CCE-CE-097

CASE INFORMATION

Case ID: CCE-2025-05
Case Name: Robert Wilson
Age: 68
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: Y77 (Malignant neoplasm, prostate)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Establishes rapport and engages with the patient empathetically.
1.2 Uses clear, patient-centred language to discuss concerns and test results.
1.4 Elicits the patient’s ideas, concerns, and expectations.
2. Clinical Information Gathering and Interpretation2.1 Takes a structured history, including urinary symptoms and risk factors.
2.2 Identifies indications for prostate cancer screening and further investigation.
2.3 Interprets PSA levels, DRE findings, and imaging results appropriately.
3. Diagnosis, Decision-Making and Reasoning3.1 Recognises early and late presentations of prostate cancer.
3.3 Determines when referral to a urologist is required.
4. Clinical Management and Therapeutic Reasoning4.1 Develops a shared decision-making approach regarding further investigations and treatment.
4.3 Explains treatment options (active surveillance, surgery, radiotherapy, hormonal therapy).
4.5 Coordinates multidisciplinary care (GP, urologist, oncologist).
5. Preventive and Population Health5.2 Discusses prostate cancer screening risks and benefits.
6. Professionalism6.1 Maintains empathetic and clear communication, particularly when discussing cancer diagnoses.
7. General Practice Systems and Regulatory Requirements7.2 Understands PSA screening recommendations and Medicare-funded testing.
9. Managing Uncertainty9.1 Recognises limitations of PSA testing and strategies for risk stratification.
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises aggressive vs. indolent prostate cancer and tailors management accordingly.

CASE FEATURES

  • Older male presenting with urinary symptoms and elevated PSA.
  • Discussing the possibility of prostate cancer with sensitivity.
  • Balancing risks and benefits of further testing and treatment.
  • Coordinating referral and multidisciplinary care.
  • Addressing the emotional and psychological impact of a potential cancer diagnosis.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

  1. Take an appropriate history.
  2. Outline the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

Robert Wilson, a 68-year-old retired engineer, presents to your clinic following a recent routine PSA test, which was elevated at 7.5 ng/mL (previously 4.2 ng/mL one year ago). He has noticed gradual worsening urinary symptoms over the past year, including hesitancy, weak stream, and nocturia (x2 per night).

He is worried about prostate cancer, as his older brother was diagnosed at 72. He has no history of bone pain, weight loss, or haematuria.

PATIENT RECORD SUMMARY

Patient Details

Name: Robert Wilson
Age: 68
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Amlodipine 5 mg OD (for hypertension)
  • Atorvastatin 20 mg OD (for hyperlipidaemia)

Past History

  • Hypertension (well controlled)
  • Hyperlipidaemia
  • No previous prostate issues

Family History

  • Brother diagnosed with prostate cancer at 72
  • Father had ischaemic heart disease

Smoking and Alcohol

  • Ex-smoker (quit 10 years ago, 20-pack-year history)
  • Drinks alcohol occasionally (1–2 standard drinks per week)

Vaccination and Preventative Activities

Regular health checks with GP

Routine vaccinations up to date

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I got my PSA results back, and I’m really worried. Does this mean I have prostate cancer?”

General Information

You are Robert Wilson, a 68-year-old retired engineer who recently had a routine PSA test, which came back higher than last year. Your PSA has risen from 4.2 ng/mL to 7.5 ng/mL in one year. You were not particularly concerned when your doctor ordered the test, but now that the result is higher, you are feeling anxious and uncertain.

Specific Information

(Revealed When Asked)

Background Information

Over the past year, you have noticed some urinary changes, but you thought it was just ageing. These include:

  • Weaker urine stream.
  • Needing to wait a few seconds before urination starts (hesitancy).
  • Waking up twice per night to urinate (nocturia).
  • Occasionally feeling like you haven’t emptied your bladder completely.

You do not have:

  • Blood in the urine.
  • Burning or pain while urinating.
  • Back pain, bone pain, or unexplained weight loss.

Your older brother was diagnosed with prostate cancer at 72, which makes you especially worried.

