Treatment of Castration-Resistant Prostate Cancer Flashcards
Vignette: A 65-year-old man is evaluated for castration-resistant prostate cancer (CRPC). Which of the following is crucial for determining his treatment plan?
Options:
A) Patient’s age
B) Presence or absence of radiographic metastases
C) Family history of prostate cancer
D) Blood testosterone levels
Correct Answer: B) Presence or absence of radiographic metastases
Explanation:
A) Age is important but not a critical determinant for therapy.
B) Correct. Determining the presence or absence of radiographic metastases is crucial for the treatment plan (Paragraph 2).
C) Family history is not a critical determinant.
D) Blood testosterone levels are not crucial in the context of CRPC.
Memory Tool: Radiographic Metastases = Road Map for CRPC Treatment.
Reference: Paragraph 2 from provided material.
Rationale for this question: Understanding the critical determinants for CRPC treatment is essential for optimal patient management.
Vignette: A 68-year-old man with metastatic CRPC (mCRPC) reports progression despite docetaxel treatment. What second-line chemotherapy can be considered?
Options:
A) Apalutamide
B) Cabazitaxel
C) Mitoxantrone
D) Abiraterone
Correct Answer: B) Cabazitaxel
Explanation:
A) Incorrect. Apalutamide is not approved for use in metastatic CRPC.
B) Correct. Cabazitaxel is a second-line option for patients who have had progressive disease during or after docetaxel treatment (Paragraph 9).
C) Incorrect. Mitoxantrone doesn’t prolong survival and is more palliative.
D) Incorrect. Abiraterone is hormonal therapy, not chemotherapy.
Memory Tool: Second place Cab (Cabazitaxel) comes after the Doc (Docetaxel).
Reference: Paragraph 9 from provided material.
Rationale for this question: Identifying appropriate second-line therapies for mCRPC is crucial for effective treatment planning.
Vignette: A 70-year-old patient with mCRPC has never undergone chemotherapy. Which androgen receptor (AR) signaling inhibitor improves survival in this setting?
Options:
A) Enzalutamide
B) Apalutamide
C) Abiraterone
D) Orteronel
orrect Answer: A) Enzalutamide
Explanation:
A) Correct. Enzalutamide improves survival in men with mCRPC in the prechemotherapy settings (Paragraph 18).
B) Incorrect. Apalutamide is not approved for use in metastatic CRPC.
C) Incorrect. Abiraterone is not specifically an AR signaling inhibitor.
D) Incorrect. Orteronel is still in clinical development.
Memory Tool: Enza-Ends the debate for prechemo survival improvement.
Reference: Paragraph 18 from provided material.
Rationale for this question: Understanding which AR signaling inhibitors are effective in prechemotherapy mCRPC is important for patient survival.
Clinical Vignette: A 66-year-old male patient with a history of prostate cancer presents with increasing PSA levels but no signs of radiographic metastases. What treatment option is most appropriate for him?
A. Apalutamide
B. Docetaxel
C. Abiraterone
D. Sipuleucel-T
Correct Answer: A. Apalutamide
In-depth Explanation:
A. Apalutamide: Correct. FDA approved for men with nonmetastatic (M0) CRPC to delay the onset of radiographic metastases.
B. Docetaxel: Incorrect. Standard first-line chemotherapy for metastatic CRPC (mCRPC), not indicated in nonmetastatic CRPC.
C. Abiraterone: Incorrect. Approved for mCRPC but not nonmetastatic CRPC.
D. Sipuleucel-T: Incorrect. Indicated for asymptomatic or minimally symptomatic mCRPC without visceral metastases.
Memory Tool: “A for Apalutamide, A for Absence of metastasis.”
Reference Citation: Paragraph 1 under Key Points: Clinical Considerations
Rationale for Question: Addresses the need to evaluate the type of CRPC (metastatic vs nonmetastatic) before choosing a therapy.
Clinical Vignette: A patient with mCRPC did not respond well to a regimen of docetaxel. What is the most appropriate second-line chemotherapy option?
A. Cabazitaxel
B. Platinum agents
C. Mitoxantrone
D. Abiraterone
Correct Answer: A. Cabazitaxel
In-depth Explanation:
A. Cabazitaxel: Correct. Second-line chemotherapy option for patients with mCRPC who have had progressive disease during or after docetaxel treatment.
B. Platinum agents: Incorrect. Indicated in patients with small cell prostate cancer and perhaps in other subsets of mCRPC.
C. Mitoxantrone: Incorrect. Does not prolong survival, used to palliate symptoms.
D. Abiraterone: Incorrect. It is a hormonal therapy, not chemotherapy.
Memory Tool: “Second chance with Cabazitaxel.”
Reference Citation: Paragraph 2 under Key Points: Cytotoxic Chemotherapy
Rationale for Question: Focuses on second-line treatment options after first-line chemotherapy failure.
Clinical Vignette: A patient with mCRPC tests negative for AR-V7. Which therapeutic strategy could be equally effective for this patient?
A. Taxane Chemotherapy
B. AR-directed therapy
C. Both A and B
D. Neither A nor B
Correct Answer: C. Both A and B
In-depth Explanation:
A. Taxane Chemotherapy: Incorrect alone. Effective in AR-V7(+) patients.
B. AR-directed therapy: Incorrect alone. Effective in AR-V7(–) patients.
C. Both A and B: Correct. AR-V7(–) men may benefit similarly from either AR-directed therapy or chemotherapy.
D. Neither A nor B: Incorrect.
Memory Tool: “AR-V7 negative? Either way, you have a play.”
Reference Citation: Paragraph 6 under Key Points: Next-Generation Hormonal Therapies
Rationale for Question: Differentiating treatment strategies based on biomarkers such as AR-V7.
Clinical Vignette: A 70-year-old male patient with mCRPC has a negative bone scan but persistent elevated PSA levels. What is the most accurate imaging technique to use for metastasis detection?
A. CT Scan
B. X-Ray
C. MRI
D. PSMA-PET/CT
Correct Answer: D. PSMA-PET/CT
In-depth Explanation:
A. CT Scan: Incorrect. Less sensitive in detecting bone metastases compared to PSMA-PET/CT.
B. X-Ray: Incorrect. Least sensitive imaging modality for detecting bone metastases.
C. MRI: Incorrect. While sensitive, it’s not as specific as PSMA-PET/CT.
D. PSMA-PET/CT: Correct. It offers the highest sensitivity and specificity for detecting prostate cancer metastases.
Memory Tool: “PSMA: Precise Scanning Makes A-difference.”
Reference Citation: Paragraph 3 under Key Points: Role of Imaging
Rationale for Question: Emphasizes the importance of using the most accurate imaging modality in complex cases.
Clinical Vignette: A 65-year-old man with prostate cancer has only 2 bone metastases. What is the most suitable management strategy?
A. Androgen Deprivation Therapy (ADT) alone
B. Chemotherapy
C. ADT and Stereotactic Body Radiation Therapy (SBRT)
D. Palliative Care
Correct Answer: C. ADT and Stereotactic Body Radiation Therapy (SBRT)
In-depth Explanation:
A. ADT alone: Incorrect. Not aggressive enough for oligometastatic disease.
B. Chemotherapy: Incorrect. Generally not the first choice for oligometastatic disease.
C. ADT and SBRT: Correct. Combining ADT with SBRT is emerging as a management strategy for oligometastatic prostate cancer.
D. Palliative Care: Incorrect. Not appropriate for a patient with only 2 bone metastases and who can tolerate aggressive treatment.
Memory Tool: “Oligo, go big—ADT and SBRT.”
Reference Citation: Paragraph 4 under Key Points: Oligometastatic Disease
Rationale for Question: Discusses the role of multimodal therapy in the management of oligometastatic disease.
Clinical Vignette: A 62-year-old male with high-risk localized prostate cancer has completed radical prostatectomy and is showing rising PSA. When should ADT be initiated?
A. Immediately
B. Wait until symptomatic
C. Upon detection of metastases
D. After salvage radiation therapy
Clinical Vignette: A 62-year-old male with high-risk localized prostate cancer has completed radical prostatectomy and is showing rising PSA. When should ADT be initiated?
A. Immediately
B. Wait until symptomatic
C. Upon detection of metastases
D. After salvage radiation therapy
Vignette: You are contemplating hormonal therapy for a 65-year-old male patient with mCRPC who hasn’t received chemotherapy.
Question: Which among the following statements is true about Abiraterone in mCRPC?
Options:
A. Abiraterone is not approved for mCRPC.
B. Abiraterone is a CYP17 inhibitor that is approved for mCRPC both before and after chemotherapy.
C. Abiraterone is approved only for nonmetastatic CRPC.
D. Abiraterone is an AR signaling inhibitor.
Correct Answer: B. Abiraterone is a CYP17 inhibitor that is approved for mCRPC both before and after chemotherapy.
Explanation:
A: Incorrect. Abiraterone is approved for mCRPC both before and after chemotherapy.
B: Correct. Abiraterone is a CYP17 inhibitor and is approved for both settings.
C: Incorrect. Abiraterone is not approved for nonmetastatic CRPC.
D: Incorrect. Abiraterone is a CYP17 inhibitor, not an AR signaling inhibitor.
Memory Tool: “Abi Before & After Chem” – to remember Abiraterone is used before and after chemotherapy.
Reference: Paragraph 1, Next-Generation Hormonal Therapies key points
Rationale: Knowing the proper hormonal treatments for specific CRPC stages is essential for patient management.
Question: In the evaluation of a patient with castration-resistant prostate cancer (CRPC), which of the following is NOT a critical determinant?
A. Radiographic metastases
B. Biochemical progression
C. PSA levels
D. Presence or absence of symptoms (e.g., pain)
Correct Answer: C. PSA levels
Explanation: Critical determinants for evaluating CRPC include the presence or absence of radiographic metastases (A), biochemical versus clinical progression (B), and the presence or absence of symptoms like pain (D). PSA levels (C) are not listed as a critical determinant.
Memory Tool: Think “RBiP” - Radiographic, Biochemical, Pain.
Reference: Paragraph 1, Clinical Considerations
Rationale: This question was chosen to test your understanding of what factors are critically important in evaluating CRPC.
Question: Which immune checkpoint inhibitor has been approved for locally advanced or metastatic urothelial carcinoma that has progressed following platinum-based chemotherapy?
A. Pembrolizumab
B. Atezolizumab
C. Ipilimumab
D. None of the above
Correct Answer: A. Pembrolizumab
Explanation: Pembrolizumab is approved for patients with locally advanced or metastatic urothelial carcinoma that has progressed after platinum-based chemotherapy. Atezolizumab (B) is also used, but Pembrolizumab has more robust data for this indication. Ipilimumab (C) is not approved for this use.
Memory Tool: “Pemb-Uro” for “Pembrolizumab in urothelial carcinoma.”
Reference: Paragraph 4, Immune Checkpoint Inhibitors
Rationale: This question is designed to clarify your understanding of the specific indications for immune checkpoint inhibitors in bladder cancer.
Clinical Vignette: A 65-year-old male is diagnosed with metastatic prostate cancer. He asks about the history of hormonal therapies in prostate cancer treatment.
Correct Answer: B. Hormonal therapy for prostate cancer was championed by Charles Huggins in 1941 and showed significant improvement in patients with metastatic cancer.
In-Depth Explanation:
A is incorrect because hormonal therapy was first championed by Charles Huggins in 1941, not the early 20th century. It is primarily for metastatic prostate cancer.
B is correct, as the vignette and key points indicate, Charles Huggins in 1941 reported significant improvement in patients with metastatic prostate cancer following castration.
C is incorrect; hormonal therapies are not a recent development and can be used independently of chemotherapy.
D is incorrect because hormonal therapies were introduced in 1941, not the 1980s, and they have shown significant effectiveness in treating metastatic prostate cancer.
Memory Tool: Think “Huggins in the 40s” to remember that Charles Huggins championed hormonal therapy in 1941.
Reference Citation: Paragraph 1, (Huggins, 1941)
Rationale: This information is essential for understanding the historical context and effectiveness of hormonal therapies in treating metastatic prostate cancer.
Clinical Vignette: A 58-year-old male is found to have elevated acid phosphatase levels. What can be concluded regarding his prostate cancer status based on phosphatase levels?
Multiple-Choice Options:
A. Elevated phosphatase levels are specific to prostate tumors.
B. Elevated phosphatase levels can also be found in normal adult and hypertrophic prostates.
C. Elevated phosphatase levels are found only in infant prostates.
D. Elevated phosphatase levels indicate the presence of neoplastic cells of a more primitive type in the prostate.
Correct Answer: B. Elevated phosphatase levels can also be found in normal adult and hypertrophic prostates.
In-Depth Explanation:
A is incorrect because elevated phosphatase levels are not specific to prostate tumors and can also be found in normal adult and hypertrophic prostates.
B is correct. Huggins observed elevated phosphatase levels in prostate tumors, as well as in normal adult and hypertrophic prostates.
C is incorrect; little to undetectable enzyme levels are present in newborn infant prostate tissues.
D is incorrect; Huggins stated that prostatic carcinomas consist of adult epithelium, not neoplastic cells of a more primitive type.
Memory Tool: Think “P levels for Prostate, but not just for Prostate tumors” to remember that phosphatase levels can be elevated in other conditions.
Reference Citation: Paragraph 1, (Huggins, 1941)
Rationale: Understanding that phosphatase levels can be elevated in various prostatic conditions is critical for diagnosis and management.
Clinical Vignette: A 72-year-old male with prostate cancer is prescribed hormonal therapy to reduce AR activity. His oncologist explains the function of the androgen receptor (AR). Which domains are key functional parts of the AR?
Multiple-Choice Options:
A. Ligand-binding, DNA-binding, and de novo steroidogenesis
B. Ligand-binding, DNA-binding, and transactivation
C. Ligand-binding, AR splice variants, and transactivation
D. Ligand-binding, DNA-binding, and amplification
Correct Answer: B. Ligand-binding, DNA-binding, and transactivation
In-Depth Explanation:
A is incorrect; de novo steroidogenesis is not a key functional domain of AR but a method of AR pathway adaptation.
B is correct, according to the key points, AR has three key functional domains: ligand-binding, DNA-binding, and transactivation.
C is incorrect; AR splice variants are not one of the key functional domains but rather a method of AR pathway adaptation.
D is incorrect; amplification is not a functional domain of the AR but another method of AR pathway adaptation.
Memory Tool: Think “L-D-T for AR” to remember Ligand-binding, DNA-binding, and Transactivation are the functional domains of AR.
Reference Citation: Key Points, (no author specified)
Rationale: Understanding the key functional domains of the AR is important for comprehending how hormonal therapy impacts prostate cancer.