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Suspected prostate cancer — MSRA MCQ

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HardPSASuspected prostate cancerMSRA

A 64-year-old man presents with 4 months of nocturia, urinary frequency and reduced urinary flow. He has no bone pain, weight loss or visible haematuria. Urinalysis is positive for nitrites and leucocytes, and a midstream urine culture subsequently grows Escherichia coli. He is systemically well and is started on culture-directed antibiotics. A PSA sample taken at presentation is 5.2 micrograms/L. Digital rectal examination identifies a firm, irregular left-sided prostatic nodule. He is fit for radical treatment should clinically significant prostate cancer be diagnosed. What is the most appropriate next management step?

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Correct answer: D — Make a suspected cancer pathway referral now while treating the urinary tract infection

A malignant-feeling prostate on digital rectal examination requires a suspected cancer pathway referral, irrespective of the PSA result. This man has a firm, irregular focal nodule, so referral should not be deferred while awaiting resolution of his culture-confirmed urinary tract infection. His PSA is also above the NICE age-specific threshold for a symptomatic man aged 60 to 69 years (>4.5 micrograms/L), although infection makes its immediate diagnostic interpretation less reliable. A is appropriate only where the decision to refer depends on a potentially infection-related PSA elevation and examination is not malignant. B addresses short-lived effects of ejaculation or vigorous cycling, not the more important confounder of proven urinary infection. C incorrectly downgrades urgency despite a malignant DRE. D incorrectly makes repeat PSA confirmation a prerequisite for urgent referral; repeat PSA after infection resolution may still be clinically useful, but must not delay the cancer pathway referral in this case.

Reference: Suspected cancer: recognition and referral (NG12), recommendations organised by site of cancer (Updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer PSA test (2024) — https://www.nhs.uk/tests-and-treatments/psa-test/?wpmobileexternal=true