Symptoms and Concerns:

  • Your urinary symptoms have been gradual, not sudden.
  • You have no significant pain but sometimes feel mild discomfort in the perineal area.
  • You read online that prostate cancer can be aggressive, and you are worried that it has already spread.
  • You know some men with prostate cancer undergo surgery or radiation, and you’re worried about side effects like erectile dysfunction and incontinence.
  • You want to know if this PSA result confirms cancer or if it could be caused by something else.

Family and Medical History:

  • Older brother diagnosed with prostate cancer at 72 but doing well after treatment.
  • No personal history of prostate issues before this.
  • No previous PSA tests above 5.0 ng/mL.
  • No history of recurrent urinary infections or previous prostate biopsy.
  • Hypertension and hyperlipidaemia are well controlled with medications.

Lifestyle Factors:

  • You are an ex-smoker (quit 10 years ago, 20-pack-year history).
  • You drink 1–2 alcoholic drinks per week.
  • You stay active but have gained a little weight recently.

Emotional Cues and Body Language

  • Worried but trying to stay calm.
  • Fidgeting slightly when discussing cancer concerns.
  • Relieved if the doctor reassures you, but will still ask, “So how do we know for sure?”
  • If the doctor is unclear, you may become frustrated or push for immediate testing.

Patient Concerns and Questions

1. “Does this mean I have cancer?”

  • You are looking for a straightforward answer.
  • If the doctor says “Not necessarily,” you will ask, “Then why is my PSA going up?”
  • If the doctor talks about BPH (benign prostatic hyperplasia), you will ask, “How do we tell the difference between BPH and cancer?”

2. “What happens next? Do I need a biopsy?”

  • You are unsure about the testing process and want clear steps.
  • If the doctor suggests watchful waiting, you may ask, “But what if we delay and it gets worse?”

3. “What are my treatment options if this is cancer?”

  • You are worried about surgery and radiation.
  • You will ask about active surveillance vs. immediate treatment.
  • You are concerned about the risks and benefits of each option.

4. “What are the side effects of treatment?”

  • You are worried about erectile dysfunction and incontinence.
  • You may ask, “Will I still be able to have sex?”
  • If the doctor mentions hormonal therapy, you may ask, “Will that affect my energy levels or cause mood changes?”

5. “Could this just be an enlarged prostate?”

  • You have read about BPH (benign prostatic hyperplasia) and wonder if this could explain your symptoms instead.
  • You will ask, “Is there a way to know without doing a biopsy?”

6. “How fast does prostate cancer grow?”

  • You are concerned about whether you have time to consider your options or if urgent action is needed.

Possible Reactions Based on the Doctor’s Approach

If the doctor reassures you and explains things clearly:

  • You feel calmer and more open to discussion.
  • You accept the plan for further testing or watchful waiting if reasonable.

If the doctor is vague or dismissive:

  • You push for immediate referral and biopsy.
  • You may say, “I just want to be sure. Why not do a biopsy now?”

If the doctor provides too much information too quickly:

  • You may feel overwhelmed and struggle to process everything.
  • You may say, “That’s a lot to take in. What’s the first step?”

If the doctor presents options clearly:

  • You engage in shared decision-making.
  • You may say, “I want to know what’s best for my situation, but I don’t want to rush into unnecessary treatment.”

Your Expectations from This Consultation

  • You want a clear diagnosis—does this PSA level mean cancer or not?
  • You need to know what tests are next and whether a biopsy is required.
  • You want to understand treatment options, including their risks and benefits.
  • You are worried about quality of life, particularly side effects of treatment.
  • You need reassurance and a plan, but you don’t want false hope.

End of Consultation Cues

  • If the doctor provides clear reassurance and explains things well, you feel more confident in the next steps.
  • If the doctor brushes off your concerns, you push for immediate action.
  • If the doctor recommends a review in a few months, you may ask why a biopsy isn’t being done now.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including urinary symptoms, risk factors, and concerns.

The competent candidate should:

  • Elicit a detailed history of urinary symptoms, including:
    • Lower urinary tract symptoms (LUTS): hesitancy, weak stream, nocturia, incomplete emptying.
    • Haematuria, dysuria, or pain that could suggest malignancy or infection.
    • Bone pain, weight loss, or constitutional symptoms, which may indicate metastatic disease.
  • Assess past medical and family history, including:
    • History of benign prostatic hyperplasia (BPH) or recurrent urinary infections.
    • Family history of prostate cancer, particularly first-degree relatives.
    • Risk factors, including age, ethnicity, and lifestyle factors.
  • Explore patient concerns and expectations:
    • “What do you understand about prostate cancer?”
    • “What are your biggest worries about your PSA result?”
    • “What are you hoping to achieve with further investigations?”

