a Likert score of 2 and prostate volume of 44 mL, and systematic prostate biopsy was negative. He chose surveillance. PSA was 5.5 micrograms/L 4 months ago and is now 5.8 micrograms/L, measured using the same assay. He has no urinary infection, retention, catheterisation, instrumentation, ejaculation or vigorous cycling in the preceding 48 hours. He has no family history of prostate cancer and remains fit for radical treatment if clinically significant disease is identified. What is the most appropriate next management plan?

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

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Correct answer: C — Offer a repeat prostate biopsy

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

This man has a previous negative MRI (Likert 2) and negative biopsy, but his PSA kinetics now create a strong suspicion of clinically significant prostate cancer. PSA has increased from 5.2 to 5.8 micrograms/L over 8 months, giving an approximate PSA velocity of 0.9 ng/mL/year, exceeding the NICE example threshold of 0.75 ng/mL/year. His PSA density is 5.8/44 = 0.13 ng/mL/mL, below 0.15, but a raised PSA velocity is independently an example of strong suspicion. NICE recommends offering prostate biopsy after a negative MRI and biopsy when strong suspicion persists, taking account of fitness and life expectancy; both favour further investigation here. A is appropriate only when suspicion is low after negative MRI and biopsy. B wrongly overlooks that serial PSA measurements have already demonstrated concerning kinetics. D may be considered in some local pathways, but repeat MRI alone does not address NICE's recommendation to offer biopsy when suspicion is high. E is incorrect because NICE does not recommend Prostate Health Index testing in people being investigated after a negative or inconclusive biopsy.

Reference: NICE NG131: Prostate cancer: diagnosis and management, Recommendations 1.2.10–1.2.13 (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: May 2025 and August 2025 exceptional surveillance of prostate cancer: diagnosis and management (13 August 2025) — https://www.nice.org.uk/guidance/ng131/evidence/may-2025-exceptional-surveillance-of-prostate-cancer-diagnosis-and-management-nice-guideline-ng131-15368818141