Prostate Cancer Screening, Diagnosis and Risk Stratification

Question 1

What is the most commonly diagnosed cancer and the second leading cause of cancer death in men in the US?
A. Lung Cancer
B. Prostate Cancer
C. Breast Cancer
D. Colorectal Cancer

Answer 1

B. Prostate Cancer
Explanation: The material states that prostate cancer is the most commonly diagnosed cancer and the second leading cause of cancer death in men in the US.

Question 2

What is the approximate number of men diagnosed with prostate cancer in 2022?
A. 200,000 men
B. 250,000 men
C. 268,490 men
D. 300,000 men

Answer 2

C. 268,490 men
Explanation: According to the text, approximately 268,490 men were diagnosed with prostate cancer in 2022.

Question 3

What is the mean age at diagnosis of prostate cancer?
A. 60 years
B. 66 years
C. 70 years
D. 75 years

Answer 3

B. 66 years
Explanation: The material states that the mean age at diagnosis of prostate cancer is 66 years.

Question 4

What grade recommendation did the U.S. Preventive Services Task Force Recommendation change to in 2018 regarding prostate cancer screening?
A. Grade A
B. Grade B
C. Grade C
D. Grade D

Answer 4

C. Grade C
Explanation: The U.S. Preventive Services Task Force changed their recommendation to Grade C in 2018, indicating moderate uncertainty regarding the benefits and harms of PSA-based screening.

Question 5

Which of the following organizations endorse shared decision-making for prostate cancer screening?
A. AUA
B. National Cancer Comprehensive Network
C. American Cancer Society
D. All of the above

Answer 5

D. All of the above
Explanation: The AUA, National Cancer Comprehensive Network, and the American Cancer Society all endorse shared decision-making for prostate cancer screening according to the provided material.

Question 6

In 2022, what percentage of men are estimated to have prostate cancer-related mortality?
A. 1.5%
B. 2.4%
C. 3.2%
D. 4.0%

Answer 6

B. 2.4%
Explanation: The material states that 2.4% of men will have prostate cancer-related mortality in 2022.

Question 7

Over what percentage of new prostate cancer cases are diagnosed in men aged 65 years and older?
A. 40%
B. 50%
C. 60%
D. 70%

Answer 7

C. 60%
Explanation: Over 60% of new cases are diagnosed in men aged 65 years and older, according to the material.

Question 8

What change has been observed in prostate cancer in relation to the Grade D recommendation from the U.S. Preventive Services Task Force Recommendation in 2012?
A. An increase in early detection
B. An inverse stage migration
C. An increase in mortality rates
D. A decrease in diagnosis rates

Answer 8

B. An inverse stage migration
Explanation: The material suggests that there has been an inverse stage migration in prostate cancer associated with the Grade D recommendation.

Question 9

What is the term used to describe the trend of diagnosing more advanced stages of prostate cancer, particularly after the Grade D recommendation from the U.S. Preventive Services Task Force in 2012?
A. Direct stage migration
B. Progressive stage migration
C. Inverse stage migration
D. Regressive stage migration

Answer 9

C. Inverse stage migration
Explanation: In the context of prostate cancer and the Grade D recommendation from the U.S. Preventive Services Task Force in 2012, the term “inverse stage migration” is used to describe a shift towards diagnosing higher-stage, more advanced prostate cancers. This is likely due to the discouragement of routine prostate-specific antigen (PSA) testing, which might have led to fewer diagnoses of early-stage, lower-risk cancers. Instead, cancers were more likely to be diagnosed when they had progressed to a later stage and were causing symptoms.

Question 10

What is the mainstay of prostate cancer screening?
A. Prostate physical examination
B. Prostate-specific antigen (PSA)
C. MRI
D. CT scan

Answer 10

B. Prostate-specific antigen (PSA)
Explanation: The text states that PSA represents the mainstay of prostate cancer screening.

Question 11

What is one reason that PSA is an imperfect screening tool?
A. PSA is not associated with prostate cancer
B. PSA can be elevated in benign conditions of the prostate
C. PSA levels are always high in men with prostate cancer
D. PSA levels cannot be measured accurately

Answer 11

B. PSA can be elevated in benign conditions of the prostate
Explanation: The text mentions that PSA is an imperfect screening tool because it can be elevated in benign conditions of the prostate.

Question 12

According to the U.S. Preventive Services Task Force recommendations in 2018, at what age should men start considering individualized shared decision-making for prostate cancer screening?
A. 40 years old
B. 50 years old
C. 55 years old
D. 70 years old

Answer 12

C. 55 years old
Explanation: The 2018 recommendation from the U.S. Preventive Services Task Force endorses individualized shared decision-making for prostate cancer screening for men aged 55 to 69 years old.

Question 13

According to the AUA’s best practice statement for PSA screening, what is the recommended routine screening interval to reduce the harms of screening?
A. Annually
B. Every two years or more
C. Every five years
D. Every ten years

Answer 13

B. Every two years or more
Explanation: The AUA recommends a routine screening interval of two years or more to reduce the harms of screening, for those men who have decided on screening through shared decision-making.

Question 14

According to multiple studies, an initial PSA less than what value at ages 40-49 or 50-59 years old is associated with a low risk of incident prostate cancer?
A. 0.5 ng/ml
B. 1 ng/ml
C. 1.5 ng/ml
D. 2 ng/ml

Answer 14

B. 1 ng/ml
Explanation: The text indicates that an initial PSA less than 1 ng/ml at ages 40-49 or 50-59 years old is associated with a low risk of incident prostate cancer.

Question 15

What phenomenon contributes to the elevation of PSA levels in the context of prostate cancer?
A. Overproduction of PSA by cancer cells
B. Disruption of glandular architecture and loss of the basal cell layer
C. Inhibition of PSA by cancer cells
D. Production of PSA by other organs

Answer 15

B. Disruption of glandular architecture and loss of the basal cell layer
Explanation: The text states that the pathophysiology of PSA elevation in prostate cancer involves the disruption of the glandular architecture and loss of the basal cell layer, which leads to PSA leaching into the bloodstream.

Question 16

Which study found a statistically significant relative reduction of 21% in prostate cancer mortality at 11 years with prostate cancer screening?
A. The U.S. Preventive Services Task Force Recommendation
B. The Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) Screening Trial
C. The European Randomized Study of Screening for Prostate Cancer (ERSPC)
D. The AUA Best Practice Statement for PSA Screening

Answer 16

C. The European Randomized Study of Screening for Prostate Cancer (ERSPC)
Explanation: The ERSPC reported a statistically significant relative reduction of 21% in prostate cancer mortality at 11 years with prostate cancer screening.

Question 17

According to the National Comprehensive Cancer Network (NCCN) Prostate Cancer Early Detection guidelines, at what age is it currently recommended to start screening?
A. 40 years old
B. 45 years old
C. 55 years old
D. 65 years old

Answer 17

B. 45 years old
Explanation: The NCCN guidelines currently recommend starting screening at age 45 years old.

Question 18

According to the AUA, which group of men should consider PSA screening through shared decision-making?
A. Men under age 40 years
B. Men between ages 40 to 54 years at average risk
C. Men ages 55 to 69 years
D. Men over age 70

Answer 18

C. Men ages 55 to 69 years
Explanation: The AUA recommends shared decision-making for men aged 55 to 69 years considering PSA screening.

Question 19

In high-risk populations, at what age should prostate cancer screening start?
A. 30 years old
B. 40 years old
C. 50 years old
D. 60 years old

Answer 19

B. 40 years old
Explanation: The text mentions that screening should start at age 40 in high-risk populations, such as patients with a family history of certain cancers, Black/African American men, and patients with certain germline mutations.

Question 20

What does Multiparametric Magnetic Resonance Imaging (mpMRI) include in its acquisition?
A. T1- and T2-weighted images, diffusion-weighted images (DWI), and dynamic contrast enhanced images (DCE)
B. T1- and T2-weighted images, and diffusion-weighted images (DWI) only
C. T1- and T2-weighted images only
D. T1- and T2-weighted images, and dynamic contrast enhanced images (DCE) only

Answer 20

A. T1- and T2-weighted images, diffusion-weighted images (DWI), and dynamic contrast enhanced images (DCE)
Explanation: The text mentions that mpMRI involves – at the minimum - the acquisition of T1- and T2-weighted images, diffusion-weighted images (DWI), and dynamic contrast enhanced images (DCE).

Question 21

According to the PROMIS study, how much more sensitive is mpMRI compared to TRUS biopsy for clinically significant cancer?
A. 41%
B. 52%
C. 93%
D. 100%

Answer 21

C. 93%
Explanation: The PROMIS study found that for clinically significant cancer, mpMRI was more sensitive (93%).

Question 22

In the PRECISION study, in which group was clinically significant prostate cancer detected more?
A. The mpMRI targeted biopsy group
B. The TRUS biopsy group
C. Both groups had the same detection rate
D. The study did not specify

Answer 22

A. The mpMRI targeted biopsy group
Explanation: The PRECISION study found that clinically significant prostate cancer was detected in 38% of the mpMRI targeted biopsy group as compared to 26% of the TRUS biopsy group.

Question 23

According to the AUA position, what is recommended for men undergoing MRI-targeted sampling for prostate cancer?
A. Only targeted biopsies should be performed
B. Only systematic biopsies should be performed
C. Both targeted and systematic biopsies should be performed
D. No biopsy is necessary

Answer 23

C. Both targeted and systematic biopsies should be performed
Explanation: The AUA position recommends that both targeted and systematic biopsies be performed in men undergoing MRI-targeted sampling.

Question 24

According to the PIRADS v2.1 scoring system, what PIRADS score indicates that clinically significant cancer is highly likely to be present?
A. 1
B. 2
C. 3
D. 5

Answer 24

D. 5
Explanation: According to the PIRADS v2.1 scoring system, a PIRADS score of 5 indicates that clinically significant cancer is highly likely to be present.

Question 25

What is the purpose of using the PIRADS v2.1 system in mpMRI?
A. To identify and score lesions for the level of suspicion for harboring clinically significant prostate cancer
B. To measure the size of the prostate gland
C. To detect benign conditions of the prostate
D. To determine the age of the patient

Answer 25

A. To identify and score lesions for the level of suspicion for harboring clinically significant prostate cancer
Explanation: The PIRADS v2.1 system is used in mpMRI to identify and score lesions, delineating the level of suspicion for harboring clinically significant prostate cancer.

Question 26

According to the PRECISION study, what is the potential benefit of using mpMRI with targeted biopsy over standard TRUS prostate biopsy?
A. Detects more clinically significant prostate cancer
B. Fewer men receive a diagnosis of clinically insignificant cancer
C. Both A and B
D. None of the above

Answer 26

C. Both A and B
Explanation: The PRECISION study found that clinically significant prostate cancer was detected more often in the mpMRI targeted biopsy group compared to the TRUS biopsy group, and fewer men in the mpMRI targeted biopsy group received a diagnosis of clinically insignificant cancer.

Question 27

What is the associated risk of prostate cancer detection with a positive mpMRI result for men with a prior negative biopsy with continued PSA rise?
A. 10-30%
B. 34-68%
C. 70-85%
D. 90-100%

Answer 27

B. 34-68%
Explanation: The associated risk of prostate cancer detection with a positive mpMRI result in men with a prior negative biopsy with continued PSA rise is 34-68%.

Question 28

What does a PIRADS score of 3 indicate in the PIRADS v2.1 scoring system?
A. Very low risk of clinically significant cancer
B. Low risk of clinically significant cancer
C. Intermediate risk or the presence of clinically significant cancer is equivocal
D. High risk of clinically significant cancer

Answer 28

C. Intermediate risk or the presence of clinically significant cancer is equivocal
Explanation: According to the PIRADS v2.1 scoring system, a score of 3 indicates that the presence of clinically significant cancer is equivocal.

Question 29

In the TRIO study, how much did the combined biopsy approach increase overall prostate cancer detection compared to either biopsy method alone?
A. 2.5%
B. 5.5%
C. 9.9%
D. 15.4%

Answer 29

C. 9.9%
Explanation: In the TRIO study, the combined biopsy approach led to a 9.9% increase in overall prostate cancer detection compared to either biopsy method alone.

Question 30

Which urine-based test measures DLX1 and HOXC6 against KLK3 mRNA levels in post-DRE urine and is validated for the risk of clinically significant prostate cancer (≥3+4) in men without a prior biopsy?
A. ExoDx™
B. miR
C. MPS (MyProstateScore, formerly Michigan Prostate Score (MiPS))
D. SelectMDx

Answer 30

D. SelectMDx
Explanation: SelectMDx is a urine-based test that measures DLX1 and HOXC6 against KLK3 mRNA levels in post-DRE urine and is validated for the risk of clinically significant prostate cancer.

Question 31

Which of the following blood-based tests uses PSA, percent free PSA, and [-2]proPSA to estimate the risk of clinically significant prostate cancer?
A. 4-kallikrein (4Kscore®) panel
B. PHI
C. Both A and B
D. None of the above

Answer 31

B. PHI
Explanation: PHI is a blood-based test that uses PSA, percent free PSA, and [-2]proPSA to estimate the risk of clinically significant prostate cancer.

Question 32

Which tissue-based test is assessed on non-cancerous biopsy tissue and is validated to predict the absence of prostate cancer on subsequent biopsy?
A. OncotypeDX Prostate
B. Prolaris
C. ProMark
D. ConfirmMDx

Answer 32

D. ConfirmMDx
Explanation: ConfirmMDx is a tissue-based test that is assessed on non-cancerous biopsy tissue and is validated to predict the absence of prostate cancer on subsequent biopsy.

Question 33

What does the Decipher test predict?
A. Risk of urinary tract infection
B. Risk of benign prostatic hyperplasia
C. Risk of metastasis, used to select patients who are better treated with definitive therapy
D. Risk of prostatitis

Answer 33

C. Risk of metastasis, used to select patients who are better treated with definitive therapy
Explanation: The Decipher test is a 22-gene genomic classifier that is validated to predict the risk of metastasis, and it’s used to select patients who are better treated with definitive therapy.

Question 34

What is the role of the ExoDx test in prostate cancer screening?
A. It measures the levels of PSA in the blood.
B. It is a urine-based 3-gene exosome expression assay validated for the risk of clinically significant prostate cancer in men without a prior biopsy.
C. It is a tissue-based test that predicts the risk of prostate cancer on subsequent biopsy.
D. It is a blood-based test that predicts the risk of clinically significant prostate cancer.

Answer 34

B. It is a urine-based 3-gene exosome expression assay validated for the risk of clinically significant prostate cancer in men without a prior biopsy.
Explanation: According to the text, the ExoDx test is a urine-based 3-gene exosome expression assay validated for the risk of clinically significant prostate cancer in men without a prior biopsy.

Question 35

Which test uses a 17-gene expression panel to predict the risk of adverse pathology at surgery and the risk of metastasis and death after treatment?
A. OncotypeDX Prostate
B. Prolaris
C. ProMark
D. Decipher

Answer 35

A. OncotypeDX Prostate
Explanation: The OncotypeDX Prostate test uses a 17-gene expression panel to predict the risk of adverse pathology at surgery and the risk of metastasis and death after treatment.

Question 36

What is the function of the 4-kallikrein (4Kscore®) panel in the screening and diagnosis of prostate cancer?
A. It’s a blood-based validated risk assessment for clinically significant prostate cancer in men at risk.
B. It’s a urine-based test that measures DLX1 and HOXC6 against KLK3 mRNA levels.
C. It’s an epigenetic test of the prostate cancer-associated genes GSTP1, APC, and RASSF1.
D. It’s a tissue-based test that predicts the risk of prostate cancer on subsequent biopsy.

Answer 36

What is the function of the 4-kallikrein (4Kscore®) panel in the screening and diagnosis of prostate cancer?
A. It’s a blood-based validated risk assessment for clinically significant prostate cancer in men at risk.
B. It’s a urine-based test that measures DLX1 and HOXC6 against KLK3 mRNA levels.
C. It’s an epigenetic test of the prostate cancer-associated genes GSTP1, APC, and RASSF1.
D. It’s a tissue-based test that predicts the risk of prostate cancer on subsequent biopsy.

Question 37

Which test, according to the table, has the highest area under curve (AUC) value?
A. ExoDx
B. miR
C. 4K Score
D. Decipher

Answer 37

B. miR
Explanation: According to the table, the miR test has an AUC of 0.98 – 0.99, which is higher than the other tests listed in the options.

Question 38

What does the SelectMDx test measure and in what type of sample?
A. DLX1 and HOXC6 against KLK3 mRNA levels in post-DRE urine
B. Serum PSA, post-DRE urine PCA3 and TMPRSS2:ERG
C. PSA, percent free PSA, and [-2]proPSA in blood
D. GSTP1, APC, and RASSF1 in non-cancerous biopsy tissue

Answer 38

A. DLX1 and HOXC6 against KLK3 mRNA levels in post-DRE urine
Explanation: According to the text, the SelectMDx test measures DLX1 and HOXC6 against KLK3 mRNA levels in post-DRE urine.

Question 39

Table 2

Question 40

Table 3

Question 41

What is the minimum recommended number of core samples in a systematic prostate biopsy (PBx) to establish a Prostate Cancer (PCa) diagnosis?

A. 6
B. 12
C. 18
D. 24

Answer 41

B. 12

Explanation: A minimum of 12-core systematic PBx is recommended to establish PCa diagnosis.

Question 42

In the case of locally advanced or metastatic prostate cancer, what type of biopsy can be used?

A. Six-core “sextant” biopsy
B. Eight-core biopsy
C. Ten-core biopsy
D. Twelve-core biopsy

Answer 42

A. Six-core “sextant” biopsy

Explanation: For obvious locally advanced or metastatic disease a six-core “sextant” biopsy can be employed.

Question 43

What should the positive biopsy rates be for biopsy naïve patients with elevated PSA using standard systematic TRUS biopsy?

A. 20-25%
B. 30-35%
C. 40-45%
D. 50-55%

Answer 43

C. 40-45%

Explanation: Positive biopsy rates with standard systematic TRUS biopsy should be ~40-45% for biopsy naïve patients with elevated PSA.

Question 44

Why should biopsy cores be labeled by location during the process?

A. It helps in preventing tangling of cores.
B. It improves tissue sampling.
C. It determines the location of disease and aids in treatment planning.
D. All of the above.

Answer 44

C. It determines the location of disease and aids in treatment planning.

Explanation: Cores should be labeled by location as this information can determine location of disease and treatment planning.

Question 45

What should be ensured in a biopsy protocol or “check-list” approach?

A. Quality and safety
B. Efficiency and speed
C. Patient comfort and satisfaction
D. Financial feasibility

Answer 45

A. Quality and safety

Explanation: A protocol or “check-list” approach to biopsy should be used to ensure quality and safety.

Question 46

Which type of prostate biopsy is currently the most common approach?

A. Transperineal PBx
B. Transrectal PBx with ultrasound guidance
C. MRI-guided biopsy
D. Finger-guided biopsy

Answer 46

B. Transrectal PBx with ultrasound guidance

Explanation: Currently, transrectal PBx with ultrasound guidance is the most common approach for PBx.

Question 47

What is a notable advantage of the transrectal PBx approach?

A. Fewer or no antibiotics necessary
B. Lower infection risk
C. Less procedural pain
D. Targets anterior prostate and apex well

Answer 47

C. Less procedural pain

Explanation: The advantages of the transrectal PBx approach include less procedural pain, less local anesthetic necessary, less equipment, shorter procedure, and it targets the posterior prostate well.

Question 48

What is one main advantage of the transperineal PBx approach over the transrectal PBx approach?

A. Fewer procedural pain
B. Lower risk of serious infection
C. Less equipment
D. Shorter procedure

Answer 48

B. Lower risk of serious infection

Explanation: Transperineal PBx is performed by passing needles through the perineum to sample the prostate. This approach has a lower risk of serious infection.

Question 49

What are some forms of MRI-targeted biopsy?

A. Cognitive fusion
B. Software-based fusion
C. In-bore MRI PBx
D. All of the above

Answer 49

D. All of the above

Explanation: There are various forms of MRI-targeted biopsy, including cognitive fusion, software-based fusion, and in-bore MRI PBx.

Question 50

In what situation might a finger-guided biopsy of the prostate be used?

A. When ultrasound guidance is not readily available, and an obvious prostate mass is present.
B. When the patient is allergic to the contrast used in MRI.
C. When the patient has a prior negative PBx and/or negative mpMRI.
D. When the patient prefers a less invasive procedure.

Answer 50

In what situation might a finger-guided biopsy of the prostate be used?

A. When ultrasound guidance is not readily available, and an obvious prostate mass is present.
B. When the patient is allergic to the contrast used in MRI.
C. When the patient has a prior negative PBx and/or negative mpMRI.
D. When the patient prefers a less invasive procedure.

Question 51

What steps would you take to reduce post-prostate biopsy infection?

A. Enema
B. Use of preparatory antibiotics
C. Rectal preparation with povidone-iodine
D. All of the above

Answer 51

D. All of the above

Explanation: Preparatory antibiotics and rectal preparation with povidone-iodine, along with optional enema, are recommended steps to reduce post-prostate biopsy infection.

Question 52

Which of the following MRI-targeted biopsy methods involves the overlay of contoured images on TRUS images for directed biopsy?

A. Cognitive fusion
B. Software-based fusion
C. In-bore MRI PBx
D. Saturation biopsy

Answer 52

B. Software-based fusion

Explanation: In software-based fusion, the prostate and MRI lesions are contoured by radiologists. The contoured images are overlaid on TRUS images, and electromagnetic tracking of the biopsy probe allows for directed biopsy of the lesions.

Question 53

When would a “saturation” biopsy pattern, including greater than 12 cores, be particularly useful?

A. In patients with a prior negative PBx and/or negative mpMRI
B. In patients with a low PSA level
C. In patients with locally advanced or metastatic disease
D. In patients with an obvious prostate mass

Answer 53

A. In patients with a prior negative PBx and/or negative mpMRI

Explanation: “Saturation” biopsy patterns including greater than 12 cores can improve the diagnostic ability of PBx and can be useful in patients with a prior negative PBx and/or negative mpMRI.

Question 54

What disadvantage is associated with the transperineal PBx approach when performed under local anesthesia?

A. Lower cancer detection rates
B. Higher pain scores
C. Lower risk of serious infection
D. Incomplete sampling of the prostate

Answer 54

B. Higher pain scores

Explanation: The transperineal PBx approach is associated with higher pain scores when performed under local anesthesia.

Question 55

Why might the transperineal PBx approach be gaining popularity in the United States, despite potential disadvantages?

A. It provides more accurate results.
B. It is a less invasive procedure.
C. It has a reduced risk of sepsis.
D. It is a quicker procedure.

Answer 55

C. It has a reduced risk of sepsis.

Explanation: The transperineal PBx approach is gaining popularity in the United States due to the reduced risk of sepsis.

Question 56

Which of the following is NOT a reason why a physician might choose the transrectal PBx approach over the transperineal PBx?

A. The transrectal PBx requires less equipment
B. The transperineal PBx is associated with higher pain scores when performed under local anesthesia
C. The transrectal PBx targets the anterior prostate and apex well
D. The transrectal PBx results in less procedural pain

Answer 56

C. The transrectal PBx targets the anterior prostate and apex well

Explanation: The transrectal PBx is advantageous because it requires less equipment, is associated with less procedural pain, and targets the posterior prostate well. However, it does not target the anterior prostate and apex well. This is an advantage of the transperineal PBx.

Question 57

A patient is scheduled for a transperineal PBx. The physician performs a brief ultrasound assessment of the prostate before administering the perineal block with local anesthetic. What crucial step has the physician missed?

A. Sterilization of the perineum
B. Rectal examination to assess the prostate for mass and ensure no rectal pathology is present
C. Full ultrasound assessment of the prostate
D. Obtaining biopsies

Answer 57

A. Sterilization of the perineum

Explanation: The steps before administering the perineal block should include a rectal examination, insertion of the TRUS probe, a brief ultrasound assessment of the prostate, and sterilization of the perineum. The physician missed sterilizing the perineum.

Question 58

How might an MRI-targeted biopsy improve the yield and grade assessment of a PBx?

A. By allowing for the biopsy of more than 12 cores
B. By providing a clearer view of the prostate and any lesions
C. By reducing the risk of serious infection
D. By allowing for the biopsy of an obvious prostate mass when ultrasound guidance is not readily available

Answer 58

B. By providing a clearer view of the prostate and any lesions

Explanation: MRI-targeted biopsies allow for a clearer view of the prostate and any lesions, leading to an improved yield and grade assessment of a PBx.

Question 59

Which of the following templates used for transperineal prostate biopsy has been shown to have significantly higher cancer detection rates?

A. Brazell template
B. Ginsburg protocol template
C. MUSIC TP template
D. None of the above

Answer 59

D. None of the above

Explanation: Several TP prostate biopsy templates such as Brazell template, Ginsburg protocol template, and MUSIC TP template are utilized by urologists. However, no one template has been shown to have significantly higher cancer detection rates.

Question 60

In a patient with an elevated PSA and a negative mpMRI, what could be a useful approach to improve the diagnostic ability of the PBx?

A. A “saturation” biopsy pattern including greater than 12 cores
B. A transperineal PBx
C. A transrectal PBx with ultrasound guidance
D. A finger-guided biopsy

Answer 60

A. A “saturation” biopsy pattern including greater than 12 cores

Explanation: “Saturation” biopsy patterns including greater than 12 cores can improve the diagnostic ability of PBx and can be useful in patients with a prior negative PBx and/or negative mpMRI.

Question 61

What percentage of patients report an unwillingness to undergo a repeat prostate biopsy due to pain?

A. 5%
B. 10%
C. 15%
D. 20%

Answer 61

D. 20%

Explanation: Up to 20% of patients report an unwillingness to undergo a repeat biopsy, which has significant implications when considering the role of active surveillance in low-risk men.

Question 62

Which nerve roots are the source of the innervation of the prostate?

A. S1-S2
B. S2-S4
C. S3-S4
D. S4-S5

Answer 62

B. S2-S4

Explanation: Prostate innervation is through the inferior hypogastric and pelvic plexus, which originate from S2-4 nerve roots.

Question 63

What are the three main approaches to local anesthesia during a prostate biopsy?

A. Anorectal, prostate, perineal tissues
B. Anorectal, pelvic plexus block, prostatic nerve block
C. Prostate, perineal tissues, superficial perineal nerve block
D. Anorectal, prostatic nerve block, periapical triangle block

Answer 63

A. Anorectal, prostate, perineal tissues

Explanation: The three main approaches to local anesthesia during a prostate biopsy are anorectal, prostate, and perineal tissues.

Question 64

Which of the following is NOT an important consideration for reducing discomfort during a prostate biopsy?

A. Use of local anesthetics
B. Use of low-dose benzodiazepine therapy
C. Thorough understanding of the neuroanatomy of the pelvis
D. Use of intravenous sedation for all patients

Answer 64

D. Use of intravenous sedation for all patients

Explanation: While local anesthetics, low-dose benzodiazepine therapy, and a thorough understanding of the neuroanatomy of the pelvis can aid in reducing discomfort, the use of intravenous sedation is not recommended for all patients. It should be considered for certain individuals who are not appropriate candidates for prostate biopsy under local anesthesia.

Question 65

What is the “Mount Everest” sign commonly used for during a prostate biopsy?

A. To describe the triangular fat pad that marks the appropriate location for a pelvic plexus block
B. To describe the location of the pudendal nerve for a perineal nerve block
C. To describe the triangular fat pad that marks the appropriate location for a prostatic nerve block
D. To describe the location of the levator muscles for a periapical triangle block

Answer 65

C. To describe the triangular fat pad that marks the appropriate location for a prostatic nerve block

Explanation: The “Mount Everest” sign is commonly used to describe the triangular fat pad that marks the appropriate location for a prostatic nerve block during a prostate biopsy.

Question 66

Which of the following is true about the innervation of the anorectal region?

A. The entire anorectal region is innervated by the pelvic plexus from S3-4 nerve roots
B. The area proximal to the dentate line is innervated by the pelvic plexus from S3-4 nerve roots
C. The area distal to the dentate line is innervated by the pelvic plexus from S3-4 nerve roots
D. The entire anorectal region is innervated by branches of the pudendal nerve

Answer 66

B. The area proximal to the dentate line is innervated by the pelvic plexus from S3-4 nerve roots

Explanation: The innervation of the anorectal region is determined relative to the dentate line. Proximal to the dentate line, the rectum is innervated by the pelvic plexus from S3-4 nerve roots.

Question 67

Where are the parasympathetic and sympathetic fibers that innervate the prostate originated from?

A. S1-2 nerve roots
B. S2-4 nerve roots
C. S3-4 nerve roots
D. S4-5 nerve roots

Answer 67

B. S2-4 nerve roots

Explanation: The parasympathetic and sympathetic fibers that innervate the prostate originate from S2-4 nerve roots. They coalesce at the tips of the seminal vesicles and then continue along the posterolateral surface of the prostate.

Question 68

What is the “Mount Everest” sign used to indicate during a prostate biopsy?

A. The appropriate location for a pelvic plexus block
B. The appropriate location for a prostatic nerve block
C. The appropriate location for a periapical triangle block
D. The appropriate location for a superficial perineal nerve block

Answer 68

B. The appropriate location for a prostatic nerve block

Explanation: The “Mount Everest” sign is commonly used to describe the triangular fat pad that marks the appropriate location for a prostatic nerve block during a prostate biopsy.

Question 69

Which local anesthetic approach often requires puncture of the rectum below the dentate line when performed transrectally, and therefore patients should be warned for the increased pain during performance of this block?

A. Pelvic plexus block
B. Prostatic nerve block
C. Periapical triangle block
D. Superficial perineal nerve block

Answer 69

C. Periapical triangle block

Explanation: The periapical triangle block, which involves the infiltration of local anesthetic at the apex of the prostate, often requires puncture of the rectum below the dentate line when performed transrectally.

Question 70

C. Periapical triangle block

Explanation: The periapical triangle block, which involves the infiltration of local anesthetic at the apex of the prostate, often requires puncture of the rectum below the dentate line when performed transrectally.

Answer 70

B. The use of benzodiazepines

Explanation: Benzodiazepines can be effective in reducing anorectal tone to reduce discomfort from probe insertion during a prostate biopsy.

Question 71

Figure 1

Answer 71

A. Ultrasound image in parasagittal plane showing triangular echogenic “Mount Everest sign” at site of neurovascular bundle (*). B. Schematic diagram demonstrating site of bi-basal injection in parasagittal plane (arrow). C. Parasagittal ultrasound image with biopsy trajectory guide-lines (dotted lines) to direct needle passage during bi-basal injections

Question 72

Figure 2

Answer 72

Figure 2
Approach to superficial perineal nerve block as described by Wang and colleagues.
How to block the BPN. (1) View of perineum in lithotomy position: the 2 black dots were the sites we punctured the anesthesia needle; (2) Sagittal transrectal ultrasound (TRUS) images: prostate (red arrow); prostate capsule where stop to inject lidocaine(yellow arrow); deep layer of superficial fascia where we start to inject lidocaine(green arrow); anesthesia needle(pink arrow); (3) Simplified diagram of sagittal transrectal ultrasound (TRUS) images of the plane of anesthesia needle insertion path: the 2 black dots were the sites we injected lidocaine. (Color version available online.)

Question 73

What is the average decline in IIEF-5 scores one month after prostate biopsy?

A. 2.3 points
B. 4.6 points
C. 6.9 points
D. 9.2 points

Answer 73

B. 4.6 points

Explanation: IIEF-5 scores declined by 4.6 points on average one month after prostate biopsy. However, these effects were transient and not experienced by all men.

Question 74

What percentage of men undergoing prostate biopsy are reported to have fluoroquinolone-resistance and extended beta-lactamase producing E. coli?

A. 10%
B. 25%
C. 50%
D. 75%

Answer 74

C. 50%

Explanation: There is a growing incidence of fluoroquinolone-resistance and extended beta-lactamase producing E. coli among men undergoing prostate biopsy, with the rate reported up to 50%.

Question 75

Which of the following is NOT a risk associated with prostate biopsy?

A. Vasovagal response
B. Hematuria
C. Sepsis
D. Permanent erectile dysfunction

Answer 75

D. Permanent erectile dysfunction

Explanation: While prostate biopsy is associated with temporary erectile dysfunction, it is not associated with permanent erectile dysfunction.

Question 76

Which of the following is used to limit the risk of post-biopsy sepsis through the identification of fluoroquinolone-resistant bacteria in the rectum?

A. Blood culture
B. Sputum culture
C. Rectal swab culture
D. Urine culture

Answer 76

C. Rectal swab culture

Explanation: A rectal swab culture can be employed to limit the risk of post-biopsy sepsis through the identification of fluoroquinolone-resistant bacteria in the rectum.

Question 77

What is the false negative rate of prostate biopsy?

A. 5-10%
B. 10-20%
C. 20-30%
D. 30-40%

Answer 77

C. 20-30%

Explanation: There is a 20-30% false negative rate of prostate biopsy. Men at risk for clinically meaningful prostate cancer should have close clinical follow-up.

Question 78

What is the percentage of sepsis risk associated with a transrectal prostate biopsy?

A. Less than 1%
B. 1%
C. 2%
D. 3%

Answer 78

D. 3%

Explanation: The risk of sepsis with a transrectal prostate biopsy is 3%, whereas with a transperineal biopsy, it’s less than 1%.

Question 79

Which of the following antibiotic therapies is NOT recommended by the current AUA guidelines on antimicrobial prophylaxis for a prostate biopsy?

A. Fluoroquinolone
B. 1st generation cephalosporin
C. 2nd generation cephalosporin
D. Tetracycline

Answer 79

D. Tetracycline

Explanation: The current AUA guidelines on antimicrobial prophylaxis guide the choice of antibiotic therapy with a recommended 24-hour dose of either a fluoroquinolone or 1st/2nd/3rd generation cephalosporin.

Question 80

What is the significance of local antibiograms in the context of prostate biopsy?

A. They help determine the appropriateness of antibiotic selection.
B. They are used to assess the extent of prostate cancer.
C. They help identify the specific strain of E. coli.
D. They determine the resistance pattern of bacteria to a specific antibiotic.

Answer 80

A. They help determine the appropriateness of antibiotic selection.

Explanation: Local antibiograms can be useful in determining the appropriateness of antibiotic selection for prophylaxis in prostate biopsy, particularly in the context of increasing resistance to fluoroquinolones.

Question 81

What additional prophylaxis might be necessary for patients with artificial heart valves or joints undergoing a prostate biopsy?

A. A higher dose of antibiotics
B. Additional local anesthetic
C. Additional systemic anesthetic
D. No additional prophylaxis is necessary

Answer 81

A. A higher dose of antibiotics

Explanation: Patients with artificial heart valves or joints may need additional antibiotic prophylaxis when undergoing a prostate biopsy.

Question 82

Table 4

Answer 82

AUA Risk Stratification

Question 83

What is the lowest and the highest grade in the current Gleason scoring system?

Answer 83

The lowest grade reported is 3 and the highest is 5, resulting in a scale that goes from 6 to 10.

Question 84

Which grading scale is currently recognized by the International Society of Urologic Pathologists (ISUP) and World Health Organization (WHO)?

Answer 84

The Gleason grade group system is the currently recognized grading scale by the International Society of Urologic Pathologists (ISUP) and World Health Organization (WHO).

Question 85

What factors are employed in risk stratification for Prostate Cancer?

Answer 85

Factors employed in risk stratification include: PSA at diagnosis, Clinical staging based on rectal examination, Gleason grade group.

Question 86

What should be obtained for patients with high-risk prostate cancer?

Answer 86

Axial Imaging or Bone Scan should be obtained for patients with high-risk prostate cancer. Axial Imaging can consist of abdominopelvic CT scan or MRI. Molecular imaging (PET-CT) can be considered for patients with high risk of metastatic disease.

Question 87

For whom is somatic testing recommended?

Answer 87

Somatic testing is recommended for Men with >10-year life expectancy and localized low, favorable intermediate, unfavorable intermediate, and high-risk prostate cancer to inform the risk of adverse pathology (biopsy under-grading / under-staging) and prognosis and Men with N1 and M1 disease for homologous recombination gene mutations, microsatellite instability, and mismatch repair deficiencies to guide treatment decision-making.

Question 88

For whom is germline testing recommended?

Answer 88

Germline testing is recommended for Men with very-high risk clinically localized, N1, or M1 disease (hormone-sensitive and castration-resistant) to identify potentially heritable genetic changes and Men with a strong family history of prostate cancer or related cancers.

Question 89

What is the purpose of germline testing?

Answer 89

The purpose of germline testing is to identify potentially heritable genetic changes. This should be done in concert with a detailed family history and with trained genetic counselors (when available).

Question 90

How many tiers does the National Comprehensive Cancer Network (NCCN) utilize in its risk stratification system?

Answer 90

The National Comprehensive Cancer Network (NCCN) utilizes a 6-tier system based on the same risk factors.

Question 91

What is the purpose of novel independent molecular/genetic risk prognostic tools?

Answer 91

The purpose of novel independent molecular/genetic risk prognostic tools is to advance our risk prediction abilities.

Question 92

What are risk calculators and nomograms used for?

Answer 92

Risk calculators and nomograms are used for assessing risk and predicting Prostate Cancer clinical outcomes. They are under development incorporating the data derived from prostate biopsy pathology obtained via MRI targeted biopsy sampling over the conventional systematic sampling schema from which most widely accepted and used nomograms have been created.

Question 93

Table 5

Answer 93

NCCN Risk Stratification

Question 94

What is the PSA level range for the low-risk group in the AUA Risk Stratification?

Answer 94

PSA <10 ng/ml

Explanation:
According to the AUA Risk Stratification, the low-risk group includes patients with a PSA level less than 10 ng/ml.

Question 95

Which risk group in the NCCN Risk Stratification includes patients with a PSA level >20?

Answer 95

Answer:
High Risk and Very High Risk

Explanation:
In the NCCN Risk Stratification, both the High-Risk and Very High-Risk groups include patients with a PSA level greater than 20.

Question 96

In the AUA Risk Stratification, what distinguishes a patient in the favorable intermediate risk group from a patient in the unfavorable intermediate risk group?

Answer 96

A patient in the favorable intermediate risk group has Grade Group 2 with PSA<10 while a patient in the unfavorable intermediate risk group has Grade Group 2 with either PSA 10-<20 or clinical stage T2b-c OR Grade Group 3 with PSA < 20.

Explanation:
In the AUA Risk Stratification, a patient in the favorable intermediate risk group has Grade Group 2 with PSA<10. An unfavorable intermediate risk patient has Grade Group 2 with either PSA 10-<20 or clinical stage T2b-c OR Grade Group 3 with PSA < 20.

Question 97

According to the NCCN Risk Stratification, what clinical features characterize the Very High-Risk group?

Answer 97

T3b-T4 OR Primary Gleason pattern 5 OR >4 cores Grade Group 4/5

Question 98

In the AUA Risk Stratification, what criteria are used to classify a patient as being at High Risk?

Answer 98

PSA >20 ng/ml OR Grade Group 4-5 OR clinical stage≥T3

Explanation:
According to the AUA Risk Stratification, a patient is classified as High Risk if they have a PSA level greater than 20 ng/ml, belong to Grade Group 4-5, or have a clinical stage of T3 or higher.

Question 99

What is the PSA density for the Very Low Risk group in the NCCN Risk Stratification?

Answer 99

PSA density <0.15

Explanation:
In the NCCN Risk Stratification, the Very Low Risk group includes patients with a PSA density less than 0.15.

Question 100

In the NCCN Risk Stratification, what features define the Favorable Intermediate Risk group?

Answer 100

Grade Group 2 OR T2b-T2c (can be Grade Group 1) OR PSA 10-20 (can be Grade Group 1) AND <50% of total cores sampled positive

Explanation:
According to the NCCN Risk Stratification, the Favorable Intermediate Risk group includes patients with Grade Group 2 OR T2b-T2c (can be Grade Group 1) OR PSA 10-20 (can be Grade Group 1) AND less than 50% of total cores sampled positive.

Question 101

What is the clinical stage for the High-Risk group in the AUA Risk Stratification?

Answer 101

Answer:
clinical stage≥T3

Explanation:
According to the AUA Risk Stratification, the High Risk group includes patients with a clinical stage of T3 or higher.

Question 102

In the AUA Risk Stratification, what features define the Intermediate Risk group?

Answer 102

PSA 10-<20 ng/ml OR Grade Group 2-3 OR clinical stage T2b-c

Explanation:
In the AUA Risk Stratification, the Intermediate Risk group includes patients with a PSA level of 10-<20 ng/ml, belong to Grade Group 2-3, or have a clinical stage of T2b-c.

Question 103

What is the primary Gleason pattern for the Very High Risk group in the NCCN Risk Stratification?

Answer 103

Primary Gleason pattern 5

Explanation:
According to the NCCN Risk Stratification, the Very High Risk group includes patients with a primary Gleason pattern of 5.

Question 104

1. The Prostate Cancer Prevention Trial (PCPT) studied the use of which medication in reducing the detection of prostate cancer in low-risk individuals (PSA<3 ng/ml)?
   A. Dutasteride
   B. Selenium
   C. Vitamin E
   D. Finasteride

Answer 104

D. Finasteride
Explanation: The PCPT was designed to evaluate the effectiveness of finasteride in reducing the detection of prostate cancer in men with low risk of disease (PSA<3 ng/ml).

Question 105

2. The FDA Oncologic Drug Advisory Committee did not issue an indication for the prevention of prostate cancer with 5-alpha reductase inhibitors based on the results of which trials?
   A. PCPT and SELECT
   B. PCPT and REDUCE
   C. REDUCE and SELECT
   D. SELECT and CALBG 70807

Answer 105

B. PCPT and REDUCE
Explanation: The FDA Oncologic Drug Advisory Committee did not issue an indication for the prevention of prostate cancer with either of these 5-alpha reductase inhibitors based on the PCPT and REDUCE results.

Question 106

The Selenium and Vitamin E Cancer Prevention Trial (SELECT) found that:
A. There was a significant difference in rates of prostate cancer across intervention groups.
B. Selenium or Vitamin E is recommended for the prevention of prostate cancer.
C. There were no significant differences in rates of prostate cancer across the intervention groups.
D. Selenium and Vitamin E together significantly reduced the rates of prostate cancer.

Answer 106

C. There were no significant differences in rates of prostate cancer across the intervention groups.
Explanation: The SELECT trial found no significant differences in rates of prostate cancer across the intervention groups. Therefore, Selenium or Vitamin E is not recommended for the prevention of prostate cancer.

Question 107

The Men’s Eating and Living Study (CALBG 70807) found that:
A. An intervention of increased vegetable consumption significantly reduced prostate cancer progression in men managed by active surveillance.
B. An intervention of increased vegetable consumption had no effect on prostate cancer progression in men managed by active surveillance.
C. The primary outcome was clinical progression due to diet.
D. The study did not complete the enrollment of 478 patients.

Answer 107

B. An intervention of increased vegetable consumption had no effect on prostate cancer progression in men managed by active surveillance.
Explanation: The MEALS study reported no significant reduction in prostate cancer progression amongst men randomized to the behavioral intervention to increase vegetable consumption compared to controls for the men managed by active surveillance.

Question 108

. Life expectancy estimates used in the context of prostate cancer screening and treatment:
A. Typically factor in comorbidities, lifestyle factors, and family history.
B. Rely on population-wide estimates using age, gender, and sometimes race.
C. Are rarely used in making informed decisions about prostate cancer screening and treatment.
D. Use individual patient-specific data only.

Answer 108

B. Rely on population-wide estimates using age, gender, and sometimes race.
Explanation: Most tools used to determine life expectancy typically do not factor in comorbidities, lifestyle factors, or family history which all influence longevity. Instead, they rely on population-wide estimates using age, gender, and sometimes race.

Question 109

Table 1

Question 110

What does a high score in the Prolaris test indicate?
A. High risk of disease-specific mortality with conservative management and the risk of metastatic disease after treatment
B. High risk of benign prostatic hyperplasia (BPH)
C. High risk of urinary tract infection (UTI)
D. High risk of prostatitis

Answer 110

A. High risk of disease-specific mortality with conservative management and the risk of metastatic disease after treatment
Explanation: The Prolaris test is a 31-gene expression panel validated to predict the risk of disease-specific mortality with conservative management and the risk of metastatic disease after treatment.