Task 2: Interpret the PSA result and discuss further investigations.

The competent candidate should:

  • Interpret the PSA level (7.5 ng/mL) in context:
    • PSA elevation is concerning but not diagnostic of prostate cancer.
    • PSA can be elevated due to BPH, prostatitis, recent ejaculation, or instrumentation.
  • Determine next steps based on PSA and risk factors:
    • Given the PSA rise and urinary symptoms, a digital rectal examination (DRE) is warranted.
    • If DRE is abnormal (nodules, asymmetry, induration), urgent urology referral is required.
    • If DRE is normal, consider repeat PSA in 6 weeks or proceed with an MRI prostate.
  • Discuss possible need for further investigations:
    • Multiparametric MRI (mpMRI): helps determine the need for biopsy.
    • Prostate biopsy: indicated if MRI is suspicious (PI-RADS 3–5) or if concerns remain.

Task 3: Explain the likely diagnosis to the patient, addressing concerns empathetically.

The competent candidate should:

  • Reassure but provide realistic expectations:
    • “Your PSA is elevated, which means we need to investigate further, but it does not necessarily mean you have cancer.”
    • “There are other possible causes, including benign prostate enlargement or inflammation.”
  • Explain the role of further testing:
    • “The next step is a prostate exam and possibly an MRI to assess for concerning changes.”
    • “A biopsy may be needed if the MRI shows suspicious areas.”
  • Acknowledge the patient’s concerns and provide support:
    • “I understand that you are worried, especially given your brother’s history.”
    • “We will take a step-by-step approach and make decisions together based on results.”

Task 4: Develop a management plan, including referral, monitoring, and treatment options.

The competent candidate should:

  • Short-term plan:
    • Perform DRE and arrange mpMRI prostate.
    • If MRI is concerning, refer for urologist review and biopsy.
  • Discuss possible management pathways if cancer is diagnosed:
    • Active surveillance for low-risk disease.
    • Radical prostatectomy or radiotherapy for localised cancer.
    • Hormonal therapy or chemotherapy for metastatic disease.
  • Provide psychological support and safety-netting:
    • “If you notice worsening urinary symptoms or new pain, please return sooner.”
    • “If you have any concerns between appointments, we can discuss them at any time.”

SUMMARY OF A COMPETENT ANSWER

  • Elicits a structured history, focusing on urinary symptoms and cancer risk factors.
  • Interprets PSA appropriately, considering benign causes and need for further testing.
  • Communicates findings clearly, addressing patient concerns about cancer.
  • Develops an evidence-based management plan, including MRI and urology referral.
  • Provides reassurance and support, ensuring the patient feels heard.

PITFALLS

  • Failing to explore urinary symptoms fully, missing important red flags.
  • Over-reassuring without planning further investigation, delaying cancer diagnosis.
  • Not explaining the limitations of PSA testing, leading to patient confusion.
  • Omitting discussion of active surveillance, over-emphasising aggressive treatments.
  • Not considering psychological impact, failing to acknowledge patient anxiety.

REFERENCES

MARKING

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

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

Competency Areas Assessed

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history of urinary symptoms and prostate cancer risk.
2.2 Identifies indications for prostate cancer screening and further investigation.
2.3 Interprets PSA levels, DRE findings, and imaging results appropriately.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises early and late presentations of prostate cancer.
3.3 Determines when referral to a urologist is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a shared decision-making approach regarding further investigations and treatment.
4.3 Explains treatment options (active surveillance, surgery, radiotherapy, hormonal therapy).
4.5 Coordinates multidisciplinary care (GP, urologist, oncologist).

5. Preventive and Population Health

5.2 Discusses prostate cancer screening risks and benefits.

7. General Practice Systems and Regulatory Requirements

7.2 Understands PSA screening recommendations and Medicare-funded testing.

Competency at Fellowship Level

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