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Possible prostate cancer in a symptomatic man taking finasteride — MSRA MCQ

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HardPSAPossible prostate cancer in a symptomatic man taking finasterideMSRA

A 47-year-old man presents with 5 months of nocturia, urinary frequency and reduced urinary flow. He also reports erectile dysfunction. He has taken finasteride 1 mg daily for androgenetic alopecia for 18 months. Urinalysis and midstream urine culture are negative. He has had no urinary retention, catheterisation, urinary instrumentation, ejaculation or vigorous cycling within the preceding 48 hours. Digital rectal examination shows a smooth, symmetrically enlarged prostate. His PSA is 1.4 micrograms/L. He has no major comorbidity, is fit for radical treatment if clinically significant prostate cancer is diagnosed, and wishes to pursue investigation if indicated. What is the most appropriate next management step in primary care?

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Correct answer: B — Arrange a suspected cancer pathway referral for prostate cancer

This man has symptoms for which NICE advises considering PSA testing and digital rectal examination. For symptomatic people aged 40 to 49 years, a PSA above 2.5 micrograms/L supports consideration of a suspected cancer pathway referral. Although his measured PSA is 1.4 micrograms/L, finasteride can lower PSA. The SmPC for finasteride 1 mg states that doubling the PSA should be considered before interpreting the result. His adjusted PSA is therefore approximately 2.8 micrograms/L, above the age-specific threshold. With confounding causes of PSA elevation excluded, benign DRE does not negate the referral indication. A repeat PSA is appropriate where a transient elevation is suspected, but there is no such trigger here and it would delay assessment of an adjusted result above threshold. Stopping finasteride to obtain an untreated value is unnecessary and similarly delays referral. A routine urology referral underestimates the cancer risk after PSA adjustment. Managing presumed benign prostatic enlargement alone is inappropriate because lower urinary tract symptoms and a smooth enlarged prostate do not exclude prostate cancer.

Reference: NICE NG12: Suspected cancer: recognition and referral — recommendations organised by site of cancer (Updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer Propecia 1 mg Film-Coated Tablets — Summary of Product Characteristics (2026) — https://www.medicines.org.uk/emc/product/2194/smpc