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Possible prostate cancer in a man taking finasteride for androgenetic alopecia — MSRA MCQ

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HardPSAPossible prostate cancer in a man taking finasteride for androgenetic alopeciaMSRA

A 53-year-old man presents in primary care with 6 months of nocturia, hesitancy and reduced urinary flow. He also reports erectile dysfunction. He has taken finasteride 1 mg daily for androgenetic alopecia for 14 months and reports good adherence. Urinalysis and midstream urine culture are negative. He has no fever, dysuria, pelvic pain, visible haematuria, urinary retention, urinary catheterisation, urinary instrumentation, ejaculation or vigorous cycling within the preceding 48 hours. Digital rectal examination is benign. His PSA is 1.9 micrograms/L. He is fit for radical treatment should clinically significant prostate cancer be diagnosed and wishes to pursue investigation. What is the most appropriate next management step?

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Correct answer: C — Make a suspected cancer pathway referral for prostate cancer

This man should be referred on a suspected cancer pathway. NICE advises considering such referral in symptomatic men aged 50–59 years when PSA is above 3.5 micrograms/L, taking account of comorbidity and preference. Although his measured PSA is 1.9 micrograms/L, he has used finasteride for longer than 6 months. The finasteride 1 mg SmPC states that PSA is reduced during treatment and that doubling the PSA should be considered before interpreting the result. His adjusted PSA is therefore approximately 3.8 micrograms/L, above the relevant age-specific threshold. A repeat PSA is reasonable when a transient cause of elevation is suspected, but infection, retention, instrumentation, ejaculation and vigorous cycling have been excluded; it would inappropriately delay referral here. Stopping finasteride to obtain an unadjusted PSA is unnecessary because the SmPC provides an interpretation adjustment. An alpha-blocker may subsequently be appropriate for bothersome LUTS, but symptomatic treatment must not replace cancer assessment when the adjusted PSA meets the referral threshold. Reassurance based on the unadjusted result fails to account for finasteride-associated PSA suppression.

Reference: NICE NG12: Suspected cancer: recognition and referral — Recommendations organised by site of cancer (2021) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer Propecia 1 mg Film-Coated Tablets — Summary of Product Characteristics (14 July 2026) — https://www.medicines.org.uk/emc/product/2194/smpc