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Localised Cambridge Prognostic Group 3 prostate adenocarcinoma — MSRA MCQ

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HardProstate CancerLocalised Cambridge Prognostic Group 3 prostate adenocarcinomaMSRA

A 63-year-old man has newly diagnosed prostate adenocarcinoma. Multiparametric MRI shows a 38 mL prostate with an organ-confined cT2a lesion. MRI-influenced biopsy shows Gleason score 3+4=7 (grade group 2) adenocarcinoma in 4 of 16 cores. His PSA is 15.8 micrograms/L. He has no symptoms of metastatic disease, is fit for radical treatment and has an estimated life expectancy of more than 10 years. Following counselling, he is particularly concerned about erectile and urinary adverse effects and does not want immediate surgery or radiotherapy, but would accept regular monitoring and radical treatment if there is evidence of progression. What is the most appropriate management recommendation?

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

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Correct answer: A — Offer radical prostatectomy or radical radiotherapy, while considering active surveillance because he does not want immediate radical treatment

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

This man has Cambridge Prognostic Group (CPG) 3 localised prostate cancer: grade group 2 disease (Gleason 3+4) together with a PSA between 10 and 20 micrograms/L and T1–T2 stage disease. For CPG 3 cancer, NICE recommends offering radical prostatectomy or radical radiotherapy because the greater risk of prostate-cancer mortality means that the expected survival benefit generally outweighs treatment harms. However, active surveillance may be considered when a person chooses not to have immediate radical treatment. His informed preference, fitness for later curative treatment and willingness to adhere to surveillance make this the relevant exception. A is incorrect because active surveillance is not the default first-line recommendation for CPG 3 disease; radical treatment should be offered. C is inappropriate because watchful waiting has no curative intent and is generally used when radical treatment is unsuitable or unwanted in a context where active monitoring for curative intervention is not intended. D is not an appropriate substitute for curative treatment in otherwise localised, potentially curable disease. E incorrectly treats CPG 3 as an absolute contraindication to active surveillance; this prohibition applies to CPG 4 and 5 disease, not CPG 3.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management — Rationale and impact, CPG 3 prostate cancer (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Rationale-and-impact NICE diagnostics assessment report: MRI fusion biopsy in people with suspected prostate cancer (2025) — https://www.nice.org.uk/guidance/htg678/documents/diagnostics-assessment-report