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Suspected clinically localised prostate cancer with negative MRI and high PSA density — MSRA MCQ

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HardPSASuspected clinically localised prostate cancer with negative MRI and high PSA densityMSRA

A 59-year-old man is reviewed in urology after referral for nocturia and reduced urinary flow. He is of Black African-Caribbean family background and his father was diagnosed with prostate cancer aged 62 years. He has no dysuria, fever, pelvic pain, visible haematuria, urinary retention, recent catheterisation or urinary instrumentation. Midstream urine culture is negative, and he avoided ejaculation and vigorous cycling for 48 hours before testing. Digital rectal examination is benign. His PSA is 5.7 micrograms/L. Multiparametric MRI shows a Likert score of 2 and a prostate volume of 30 mL. He is fit for radical treatment should clinically significant prostate cancer be identified and wishes to proceed with further assessment. What is the most appropriate next management step?

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Correct answer: C — Offer a systematic prostate biopsy

The PSA density is 5.7/30 = 0.19 ng/mL/mL, which exceeds the NICE threshold of 0.15 ng/mL/mL indicating strong suspicion of clinically significant prostate cancer. Although a Likert 1 or 2 MRI can support omission of biopsy after shared decision-making, this is not appropriate where PSA density is above 0.15, particularly in a man fit for radical treatment who wishes to continue investigation. His Black African-Caribbean family background and first-degree family history further strengthen pre-test probability, while infection, retention, instrumentation, ejaculation and vigorous exercise have been excluded as explanations for the raised PSA. A systematic biopsy should therefore be offered. A repeat PSA at 3 to 6 months is appropriate after a negative MRI only when suspicion is low. Primary-care discharge with surveillance is likewise reserved for low suspicion. Repeating MRI delays diagnosis without addressing the high PSA density. Mapping transperineal template biopsy is not routinely recommended as part of the initial diagnostic assessment outside a clinical trial.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations Prostate Cancer Risk Management Programme: benefits and risks of PSA testing (2016) — https://www.gov.uk/government/publications/prostate-cancer-risk-management-programme-psa-test-benefits-and-risks/prostate-cancer-risk-management-programme-pcrmp-benefits-and-risks-of-psa-testing