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Suspected clinically localised prostate cancer with low-suspicion MRI and persistently concerning PSA-derived

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HardProstate CancerSuspected clinically localised prostate cancer with low-suspicion MRI and persistently concerning PSA-derived riskMSRA

A 61-year-old man is reviewed in urology after investigation for an elevated PSA. Four months ago, his PSA was 5.8 micrograms/L. Multiparametric MRI showed a 40 mL prostate and a Likert score of 2; after discussion, he chose not to have an immediate biopsy. He has no urinary infection, catheterisation, acute urinary retention or prostatitis symptoms. His father was diagnosed with prostate cancer aged 68 years. He is otherwise well, has an estimated life expectancy of more than 10 years, and his repeat PSA is now 7.0 micrograms/L. What is the most appropriate next management step?

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Correct answer: D — Offer a systematic prostate biopsy after discussing its benefits and risks

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

The appropriate next step is to offer a systematic prostate biopsy. Although his MRI is Likert 2, a low-suspicion MRI does not exclude clinically significant prostate cancer. NICE advises repeating PSA after 3 to 6 months in people with raised PSA and MRI Likert 1 or 2 who have not had a biopsy, then offering biopsy where there is strong suspicion of cancer. This man has several convergent indicators of strong suspicion. His current PSA density is 7.0/40 = 0.175 ng/mL/mL, exceeding the NICE example threshold of 0.15. His PSA has increased by 1.2 micrograms/L over 4 months, equivalent to an approximate velocity of 3.6 micrograms/L/year, also well above the example threshold of 0.75 micrograms/L/year. In addition, he has a first-degree family history and sufficient life expectancy to benefit from diagnosis and possible radical treatment. A is appropriate only when suspicion remains low after reassessment. B delays investigation despite both adverse PSA-derived measures. C is not the recommended substitute for biopsy in this situation. D is inappropriate because a Likert 2 MRI does not provide a suspicious target; if biopsy is undertaken after low-suspicion MRI, it should be systematic.

Reference: NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy recommendations (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy recommendations (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations