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Possible prostate cancer — MSRA MCQ

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HardPSAPossible prostate cancerMSRA

A 74-year-old man presents with progressive nocturia, hesitancy and reduced urinary flow. He has taken finasteride 5 mg daily for benign prostatic enlargement for 18 months with good adherence. His PSA was 2.0 micrograms/L after 6 months of treatment, 2.4 micrograms/L after 12 months, and is now 2.7 micrograms/L, measured using the same assay. Urinalysis and midstream urine culture are negative. He has had no recent urinary retention, catheterisation, instrumentation, ejaculation or vigorous cycling. Digital rectal examination identifies a hard, irregular right-sided prostatic nodule. He is fit for radical treatment if clinically significant prostate cancer is diagnosed and wishes to pursue investigation. What is the most appropriate next management step?

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

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

A suspected cancer pathway referral for prostate cancer is indicated now because the prostate feels malignant on digital rectal examination. NICE recommends this referral independently of the PSA result or age-specific PSA threshold. Finasteride complicates PSA interpretation: after at least 6 months of treatment, the measured PSA should be doubled for comparison with ranges in untreated men. His current PSA of 2.7 micrograms/L therefore approximates to 5.4 micrograms/L. This remains below the NICE referral threshold of more than 6.5 micrograms/L for a symptomatic man aged 70–79 years, so PSA alone would not mandate referral. However, that does not override the suspicious rectal examination. His serial PSA rise while taking finasteride is also concerning and merits evaluation, but it is not a reason to delay referral where a malignant-feeling nodule is present. A and C inappropriately defer urgent assessment to obtain further PSA confirmation. D is inappropriate because stopping finasteride delays investigation and is unnecessary for PSA interpretation. E neglects a potentially malignant examination finding; symptomatic treatment may be considered separately but must not substitute for urgent referral.

Reference: NICE NG12: Suspected cancer: recognition and referral — Recommendations organised by site of cancer (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer Finasteride 5 mg film-coated tablets — Summary of Product Characteristics (Updated 2025) — https://www.medicines.org.uk/emc/product/13543/smpc