Clinically localized prostate cancer

Question 1

What should be obtained for risk stratification of prostate cancer?

Answer 1

risk stratification of prostate cancer severity or aggressiveness should include PSA, clinical stage digital rectal exam (DRE), Grade Group, and amount of cancer on biopsy (i.e. number of cores involved, maximum involvement of any single core) PSA density, and imaging

Question 2

What are the various risk categories for Prostate cancer?

Answer 2

Very low risk
low risk
favorable intermediate
unfavorable intermed
high risk

Question 3

What are the criteria for very low risk prostate cancers?

Answer 3

2 or fewer cores
less than 50% of a core
Gleason 3+3/GG-1
PSA < 10
PSA density <0.15

Question 4

What are the criteria for low risk prostate cancer?

Answer 4

PSA <10
and
Grade group 1
and
Stage T1-T2a

Question 5

What are the criteria for favorable intermediate risk?

Answer 5

Grade group 1 with PSA 10-20
or
Grade group 2 with PSA < 10

Question 6

What are the criteria for unfavorable intermediate risk prostate cancer?

Answer 6

GG 2 with PSA 10-20
or 
Clinical stage T2b-c
or 
GG3 with PSA <20

Question 7

What are the criteria for high risk prostate cancer?

Answer 7

PSA >20
or 
GG 4-5
or  
clinical stage T3 or greater

Question 8

How should clinical decision making about prostate cancer treatment be approached

Answer 8

With Shared decision making

Question 9

What behavioral modification should be included in counseling a patient with prostate cancer?

Answer 9

Smoking and obesity.

Question 10

Imaging for low or very low risk prostate cancer?

Answer 10

Clinicians should not perform abdomino-pelvic CT or routine bone scans in the staging of asymptomatic very low- or low-risk localized prostate cancer patients.

Question 11

What is the recommended treatment option for very low risk prostate cancer?

Answer 11

Clinicians should recommend active surveillance as the best available care option for very low-risk localized prostate cancer patients

Question 12

What is the rate of metastatic progression for very low risk prostate cancer at 15 years?

Answer 12

<1%

Question 13

What is the recommended treatment for most low risk prostate cancer patients?

Answer 13

Active surveillance is the recommended option. Prostatectomy and radiation may be offered if there seems to be a greater risk of progression.

Question 14

What are the clinical predictors of increased risk of progression?

Answer 14

Clinical predictors for an increased risk of higher grade disease or reclassification of subsequent biopsy include PSA density > 0.15, obesity as measured by BMI, African American race, family history, and extensive Gleason 6 cancer on systematic biopsy cores

Question 15

Role of ADT for low risk localized prostate cancer?

Answer 15

Clinicians should not add ADT along with radiotherapy for low-risk localized prostate cancer with the exception of reducing the size of the prostate for brachytherapy.

Question 16

What is the role of cyrosurgery in the low risk prostate cancer population?

Answer 16

Clinicians should inform low-risk prostate cancer patients considering whole gland cryosurgery that consequent side effects are considerable and survival benefit has not been shown in comparison to active surveillance

Question 17

What is the role of HIFU and focal therapy for low risk prostate cancer patients?

Answer 17

HIFU and focal therapy lack robust evidence and are therefore not considered standard of care.

Question 18

What are the recommended treatment options for a patient with < 5 years life expectancy and prostate cancer?

Answer 18

Men with a life expectancy of ≤5 years do not benefit from prostate cancer screening,79 diagnosis, or treatment. Prostate cancer treatment does not improve survival within five years of follow-up

Question 19

A patient has unfavorable intermediate risk prostate cancer on biopsy. What additional workup is recommended?

Answer 19

Clinicians should consider staging unfavorable intermediate-risk localized prostate cancer patients with cross sectional imaging (CT or MRI) and bone scan

Question 20

Specifically what findings should guide the physician to seek metastatic staging?

Answer 20

metastasis staging for men with two or more of the following features – palpable nodule on DRE (stage T2b/c), Gleason 7 (3+4 or 4+3) or PSA >10.

Question 21

What are the NCCN/ACR recommendations for obtaining a bone scan?

Answer 21

bone scan for T2 and PSA >10 and CT if T2 and have a nomogram probability for nodal involvement >10%

Question 22

What are the recommended treatment options patient’s with intermediate risk localized prostate cancer?

Answer 22

Clinicians should recommend radical prostatectomy or radiotherapy plus androgen deprivation therapy (ADT) as standard treatment options for patients with intermediate-risk localized prostate cancer.

Question 23

What was the risk reduction of prostatectomy for intermediate risk prostate cancer per the SPCG-4 trial?

Answer 23

relative risk of dying after surgery was observed to be reduced at 0.62 (95% CI 0.44 to 0.87, p=0.01) with a reduction of cumulative incidence of death from prostate cancer from 20.7% to 14.6% at fifteen years.

Question 24

What are the tx options other than prostatectomy for a patient with favorable intermediate risk prostate cancer?

Answer 24

Active surveillance
EBRT +/- ADT
Cryosurgery

Question 25

What are the recommendations for EBRT +/- ADT?

Answer 25

Clinicians should inform patients that favorable intermediate-risk prostate cancer can be treated with radiation alone, but that the evidence basis is less robust than for combining radiotherapy with ADT.

Question 26

What patient’s may benefit most from Cryotherapy?

Answer 26

Whole gland ablative therapies such as cryosurgery may be appropriate for patients with contraindications to more traditional therapies, such as prostatectomy or radiotherapy (e.g. medically inoperable patients with either previous pelvic radiotherapy or autoimmune disorders).

Question 27

What additional work up my be necessary for intermediate risk prostate cancer patients who are considering active surveillance?

Answer 27

Patients who are considering surveillance may benefit from an MRI and targeted biopsy

Question 28

Patient with intermediate risk prostate cancer and less than 5 year life expectancy?

Answer 28

Observation or watchful waiting.

Question 29

Role of HIFU or focal therapy for intermediate risk patients?

Answer 29

Not standard of care

Question 30

Patient with high risk prostate cancer. What additional workup would be recommended?

Answer 30

Clinicians should stage high-risk localized prostate cancer patients with cross sectional imaging (CT or MRI) and bone scan.

Question 31

Does PSA predict diagnostic efficacy of a bone scan?

Answer 31

PSA <10 ng/ml has a negative predictive value of 99.5% for significant findings on bone scan, and <1% of patients with PSA < 20ng/ml have positive bone scans or CTs

Question 32

What are the recommended tx options for high risk prostate cancer?

Answer 32

Clinicians should recommend radical prostatectomy or radiotherapy plus androgen deprivation therapy as standard treatment options for patients with high-risk localized prostate cancer.

Question 33

What is the efficacy of radical prostatectomy for high risk patients?

Answer 33

The SPCG-4 trial compared radical prostatectomy and watchful waiting.96 At 15 years, all-cause mortality favored radical prostatectomy (46.1% versus 52.7%, RR, 0.75; 95% CI, 0.61 to 0.92), and prostate cancer-specific mortality favored radical prostatectomy (14.6% versus 20.7%, RR, 0.62; 95% CI, 0.44 to 0.87)

Question 34

Patient presents with high risk localized prostate cancer and wants active surveillance?

Answer 34

Clinicians should not recommend active surveillance for patients with high-risk localized prostate cancer. Watchful waiting should only be considered in asymptomatic men with limited life expectancy (≤5 years).

Question 35

What is the risk of dying from gleason 8-10 prostate cancer?

Answer 35

Men with Gleason 8-10 tumors had a 60-87% chance of dying from prostate cancer within 15 years of diagnosis

Question 36

What is the benefit of prostatectomy vs active surveillance for high risk prostate cancer?

Answer 36

PIVOT: Prostate cancer mortality was lower for high-risk patients in the prostatectomy cohort compared to observation (9.1% versus 17.5%, p=0.04)

SPCG-4: prostatectomy was associated with reduced mortality in all groups with the most benefit in the younger men (<65 years, relative risk 0.38).

Question 37

Patient with high risk prostate cancer is interested in Cyrotherapy?

Answer 37

Cryosurgery, focal therapy and HIFU treatments are not recommended for men with high-risk localized prostate cancer outside of a clinical trial. Data is lacking.

Question 38

Patient with high risk prostate cancer is interested in ADT?

Answer 38

Clinicians should not recommend primary ADT for patients with high-risk localized prostate cancer unless the patient has both limited life expectancy and local symptoms.

Question 39

Why shouldn’t ADT be offered as primary therapy for localized prostate cancer?

Answer 39

A randomized prospective study comparing the androgen receptor inhibitor bicalutamide 150 mg to placebo found no significant difference in overall survival or prostate cancer specific survival in men with localized prostate cancer

Question 40

A patient presents with high risk prostate cancer and a strong family history of other cancers?

Answer 40

Clinicians may consider referral for genetic counseling for patients (and their families) with high-risk localized prostate cancer and a strong family history of specific cancers (e.g., breast, ovarian, pancreatic, other gastrointestinal tumors, lymphoma)

Question 41

What factors might put the patient at high risk of having a genetic inheritable prostate cancer mutation?

Answer 41

High Gleason score (8-10) and family history of cancer (breast, ovarian, pancreatic, other gastrointestinal, lymphoma) in first-degree relatives was associated with germline DNA repair mutations in mCRPC patients (5-10%)

Question 42

What is the next step if a prostate cancer patient elects active surveillance?

Answer 42

Localized prostate cancer patients who elect active surveillance should have accurate disease staging including systematic biopsy with ultrasound or MRI-guided imaging

Question 43

What proportion of men getting a targeted biopsy can be expected to have their diagnosis upgraded?

Answer 43

30%

Question 44

How should patients on active surveillance be followed?

Answer 44

PSA and DRE every 3 months for one year. Then every 6 months thereafter. Repeat prostate biopsy at 1 year then every 3-5 years thereafter.

Question 45

Multiparametric prostate MRI should include what sequences?

Answer 45

1.5 Tesla magnet MRI

diffusion weighted imaging (DWI)

apparent diffusion coefficient (ADC)

T2-weighted (T2W) imaging

dynamic intravenous contrast-enhanced (DCE) imaging

Question 46

A patient on active surveillance develops and adverse reclassification on repeat biopsy. What should be done?

Answer 46

The patient should be offered treatment.

Question 47

What proportion of patients on active surveillance eventually receive treatment?

Answer 47

20% (PIVOT)

50% (ProTect)

Question 48

How do the outcomes compare between open, laparoscopic, and robotic assisted radical prostatectomy?

Answer 48

linicians should inform localized prostate cancer patients that open and robot-assisted radical prostatectomy offer similar cancer control, continence recovery, and sexual recovery outcomes.

Question 49

What differences are there between open and robotic radical prostatectomy?

Answer 49

Clinicians should inform localized prostate cancer patients that robotic/laparoscopic or perineal techniques are associated with less blood loss than retropupic prostatectomy.

Question 50

A patient is interested in adjuvant therapy in addition to prostatectomy?

Answer 50

Clinicians should not treat localized prostate cancer patients who have elected to undergo radical prostatectomy with neoadjuvant ADT or other systemic therapy outside of clinical trials.

Question 51

What is the role of age on erections following prostatectomy?

Answer 51

15-20% reduction in erections per decade from 50-70 years old.

Question 52

What is the role of age on incontinence after prostatectomy?

Answer 52

Men 70 years old are 2 fold more likely to develop significant incontinence.

Question 53

Who should receive lymphadenectomy during radical prostatectomy?

Answer 53

unfavorable intermediate risk disease and high risk disease.

Question 54

A patient with unfavorable intermediate risk disease is found to have locally extensive prostate cancer after prostatectomy. What next?

Answer 54

Clinicians should inform localized prostate cancer patients with unfavorable intermediate-risk or high-risk prostate cancer about benefits and risks related to the potential option of adjuvant radiotherapy

Question 55

What are the adverse effects of adjuvant radiotherapy for locally advanced prostate cancer?

Answer 55

GI toxicity 59%
Urinary symptoms 37%
No differences in symptoms persisted at 5 years.

Question 56

A patient with high risk prostate cancer is interested in radiotherapy?

Answer 56

EBRT + ADT
EBRT + brachy + ADT
ADT should be for 24-36 months

Question 57

What are the adverse effects of ADT?

Answer 57

hot flashes
decrease bone mass
depression
fatigue 
weight gain.

Question 58

What happens when you take ADT with radiotherapy?

Answer 58

The adverse effects of ADT are increased.

Question 59

A patient with localized prostate cancer has a previous TURP but is seeking definitive treatment. What is the recommended treatment?

Answer 59

Prostatectomy
EBRT
brachy is discouraged.

Question 60

What is one of the theoretical advantages of proton therapy?

Answer 60

They stop depositing dose at an energy dependent distance from the source. Good for sparing adjacent tissue.

Question 61

Overall how does proton therapy compare with other treatments?

Answer 61

No overall difference

Question 62

What is the difference in adverse effects between proton therapy and IMRT?

Answer 62

IMRT actually had lower GI toxicity. Otherwise they were the same.

Question 63

What are the difference between brachytherapy and EBRT?

Answer 63

Similar adverse effects except that brachy has a higher risk of obstructive symptoms.

Question 64

Who is the ideal candidate for cryosurgery?

Answer 64

low or intermediate risk prostate cancer and not suitable for prostatectomy or radiotherapy.

Question 65

What are some contraindications to cryosurgery for prostate cancer?

Answer 65

discouraged for high risk
Prior TURP
unable to have TRUS

Question 66

What is the desired nadir temperature for cryosurgery?

Answer 66

-40c with double freeze thaw protocol

Question 67

If considering cryosurgery for a gland greater than 40g what should be done?

Answer 67

3-6 months of ADT to shrink the gland.

Question 68

What is the rate of ED after cryotherapy?

Answer 68

80-90%

Question 69

What are the rates of ED following various treatments for prostate cancer?

Answer 69

Prostatectomy: increased 44%
EBRT: increased 23%
Brachy: increased 21%

Question 70

How should localized prostate cancer patient’s be followed up after treatment?

Answer 70

Monitor PSA for at least 10 years

Question 71

What is the overall 5 year relative survival for localized prostate cancer?

Answer 71

99%

Question 72

Topic: PSA Recurrence Definition

Clinical Vignette:
A 58-year-old male patient underwent prostatectomy for localized prostate cancer. His post-operative PSA level was 0.1 ng/mL. Two months later, his PSA was 0.22 ng/mL on repeat testing.

Which of the following PSA levels would meet the criteria for PSA recurrence, as defined by the AUA Guidelines Panel?

A) 0.15 ng/mL
B) 0.18 ng/mL
C) 0.21 ng/mL
D) 0.25 ng/mL

Answer 72

Correct Answer: C) 0.21 ng/mL

Explanation:
PSA recurrence is defined as a value greater than or equal to 0.2 ng/mL with a second confirmatory laboratory value (Cookson et al., 2007). In this case, the patient’s initial PSA of 0.22 ng/mL meets this criteria, indicating PSA recurrence.

Reference: Cookson et al., 2007 - AUA Guidelines Panel

Question 73

opic: PSA Monitoring Post-Prostatectomy

Clinical Vignette:
A 62-year-old male patient had a radical prostatectomy for prostate cancer. He has been regularly monitored post-surgery. His PSA levels have been consistently undetectable for the past 5 years.

What is the significance of undetectable PSA levels in the post-prostatectomy period?

A) Indication of disease progression
B) Suggestive of PSA recurrence
C) Expected outcome after surgery
D) Need for additional imaging

Answer 73

Correct Answer: C) Expected outcome after surgery

Explanation:
In the post-prostatectomy period, undetectable PSA levels are an expected outcome after successful surgery. They indicate the removal of the prostate gland and the absence of prostate tissue producing PSA. This is a positive outcome and signifies a successful surgical result.

Question 74

Topic: Imaging Modalities for Prostate Cancer Recurrence

Clinical Vignette:
A 65-year-old patient who underwent prostatectomy for prostate cancer presents with a rising PSA level of 0.18 ng/mL. His physician is considering imaging options to detect recurrence.

Which of the following statements about PET/CT and multiparametric magnetic resonance imaging (mpMRI) is accurate?

A) PET/CT is the preferred option for detecting local recurrence.
B) PET/CT is less expensive than mpMRI.
C) mpMRI has limited clinical utility at low PSA levels.
D) mpMRI outperforms PET/CT in identifying local recurrence, especially at low PSA levels.

Answer 74

Correct Answer: D) mpMRI outperforms PET/CT in identifying local recurrence, especially at low PSA levels.

Explanation:
Multiparametric magnetic resonance imaging (mpMRI) has been shown to perform better than PET/CT in identifying local recurrence, especially at low levels of biochemical failure. PET/CT has demonstrated promise in detection but is limited by cost and variable clinical utility at extremely low PSA levels.

Reference: Panebianco et al., 2012

Question 75

Topic: Limitations of Imaging Modalities

Clinical Vignette:
A 54-year-old patient with a history of prostate cancer recurrence is considering undergoing PET/CT for further evaluation. He is concerned about the potential limitations of this imaging modality.

Which of the following represents a limitation of using PET/CT for detecting prostate cancer recurrence?

A) PET/CT is cost-effective for all patients.
B) PET/CT is highly accurate even at extremely low PSA levels.
C) PET/CT is widely available and accessible.
D) PET/CT’s clinical utility is limited at extremely low PSA levels, leading to variable detection.

Answer 75

Correct Answer: D) PET/CT’s clinical utility is limited at extremely low PSA levels, leading to variable detection.

Explanation:
PET/CT has demonstrated promise in the detection of prostate cancer recurrence, but its clinical utility is limited at extremely low PSA levels. This limitation results in variable detection rates and contributes to its restricted widespread usage.

Question 76

Topic: Salvage Radiation Therapy for PSA Recurrence

Clinical Vignette:
A 58-year-old patient who underwent radical prostatectomy for prostate cancer is now experiencing PSA recurrence. He is considering treatment options for long-term freedom from progression.

What is the recommended treatment option for men with PSA recurrence after radical prostatectomy, and why is it considered the clearest choice?

A) Chemotherapy for improved cancer control
B) Hormone therapy to manage symptoms
C) Salvage radiation therapy for long-term freedom from progression
D) Radical prostatectomy with higher dosages

Answer 76

Correct Answer: C) Salvage radiation therapy for long-term freedom from progression

Explanation:
Salvage radiation therapy is the recommended choice for men with PSA recurrence after radical prostatectomy. It provides the best chance for long-term freedom from progression. Modern series using higher dosages of radiation therapy have shown improved cancer control results, making it a clear choice for treatment.

Question 77

Clinical Vignette:
A 63-year-old patient is scheduled to undergo salvage radiation therapy for PSA recurrence following radical prostatectomy. He is concerned about potential side effects and toxicities associated with radiation therapy.

What advantage do modern radiation delivery systems offer in terms of toxicity profile for patients undergoing salvage radiation therapy?

A) They reduce the need for hormone therapy.
B) They eliminate all potential side effects.
C) They improve cancer control results.
D) They provide an improved toxicity profile compared to older delivery systems.

Answer 77

Correct Answer: D) They provide an improved toxicity profile compared to older delivery systems.

Explanation:
Modern radiation delivery systems have an advantage in terms of toxicity profile. They offer an improved toxicity profile compared to older delivery systems, contributing to better patient outcomes and reducing potential side effects.

Question 78

Answer 78

Table 1: Randomized Trials Comparing Observation versus Radical Prostatectomy

Question 79

Which treatment options are considered for localized prostate cancer?
A. Active surveillance
B. Radical prostatectomy
C. Radiation therapy
D. All of the above

Answer 79

All of the above
Explanation: Active surveillance, radical prostatectomy, and radiation therapy are all primary treatment options for localized prostate cancer. The choice of treatment is guided by prostate cancer risk stratification, patient life expectancy, assessment of oncologic and quality of life outcomes, and patient preference.

Question 80

What is the role of shared decision-making in prostate cancer management?
A. It emphasizes the critical role of an educated patient in choosing a management strategy.
B. It allows the doctor to make all the decisions.
C. It is a way to limit patient involvement in treatment decisions.
D. It is not important in prostate cancer management.

Answer 80

It emphasizes the critical role of an educated patient in choosing a management strategy.
Explanation: Shared decision-making between the patient, urologist, and radiation oncologist emphasizes the critical role of an educated patient in choosing a prostate cancer management strategy most consistent with an individual’s preferences and values.

Question 81

Which trial reported an improvement in overall and disease-specific mortality for men undergoing radical prostatectomy compared to watchful waiting?
A. Scandinavian Prostate Cancer Group Study No. 4 (SPCG 4)
B. Prostate Cancer Intervention Versus Observation Trial (PIVOT)
C. Prostate Testing for Cancer and Treatment (ProtecT) trial
D. None of the above

Answer 81

Scandinavian Prostate Cancer Group Study No. 4 (SPCG 4)
Explanation: The Scandinavian Prostate Cancer Group Study No. 4 (SPCG 4) reported an improvement in overall and disease-specific mortality for men undergoing radical prostatectomy compared to watchful waiting.

Question 82

Which trial found that radical prostatectomy did not improve overall or disease-specific mortality but reduced the risk of progression and treatment for progression compared to watchful waiting?
A. Scandinavian Prostate Cancer Group Study No. 4 (SPCG 4)
B. Prostate Cancer Intervention Versus Observation Trial (PIVOT)
C. Prostate Testing for Cancer and Treatment (ProtecT) trial
D. None of the above

Answer 82

Prostate Cancer Intervention Versus Observation Trial (PIVOT)
Explanation: The Prostate Cancer Intervention Versus Observation Trial (PIVOT) found that radical prostatectomy did not improve overall or disease-specific mortality but reduced the risk of progression and treatment for progression compared to watchful waiting.

Question 83

In the Prostate Testing for Cancer and Treatment (ProtecT) trial, which group observed more metastases?
A. Active monitoring group
B. Surgery group
C. Radiation therapy group
D. There was no difference among the groups

Answer 83

Active monitoring group
Explanation: In the ProtecT trial, more metastases were observed in the active monitoring group compared to the surgery or radiation therapy groups.

Question 84

Answer 84

Table 2: Active Surveillance Inclusion Criteria for Current Protocols

Question 85

Topic: Treatment of Locally Advanced Prostate Cancer
Statement: Currently, no consensus exists regarding the optimal management of locally advanced prostate cancer.

Clinical Vignette
A 60-year-old male is diagnosed with locally advanced prostate cancer. He seeks your opinion on the best treatment approach. What should you tell him about the current consensus on managing his condition?

Options
A. Surgery is the universally accepted best treatment option
B. Radiation therapy is the only recommended treatment
C. There’s a definitive consensus on the optimal treatment
D. No consensus exists on the optimal treatment

Answer 85

Correct Answer
D. No consensus exists on the optimal treatment

Explanation
A: Surgery may not be suitable for all cases of locally advanced prostate cancer.
B: Radiation therapy alone may not be enough for comprehensive management.
C: Contrary to this choice, no universal consensus exists on the optimal treatment.
D: The current state of practice does not have a consensus on the optimal treatment for locally advanced prostate cancer.

Memory Tool
Remember NCO for No Consensus Optimal when thinking of treatment options for locally advanced prostate cancer.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Being aware that no consensus exists aids in having a nuanced discussion with patients about treatment options, benefits, and risks.

Question 86

Topic: Treatment of Locally Advanced Prostate Cancer
Statement: Risk assessment is best performed by a combination of serum PSA level, T stage, cancer grade, and extent of cancer on biopsy.

Clinical Vignette
A 67-year-old male patient comes to your clinic for an evaluation of an elevated PSA level of 15 ng/mL. He has no urinary symptoms but is concerned about prostate cancer. You perform a digital rectal examination, noting a firm, irregular prostate. A biopsy reveals a Gleason score of 8. What is the most appropriate method for risk assessment in this patient?

Options
A. Serum PSA level only
B. Gleason score only
C. Serum PSA level and Gleason score
D. Serum PSA level, T stage, cancer grade, and extent of cancer on biopsy

Answer 86

Correct Answer
D. Serum PSA level, T stage, cancer grade, and extent of cancer on biopsy

Explanation
A: Relying solely on the serum PSA level may miss other significant risk factors.
B: Gleason score alone is not sufficient for comprehensive risk assessment.
C: While both PSA and Gleason score are important, they’re not enough for a full assessment.
D: The best approach for risk assessment combines serum PSA level, T stage, cancer grade, and extent of cancer on biopsy.

Memory Tool
Think of PTEC as a mnemonic for PSA, T stage, Extent, and Cancer grade.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Understanding comprehensive risk assessment is crucial for determining appropriate treatment options and outcomes in locally advanced prostate cancer.

Question 87

Clinical Vignette
A 62-year-old man presents with a PSA level of 12 ng/mL and a Gleason score of 7. You’re considering additional imaging studies to evaluate high-risk features. How useful would imaging be in identifying such features?

Options
A. Highly effective
B. Moderately effective
C. Limited effectiveness
D. Not effective at all

Answer 87

Correct Answer
C. Limited effectiveness

Explanation
A: Imaging is not highly effective in identifying high-risk features for treatment failure.
B: Imaging has a limited role, making it less than moderately effective.
C: Imaging plays a limited role in identifying patients with high-risk features for whom local therapy may fail.
D: Although limited, imaging does have some role and is not completely ineffective.

Memory Tool
Remember LIT for Limited Imaging in Therapy failure risk.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Understanding the limitations of imaging in evaluating high-risk features is essential for effective patient management.

Question 88

Topic: Definition of Advanced Prostate Cancer
Statement: Features other than clinical T stage most often contribute to the identification of men with advanced disease and a concomitant increased risk for failure after primary therapy.

Clinical Vignette
A 58-year-old male is diagnosed with prostate cancer. His clinical T stage is T2. What other factors should you consider to accurately assess his risk for disease progression?

Options
A. Only consider clinical T stage
B. Serum PSA level and extent of cancer on biopsy
C. Family history and age
D. All of the above

Answer 88

Correct Answer
B. Serum PSA level and extent of cancer on biopsy

Explanation
A: Relying solely on clinical T stage is insufficient for a comprehensive risk assessment.
B: Features other than clinical T stage, such as serum PSA level and extent of cancer on biopsy, contribute to identifying men with advanced disease.
C: While these are important factors, they are not the most often contributing features in identifying advanced disease.
D: All of the above would include clinical T stage, which is not the most contributing factor in this case.

Memory Tool
For advanced disease risk, don’t just look at T, peek at PSA and Biopsy too. (PTB)

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Recognizing that factors other than clinical T stage contribute to advanced disease risk is essential for effective management.

Question 89

Topic: Contemporary Risk Assessment
Statement: The most important pathologic criteria predicting prognosis after radical prostatectomy are Gleason score, surgical margin status, and presence of non–organ-confined disease.

Clinical Vignette
You perform a radical prostatectomy on a 65-year-old male with prostate cancer. Postoperatively, what pathologic criteria are most important for predicting his prognosis?

Options
A. Gleason score only
B. Gleason score and surgical margin status
C. Gleason score, surgical margin status, and lymph node involvement
D. Gleason score, surgical margin status, and presence of non–organ-confined disease

Answer 89

Correct Answer
D. Gleason score, surgical margin status, and presence of non–organ-confined disease

Explanation
A: Gleason score alone is insufficient for a full risk assessment.
B: Both Gleason score and surgical margin status are important, but not comprehensive.
C: Lymph node involvement is not listed as one of the most important criteria.
D: The most important pathologic criteria for predicting prognosis are Gleason score, surgical margin status, and presence of non–organ-confined disease.

Memory Tool
Think GSM-N for Gleason, Surgical Margin, and Non–organ-confined disease.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Knowing the most important pathologic criteria helps in accurately predicting postoperative prognosis and guiding further treatment.

Question 90

Topic: Trends in Incidence and Treatment
Statement: Within the Cancer of the Prostate Strategic Urological Research Endeavor (CaPSURE), Cooperberg et al. observed a significant decrease in the fraction of men presenting with high-risk disease characteristics, from 40.9% in 1989 to 1990 to 14.8% in 2001 to 2002.

Clinical Vignette
You’re attending a urology conference, and the topic of changes in prostate cancer incidence comes up. What trend has been observed in the presentation of high-risk prostate cancer according to the CaPSURE study?

Options
A. An increase in high-risk cases
B. No significant change
C. A decrease in high-risk cases
D. Fluctuating trends

Answer 90

Correct Answer
C. A decrease in high-risk cases

Explanation
A: Contrary to this, the CaPSURE study showed a decrease in high-risk cases.
B: The study did indicate a significant change, specifically a decrease.
C: CaPSURE observed a decrease in men presenting with high-risk disease characteristics.
D: The study specifically noted a decrease, not fluctuating trends.

Memory Tool
Remember CaPSURE CAPTURED a Decrease to recall the trend in high-risk cases.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Awareness of epidemiological trends helps in resource allocation and understanding the changing landscape of prostate cancer.

Question 91

Topic: Natural History
Statement: Men with high-risk prostate cancer, including those with locally advanced disease, are at significant risk for disease progression and disease-specific death if left untreated.

Clinical Vignette
A 55-year-old male is diagnosed with high-risk prostate cancer but wishes to avoid treatment due to personal reasons. What is the risk for this patient if he remains untreated?

Options
A. Low risk for disease progression
B. Moderate risk for disease progression
C. High risk for disease progression and disease-specific death
D. Uncertain risk due to individual variability

Answer 91

Correct Answer
C. High risk for disease progression and disease-specific death

Explanation
A: High-risk prostate cancer left untreated has a high risk for disease progression.
B: The risk is significant and not just moderate.
C: Men with high-risk prostate cancer are at a significant risk for disease progression and disease-specific death if untreated.
D: While individual variability exists, high-risk cases are generally at significant risk if left untreated.

Memory Tool
Think High-Risk = High Stakes to remember the outcome of untreated high-risk prostate cancer.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Understanding the high stakes involved in untreated high-risk prostate cancer is critical for patient counseling.

Question 92

Topic: Radical Prostatectomy
Statement: In examining all reports, overall survival ranges from 64% to 96% at 5 years, 12.5% to 72% at 10 years, and 20% to 51% at 15 years after treatment.

Clinical Vignette
A 50-year-old man with prostate cancer is considering radical prostatectomy and asks about long-term survival rates. What should you tell him about the overall survival rates after radical prostatectomy?

Options
A. Overall survival is over 90% for up to 15 years
B. Overall survival ranges from 64% to 96% at 5 years, 12.5% to 72% at 10 years, and 20% to 51% at 15 years
C. Overall survival is less than 50% at 5 years
D. Data on long-term survival after radical prostatectomy is inconclusive

Answer 92

Correct Answer
B. Overall survival ranges from 64% to 96% at 5 years, 12.5% to 72% at 10 years, and 20% to 51% at 15 years

Explanation
A: The range of survival is more variable and does not stay over 90% for up to 15 years.
B: This option accurately reflects the range of survival rates at different time intervals after treatment.
C: The lower limit at 5 years is 64%, not less than 50%.
D: Data on long-term survival is available and has been quantified.

Memory Tool
Remember 5-10-15 to recall the three key time intervals for survival rates.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Having accurate survival statistics is crucial for informed decision-making and patient counseling.

Question 93

Topic: Outcomes of Prostatectomy for Pathologically Advanced Disease
Statement: The presence of focal or established extracapsular extension increases the rate of clinical progression from 7% for organ-confined disease to 18% and 35%, respectively, at 5 years.

Clinical Vignette
A 60-year-old patient underwent a radical prostatectomy, and the pathology report showed established extracapsular extension. What is his risk of clinical progression at 5 years?

Options
A. 7%
B. 18%
C. 35%
D. 50%

Answer 93

Correct Answer
C. 35%

Explanation
A: This percentage is for organ-confined disease, not for cases with established extracapsular extension.
B: 18% is the rate for focal extracapsular extension, not established extracapsular extension.
C: The presence of established extracapsular extension increases the rate of clinical progression to 35% at 5 years.
D: The rate is not as high as 50% for established extracapsular extension.

Memory Tool
For established extracapsular extension, think EE = 35 (Extracapsular Established equals 35% risk).

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Understanding the increased risk associated with extracapsular extension is critical for postoperative management and surveillance.

Question 94

Topic: Adjuvant Radiation Therapy
Statement: The use of adjuvant RT is associated with a range of BDFS from 50% to 88% at 5 years.

Clinical Vignette
A 62-year-old man who recently underwent radical prostatectomy for prostate cancer is considering adjuvant radiation therapy. What can you tell him about the expected 5-year BDFS rates with adjuvant RT?

Options
A. Below 50%
B. 50% to 88%
C. 90% to 95%
D. Data is inconclusive

Answer 94

Correct Answer
B. 50% to 88%

Explanation
A: The lower limit for BDFS with adjuvant RT is 50%, not below it.
B: The use of adjuvant RT is associated with a BDFS range of 50% to 88% at 5 years.
C: The upper limit is 88%, not as high as 90% to 95%.
D: Data on this topic is available and conclusive.

Memory Tool
Remember RT: 50-88 at 5 to recall the 5-year BDFS rates with adjuvant RT.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Knowledge of BDFS rates is essential for discussing adjuvant treatment options and expectations with patients.

Question 95

Topic: Radiation Therapy
Statement: Neoadjuvant and concurrent AD appears to be appropriate in high-risk patients undergoing RT.

Clinical Vignette
A 70-year-old man with high-risk prostate cancer is scheduled for radiation therapy. What additional treatment should be considered?

Options
A. Neoadjuvant and concurrent AD
B. Concurrent chemotherapy
C. Adjuvant hormone therapy only
D. No additional treatment is needed

Answer 95

Correct Answer
A. Neoadjuvant and concurrent AD

Explanation
A: Neoadjuvant and concurrent AD is appropriate for high-risk patients undergoing RT.
B: Concurrent chemotherapy is not the standard recommendation for high-risk patients undergoing RT.
C: Adjuvant hormone therapy alone is not the recommendation for these patients.
D: Additional treatment is beneficial in high-risk patients.

Memory Tool
Think High Risk = AD + RT for concurrent Androgen Deprivation and Radiation Therapy.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Combining AD with RT can offer better treatment outcomes for high-risk patients.

Question 96

Topic: Adjuvant Androgen Deprivation and Radiation Therapy
Statement: Thus a limited period of AD (2 to 4 months) appears to be appropriate for men with intermediate-risk cancers; more prolonged AD may be beneficial for those with high-risk disease characteristics.

Clinical Vignette
You have a 55-year-old patient with intermediate-risk prostate cancer. How long should he be on androgen deprivation therapy if he’s also undergoing radiation therapy?

Options
A. 1 month
B. 2 to 4 months
C. 6 to 12 months
D. Indefinitely

Answer 96

Correct Answer
B. 2 to 4 months

Explanation
A: A 1-month period is too short for intermediate-risk patients.
B: A limited period of 2 to 4 months of AD is appropriate for men with intermediate-risk cancers.
C: Longer periods are recommended for high-risk patients, not intermediate-risk.
D: Indefinite AD is not recommended for intermediate-risk patients.

Memory Tool
For intermediate risk, remember AD: 2-4 to recall the recommended months for AD.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Tailoring the duration of AD according to risk stratification optimizes patient outcomes.

Question 97

Topic: Androgen Deprivation and Its Timing
Statement: Early AD may improve survival.

Clinical Vignette
A 63-year-old male with newly diagnosed prostate cancer is discussing treatment options. What is the benefit of early androgen deprivation therapy?

Options
A. No significant benefit
B. May worsen survival
C. May improve survival
D. Benefits are inconclusive

Answer 97

Correct Answer
C. May improve survival

Explanation
A: Early AD has been shown to improve survival, not to have no benefit.
B: There is no evidence to suggest that early AD may worsen survival.
C: Early AD may improve survival in prostate cancer patients.
D: Benefits are not inconclusive; they point towards improved survival.

Memory Tool
Think Early AD = Early Advantage to remember the benefit of early AD.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
The timing of androgen deprivation can influence survival outcomes, making it an important consideration in treatment planning.

Question 98

Topic: Alternative Methods of Androgen Manipulation
Statement: Alternative methods of androgen manipulation (antiandrogen, intermittent) remain investigational.

Clinical Vignette
A 68-year-old male patient is keen on exploring alternative methods of androgen manipulation for his prostate cancer. What should you inform him about these methods?

Options
A. Widely accepted and proven effective
B. Only effective in low-risk patients
C. Remain investigational
D. Not recommended under any circumstance

Answer 98

Correct Answer
C. Remain investigational

Explanation
A: These methods are not widely accepted as proven effective yet.
B: The investigational status applies across the risk spectrum, not just to low-risk patients.
C: Alternative methods of androgen manipulation like antiandrogen and intermittent therapies remain investigational.
D: They are not outright rejected, but they are still under investigation.

Memory Tool
When considering alternative AD, think I for Investigational.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Being up-to-date on the investigational status of alternative treatments is vital for informed patient counseling.

Question 99

Topic: Trends in Incidence and Treatment
Statement: Overall, the presence of clinically advanced disease (i.e., T3-4) decreased from 11.8% to 3.5%.

Clinical Vignette
You’re discussing recent trends in prostate cancer with your colleagues. What has happened to the incidence of clinically advanced disease (T3-4) over time?

Options
A. Increased to 11.8%
B. Decreased to 3.5%
C. Remained stable
D. Fluctuated without a clear pattern

Answer 99

Correct Answer
B. Decreased to 3.5%

Explanation
A: The incidence actually decreased, not increased.
B: The presence of clinically advanced disease (T3-4) has decreased to 3.5%.
C: The incidence did not remain stable; it decreased.
D: There is a clear pattern of decrease, not fluctuation.

Memory Tool
Remember T3-4 to 3.5 to recall the decreased incidence of clinically advanced disease.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Being aware of trends in disease incidence helps inform screening and treatment strategies.

Question 100

Topic: Trends in Incidence and Treatment
Statement: Fewer men are presenting with locally advanced prostate cancer.

Clinical Vignette
During a department meeting, you’re asked about the current epidemiology of locally advanced prostate cancer. What is the trend?

Options
A. Increasing incidence
B. Stable incidence
C. Decreasing incidence
D. Data is inconclusive

Answer 100

Correct Answer
C. Decreasing incidence

Explanation
A: The statement specifies that fewer men are presenting, indicating a decrease.
B: The incidence is not stable; it is decreasing.
C: Fewer men are presenting with locally advanced prostate cancer, indicating a decreasing incidence.
D: Data is conclusive regarding the decreasing incidence.

Memory Tool
Think Less Locally Advanced to remember the trend of decreasing incidence.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Understanding epidemiological trends is important for anticipating healthcare needs and resource allocation.

Question 101

Topic: Trends in Incidence and Treatment
Statement: There has been an increase in organ-confined cancers identified after radical prostatectomy.

Clinical Vignette
A colleague inquires about the trends in pathology findings after radical prostatectomy. What can you say about the incidence of organ-confined cancers?

Options
A. Increased incidence
B. Decreased incidence
C. No significant change
D. Data is inconclusive

Answer 101

Correct Answer
A. Increased incidence

Explanation
A: The statement specifies an increase in organ-confined cancers identified after radical prostatectomy.
B: The incidence has not decreased; it has increased.
C: There has been a significant change, specifically an increase.
D: Data is conclusive regarding the increasing incidence.

Memory Tool
Remember Radical Rise in Organ-Confined to recall the increasing incidence after radical prostatectomy.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Awareness of trends in pathological outcomes helps in understanding the evolving nature of prostate cancer and its management.

Question 102

Topic: Radical Prostatectomy
Statement: Many men with clinical stage T3 disease have regional spread and may not benefit from prostatectomy; however, select patients may benefit because local control may be achieved in most, and complete cancer excision is possible in some men.

Clinical Vignette
A 59-year-old man with clinical stage T3 prostate cancer is considering radical prostatectomy. What should you counsel him regarding the potential benefits of the surgery?

Options
A. No benefit in stage T3 disease
B. Guaranteed benefit in all cases
C. Possible benefit in select cases
D. Complete cancer excision is guaranteed

Answer 102

Correct Answer
C. Possible benefit in select cases

Explanation
A: While many men with stage T3 may not benefit, select cases may.
B: The benefit is not guaranteed for all men with stage T3 disease.
C: Select patients with clinical stage T3 may benefit from local control and possible complete cancer excision.
D: Complete cancer excision is possible in some men, but it’s not guaranteed.

Memory Tool
Remember T3 = Think Thrice for considering the pros and cons in these select cases.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Understanding the nuanced benefits of radical prostatectomy in stage T3 disease helps in patient counseling and decision-making.

Question 103

Topic: Outcomes of Prostatectomy for Pathologically Advanced Disease
Statement: Overall, the actuarial PSA-free survival after surgery in high-risk men is approximately 50% at 5 to 7 years.

Clinical Vignette
A 64-year-old man with high-risk prostate cancer asks about the likelihood of achieving PSA-free survival after radical prostatectomy. What would you tell him?

Options
A. Below 20%
B. Approximately 50%
C. Above 75%
D. Nearly 100%

Answer 103

Correct Answer
B. Approximately 50%

Explanation
A: The rate is higher than 20%.
B: Actuarial PSA-free survival after surgery in high-risk men is approximately 50% at 5 to 7 years.
C: The rate is not above 75%; it’s approximately 50%.
D: The rate is far from 100%; it’s approximately 50%.

Memory Tool
Think High Risk = Half Chance to remember the 50% PSA-free survival rate in high-risk men.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Understanding the likelihood of PSA-free survival in high-risk men is crucial for patient counseling.

Question 104

Topic: Adjuvant Radiation Therapy
Statement: The benefit of adjuvant RT may be greatest in cases with positive surgical margins.

Clinical Vignette
A 66-year-old patient undergoes radical prostatectomy, and the pathology report indicates positive surgical margins. What can you say about the benefit of adjuvant radiation therapy in his case?

Options
A. No added benefit
B. Minimal benefit
C. Moderate benefit
D. Greatest benefit

Answer 104

Correct Answer
D. Greatest benefit

Explanation
A: Adjuvant RT has significant benefit in cases with positive surgical margins.
B: The benefit is not minimal; it may be the greatest.
C: The benefit is described as potentially the “greatest,” not just moderate.
D: The benefit of adjuvant RT may be greatest in cases with positive surgical margins.

Memory Tool
Think Positive Margins = Peak RT Benefit to remember the greatest benefit of adjuvant RT.

Reference
Campbell’s Urology

Question 105

Clinical Vignette
A 58-year-old man who recently underwent radical prostatectomy is considering adjuvant radiation therapy. What dose is associated with improved outcomes in adjuvant RT?

Options
A. 45 Gy
B. 55 Gy
C. 64 Gy
D. 72 Gy

Answer 105

Correct Answer
C. 64 Gy

Explanation
A, B, D: These doses are not specifically associated with improved outcomes in adjuvant RT.
C: Improved outcomes of adjuvant RT are associated with dose escalation to 64 Gy.

Memory Tool
Remember 64 for More to recall the dose associated with improved outcomes in adjuvant RT.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Choosing the right radiation dose is essential for optimizing treatment outcomes.

Question 106

Topic: Radiation Therapy
Statement: Adjuvant AD after RT may benefit those with very high-risk disease.

Clinical Vignette
A 72-year-old male with very high-risk prostate cancer just completed his course of radiation therapy. What additional treatment should be considered?

Options
A. No further treatment
B. Adjuvant chemotherapy
C. Adjuvant AD
D. Neoadjuvant AD

Answer 106

Correct Answer
C. Adjuvant AD

Explanation
A: Very high-risk patients may benefit from additional treatment.
B: Adjuvant chemotherapy is not the recommended additional treatment.
C: Adjuvant AD may benefit those with very high-risk disease after radiation therapy.
D: Neoadjuvant AD is not the recommendation for post-radiation treatment.

Memory Tool
Think Very High = Very ADd-on to recall the benefit of adjuvant AD in very high-risk patients.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Being aware of adjuvant options for very high-risk patients aids in comprehensive treatment planning.

Question 107

Topic: Adjuvant Androgen Deprivation and Radiation Therapy
Statement: More prolonged AD may be beneficial for those with high-risk disease characteristics, including high-stage cancers, or men with high pretreatment serum PSA values.

Clinical Vignette
A 60-year-old man with high-stage prostate cancer and a high pretreatment PSA is about to begin radiation therapy. What should be the duration of his androgen deprivation therapy?

Options
A. Short-term (1-2 months)
B. Intermediate-term (3-6 months)
C. Prolonged
D. Indefinite

Answer 107

Correct Answer
C. Prolonged

Explanation
A, B: Short or intermediate-term AD is not recommended for those with high-risk disease characteristics.
C: More prolonged AD may be beneficial for those with high-risk disease characteristics.
D: Prolonged but not indefinite AD is recommended.

Memory Tool
Remember High Risk = High Time to recall the need for prolonged AD in high-risk patients.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Understanding the appropriate duration of AD in high-risk patients helps in optimizing treatment outcomes.

Question 108

Topic: Androgen Deprivation and Its Timing
Statement: Alternative methods of androgen manipulation (antiandrogen, intermittent) remain investigational.

Clinical Vignette
A 54-year-old patient asks if he can consider alternative methods like antiandrogen or intermittent AD for his prostate cancer. How should you counsel him?

Options
A. Highly recommended
B. Conditionally recommended
C. Investigational
D. Strictly not recommended

Answer 108

Correct Answer
C. Investigational

Explanation
A, B, D: These methods are not highly or conditionally recommended, nor are they strictly not recommended.
C: Alternative methods like antiandrogen and intermittent AD remain investigational.

Memory Tool
Think Alternative = Awaiting Approval to remember the investigational status.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Keeping patients informed about the investigational status of alternative treatments helps in shared decision-making.

Question 109

Statement: The studies also clearly show that alternatives to estrogen should be used, given the cardiovascular toxicity associated with higher doses of DES.

Clinical Vignette
A 67-year-old male patient with prostate cancer is considering androgen deprivation therapy and asks about using estrogen. What should you advise?

Options
A. Estrogen is a viable option
B. Use estrogen but with caution
C. Avoid estrogen due to cardiovascular toxicity
D. Estrogen is most effective

Answer 109

Correct Answer
C. Avoid estrogen due to cardiovascular toxicity

Explanation
A, B, D: These options do not adequately address the cardiovascular toxicity associated with higher doses of DES.
C: Alternatives to estrogen should be used because of the cardiovascular toxicity associated with higher doses of DES.

Memory Tool
Remember Estrogen = Extra Caution to recall the cardiovascular toxicity risks.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Understanding the cardiovascular risks associated with certain hormonal treatments is crucial for patient safety.

Question 110

opic: Androgen Deprivation and Its Timing
Statement: Early AD may improve survival.

Clinical Vignette
A 63-year-old male patient diagnosed with prostate cancer is skeptical about starting AD therapy early. What potential benefit should you discuss with him?

Options
A. No significant impact on survival
B. May worsen survival
C. May improve survival
D. Survival benefits are inconclusive

Answer 110

Correct Answer
C. May improve survival

Explanation
A: Early AD has been shown to potentially improve survival.
B: There’s no evidence suggesting early AD may worsen survival.
C: Early AD may improve survival in prostate cancer patients.
D: The benefits of early AD on survival are not inconclusive; they may improve survival.

Memory Tool
Think Early Bird Gets the Survival to remember the benefit of early AD.

Reference
Campbell’s Urology, 12th Edition, Chapter 159

Rationale
Understanding the benefits of early initiation of AD therapy aids in patient counseling and treatment planning.