EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for John’s urinary symptoms?

• Prompt: How do you differentiate between benign and malignant causes?
• Prompt: What features would make you suspect prostate cancer over benign prostatic hyperplasia (BPH)?

Q2. What further history and investigations would be useful in this case?

• Prompt: What risk factors would you assess?
• Prompt: What further tests would confirm or rule out malignancy?

Q3. How would you explain the diagnosis and next steps to John?

• Prompt: How do you communicate the suspicion of prostate cancer empathetically?
• Prompt: How do you discuss biopsy and referral options?

Q4. Outline your management plan for John’s suspected prostate cancer.

• Prompt: When would you refer to a urologist?
• Prompt: What are the treatment options, and how do you involve John in shared decision-making?

Q5. What are the key preventive health considerations for John?

• Prompt: How do you discuss prostate cancer screening in asymptomatic men?
• Prompt: What other preventive measures are relevant at his age?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for John’s urinary symptoms?

A structured differential diagnosis is essential to differentiate benign vs malignant causes of lower urinary tract symptoms (LUTS).

• Benign Causes (most likely):
  • Benign prostatic hyperplasia (BPH): Most common cause in older men; symptoms include hesitancy, weak stream, nocturia, post-micturition dribbling. Prostate is usually symmetrically enlarged and smooth.
  • Urinary tract infection (UTI): Typically associated with dysuria, frequency, urgency, suprapubic pain. Less common in men but possible, especially with urinary stasis from BPH.
  • Prostatitis: Acute (infectious, associated with fever, perineal pain, dysuria) or chronic (more subtle LUTS with pelvic discomfort).
• Malignant Causes (must be considered due to red flags):
  • Prostate cancer: Symptoms overlap with BPH but may include asymmetry, nodularity, firm texture on DRE, and elevated PSA. Advanced disease may cause bone pain, weight loss, haematuria.
  • Bladder cancer: Presents with painless haematuria, voiding dysfunction, or recurrent UTIs.
  • Urethral stricture or neurogenic bladder: Less common, usually secondary to past trauma, infections, or neurological conditions.

A competent candidate prioritises prostate cancer given the irregular nodule on DRE and elevated PSA, while considering BPH as a common cause.

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Q2: What further history and investigations would be useful in this case?

• Further History:
  • Systemic symptoms: Weight loss, fatigue, back pain (suggests metastases).
  • Haematuria or blood in semen: Concerning for malignancy.
  • Erectile dysfunction or perineal pain: May indicate local invasion.
  • Family history: Prostate, bladder, or other cancers.
  • Medication history: Anticholinergics, diuretics affecting urination.
• Investigations:
  • Confirmatory Tests:
    • Repeat PSA in 6 weeks if mildly elevated to assess persistence.
    • Free/Total PSA Ratio: Low free PSA (<10%) suggests malignancy.
  • Imaging and Specialist Referral:
    • Multiparametric MRI of the prostate (if PSA remains elevated or DRE suspicious).
    • Transrectal ultrasound (TRUS)-guided biopsy if high suspicion of cancer.
  • Metastatic Workup (if indicated):
    • Bone scan or CT abdomen/pelvis for suspected metastases.

A competent candidate tailors investigations based on clinical findings, avoiding unnecessary testing while ensuring timely diagnosis.

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Q3: How would you explain the diagnosis and next steps to John?

1. Acknowledge concerns:
   • “I understand that you’re worried about your urinary symptoms and the possibility of cancer.”
2. Explain findings:
   • “Your prostate examination revealed a firm, irregular area, and your PSA is elevated. These findings mean we need further tests to check for prostate cancer.”
3. Discuss next steps:
   • “The next step is an MRI to assess the prostate in more detail. If the MRI confirms a suspicious area, a biopsy will be needed to determine if cancer is present.”
4. Reassure about treatment options:
   • “Even if prostate cancer is diagnosed, it is often slow-growing and has many treatment options. Some cases do not require immediate treatment.”
5. Provide safety-netting:
   • “If you develop bone pain, difficulty passing urine, or unexpected weight loss, please let me know as soon as possible.”

A competent candidate communicates clearly, reassures appropriately, and involves the patient in decision-making.

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Q4: Outline your management plan for John’s suspected prostate cancer.

1. Referral and Further Testing:
   • Urgent referral to a urologist for MRI and possible biopsy.
   • Consider repeat PSA in 6 weeks if borderline elevation.
2. Discuss Treatment Pathways (if cancer confirmed):
   • Active surveillance (for low-risk cases, involves regular PSA and MRI).
   • Radical prostatectomy (for localised disease in younger patients).
   • Radiotherapy (external beam or brachytherapy).
   • Androgen deprivation therapy (ADT) (for metastatic disease).
3. Multidisciplinary Team Involvement:
   • Oncologist if cancer is locally advanced or metastatic.
   • General practitioner ongoing monitoring for LUTS and treatment side effects.
4. Psychosocial Support:
   • Discuss sexual health and continence issues.
   • Provide resources such as Prostate Cancer Foundation of Australia.

A competent candidate ensures timely referral, explains treatment options, and provides holistic support.

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Q5: What are the key preventive health considerations for John?

1. Prostate Cancer Screening:
   • “For men aged 50–69, PSA testing is an option after discussing risks and benefits.”
   • “As you have a family history, screening can be considered earlier.”
   • Follow RACGP and NHMRC guidelines, emphasising shared decision-making.
2. General Health Maintenance:
   • Cardiovascular risk reduction: Blood pressure, lipids, diabetes screening.
   • Bowel cancer screening: FOBT every 2 years from age 50–74.
   • Vaccinations: Influenza, pneumococcal, and COVID-19 boosters.
3. Lifestyle Advice:
   • Healthy diet, regular exercise, weight management.
   • Reduce alcohol intake and avoid smoking.

A competent candidate takes an opportunistic approach to prevention, ensuring holistic care beyond prostate health.

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SUMMARY OF A COMPETENT ANSWER

• Differentiates between benign and malignant causes of urinary symptoms.
• Recognises red flags suggestive of prostate cancer (DRE abnormality, elevated PSA).
• Orders appropriate investigations, including MRI, biopsy, and PSA monitoring.
• Communicates sensitively and clearly, addressing patient concerns.
• Develops an evidence-based management plan, including urology referral and treatment discussions.
• Implements preventive strategies, including screening recommendations and lifestyle advice.

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PITFALLS

• Failing to consider prostate cancer and assuming LUTS is only due to BPH.
• Not performing a DRE, missing a key diagnostic clue.
• Over-relying on PSA alone without considering MRI or biopsy.
• Failing to discuss active surveillance as an option for low-risk cases.
• Not addressing patient concerns adequately, leading to anxiety or misinformation.

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REFERENCES

• RACGP – RACGP Guidelines on PSA Testing
• Cancer Council Australia – Prostate Cancer Guidelines
• GP Exams – Malignant neoplasm prostate

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communicates effectively and appropriately to provide quality care.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information effectively.
2.3 Identifies red flags and important diagnostic features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies a structured approach to making a diagnosis.
3.3 Identifies and manages urgent and serious conditions.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD