Hormonal Therapy for Prostate Cancer

Question 1

Clinical Vignette: A 58-year-old male with prostate cancer undergoes castration as a part of his treatment. Which androgen is insufficient to maintain prostate epithelium in castrated men?
Options:
A. Testosterone
B. Dihydrotestosterone
C. Androstenedione
D. Dehydroepiandrosterone

Answer 1

Correct Answer: D. Dehydroepiandrosterone
Explanation:

A: Testosterone, produced mainly by the testes, is one of the potent androgens that maintains prostate epithelium. It’s not the answer.
B: Dihydrotestosterone (DHT) is converted from testosterone and has a potency between 160-190, making it quite effective in maintaining prostate epithelium.
C: Androstenedione, although weaker compared to testosterone, still has a relative potency of 39, which isn’t insufficient for maintaining the prostate epithelium.
D: Dehydroepiandrosterone (DHEA) is produced in the adrenal glands and has a relative potency of just 15, making it insufficient for maintaining prostate epithelium in castrated men, according to Walsh and Siiteri, 1975.
Memory Tool: “D-Efficient: DHEA is deficient for the prostate.”
Reference: Paragraph 2, Walsh and Siiteri, 1975.
Rationale for Question: The importance of knowing the relative potency and sources of different androgens is crucial for understanding the pathophysiology and treatment options for conditions like prostate cancer.

Question 1

Clinical Vignette: A 35-year-old male athlete is seeking advice to improve his muscle performance. Which enzyme converts testosterone to DHT, potentially affecting muscle tissue?
Options:
A. Aromatase
B. 5α-reductase
C. Cytochrome P450
D. Lactase

Answer 1

Correct Answer: B. 5α-reductase
Explanation:

A: Aromatase converts androgens to estrogens and is not involved in converting testosterone to DHT.
B: 5α-reductase is the enzyme that converts testosterone to DHT. DHT is even more potent than testosterone and can affect tissues like muscles that express androgen receptors.
C: Cytochrome P450 is involved in the metabolism of various substances but not in the specific conversion of testosterone to DHT.
D: Lactase is an enzyme that breaks down lactose and is unrelated to androgen conversion.
Memory Tool: “5α-Reds lift: 5α-reductase helps muscles get a lift from DHT.”
Reference: Paragraph 1, Montgomery et al., 2008.
Rationale for Question: Understanding the role of enzymes in androgen biochemistry is essential for understanding their tissue-specific effects and can be important in cases like enhancing athletic performance or managing conditions like prostate cancer.

Question 2

Clinical Vignette: A laboratory report indicates elevated levels of an androgen with the highest potency per amount produced. Which androgen is it likely to be?
Options:
A. Testosterone
B. Dihydrotestosterone
C. Androstenedione
D. Dehydroepiandrosterone

Answer 2

Correct Answer: B. Dihydrotestosterone
Explanation:

A: Testosterone has a relative potency of 100, and its potency per amount produced is 15.2, which is not the highest.
B: Dihydrotestosterone (DHT) has a relative potency between 160–190, and its potency per amount produced is 533–633, making it the most potent per amount produced.
C: Androstenedione has a relative potency of 39, and its potency per amount produced is 27.9, which is not the highest.
D: Dehydroepiandrosterone (DHEA) has a relative potency of 15, and its potency per amount produced is 0.5, which is the lowest.
Memory Tool: “DHT: ‘D’ for Dominant in potency.”
Reference: Table 161.2
Rationale for Question: This question emphasizes the need to understand the potency per amount produced for different androgens, which can be critical in diagnosis and treatment planning.

Question 3

Clinical Vignette: A 44-year-old male has recently been diagnosed with prostate cancer. A biopsy shows elevated androgen receptors (AR) in his prostate cells. What is the function of AR when engaged by DHT?
Options:
A. Converts DHT back to testosterone
B. Translocates into the nucleus to regulate gene expression
C. Increases the expression of 5α-reductase
D. Exits the cell to bind with circulating androgens

Answer 3

Correct Answer: B. Translocates into the nucleus to regulate gene expression
Explanation:

A: Conversion of DHT back to testosterone is not a function of AR.
B: When engaged by DHT, AR translocates into the nucleus, where it binds with androgen response elements (AREs) in gene promoters to regulate gene expression.
C: AR itself doesn’t increase the expression of 5α-reductase; it regulates genes once it’s in the nucleus.
D: AR does not exit the cell to bind with circulating androgens; it works within the cell nucleus.
Memory Tool: “AR Trans: AR Translocates to the Nucleus with DHT.”
Reference: Key Points, 2nd Bullet Point.
Rationale for Question: Knowing the function of AR when engaged by DHT is crucial for understanding how prostate cancer cells might behave.

Question 4

Clinical Vignette: A research team is studying muscle cells to determine how they respond to androgens. What enzyme should they focus on that converts testosterone to DHT in muscle cells?
Options:
A. Cytochrome P450
B. Aromatase
C. 5α-reductase
D. Amylase

Answer 4

Correct Answer: C. 5α-reductase
Explanation:

A: Cytochrome P450 is a general enzyme involved in the metabolism of various substances but is not specific for the conversion of testosterone to DHT.
B: Aromatase converts androgens to estrogens; it doesn’t convert testosterone to DHT.
C: 5α-reductase is the enzyme that converts testosterone to DHT, and cells like muscle cells that are responsive to testosterone express this enzyme.
D: Amylase is involved in carbohydrate metabolism and is not relevant to androgen biochemistry.
Memory Tool: “Muscle Memory: Remember 5α-reductase for muscles.”
Reference: Paragraph 1 and Key Points, 1st Bullet Point.
Rationale for Question: Understanding which enzymes are involved in specific tissues, like muscles, helps in both clinical and research settings.

Question 5

Clinical Vignette: A 55-year-old woman with adrenal tumors has an imbalance of androgens. Which adrenal androgen has the lowest relative potency per amount produced?
Options:
A. Androstenedione
B. Dehydroepiandrosterone
C. Dihydrotestosterone
D. Testosterone

Answer 5

Correct Answer: B. Dehydroepiandrosterone
Explanation:

A: Androstenedione has a relative potency of 39 and a potency per amount produced of 27.9, which isn’t the lowest.
B: Dehydroepiandrosterone (DHEA) has a relative potency of 15 and a potency per amount produced of 0.5, making it the lowest in relative potency per amount produced.
C: Dihydrotestosterone is not produced by the adrenal glands.
D: Testosterone is not exclusively produced by the adrenal glands.
Memory Tool: “Low DHEA: DHEA has the lowest punch per pinch.”
Reference: Table 161.2
Rationale for Question: Understanding the potency of adrenal androgens is crucial for managing conditions like adrenal tumors.

Question 6

Clinical Vignette: A 29-year-old male bodybuilder is considering androgen supplementation. Which cells are primed to respond to testosterone?
Options:
A. Liver cells
B. Prostate and muscle cells
C. Neurons
D. Kidney cells

Answer 6

Correct Answer: B. Prostate and muscle cells
Explanation:

A: Liver cells are involved in metabolism but are not specifically primed to respond to testosterone.
B: Prostate and muscle cells express AR and the enzyme 5α-reductase, making them primed to respond to testosterone.
C: Neurons are not specifically primed to respond to testosterone.
D: Kidney cells are more involved in filtration and electrolyte balance and are not specifically primed to respond to testosterone.
Memory Tool: “Pro-Muscle: Prostate and Muscle are Pro-Testosterone.”
Reference: Paragraph 1.
Rationale for Question: Understanding which cells are responsive to androgens like testosterone is important for targeting interventions, like androgen supplementation.

Question 7

Clinical Vignette: A 63-year-old man is diagnosed with advanced prostate cancer, and genomic analysis shows altered androgen response elements (AREs). What is the role of AREs in androgen action?
Options:
A. Convert DHT back to testosterone
B. Regulate gene expression when bound by AR
C. Act as an external ligand for AR
D. Facilitate the export of AR from the nucleus

Answer 7

Correct Answer: B. Regulate gene expression when bound by AR
Explanation:

A: Conversion of DHT back to testosterone is not the role of AREs.
B: AREs are bound by AR in the nucleus, which then regulates gene expression.
C: AREs are not external ligands for AR; they act as gene promoters.
D: AREs don’t facilitate the export of AR; they are involved in gene regulation within the nucleus.
Memory Tool: “A-REady to Regulate: AREs are ready to regulate genes when bound by AR.”
Reference: Key Points, 2nd Bullet Point.
Rationale for Question: Understanding the genetic mechanisms by which androgens exert their effects is crucial, especially in conditions like advanced prostate cancer where genomic alterations could play a role.

Question 8

Clinical Vignette: A 68-year-old male patient with metastatic prostate cancer is being considered for hormonal therapy. You opt for a GnRH agonist.

Multiple-Choice Options:

A. Triptorelin
B. Ketoconazole
C. Flutamide
D. Enzalutamide

Answer 8

Correct Answer: A. Triptorelin

In-Depth Explanation:

A: Triptorelin is a GnRH agonist that stimulates the release of LH from the pituitary gland. It is the mainstay of therapy for metastatic prostate cancer (Paragraph 1).
B: Ketoconazole is an adrenal-targeting drug, not a GnRH agonist (Paragraph 3).
C: Flutamide is a first-generation AR antagonist, not a GnRH agonist (Paragraph 5).
D: Enzalutamide is a second-generation AR antagonist, not a GnRH agonist (Paragraph 7).
Memory Tool: “Tri” as in “Triple action” for LH release, decrease in LH production, and treatment of metastatic disease.

Reference Citation: Table 161.1, Paragraph 1.

Rationale: GnRH agonists like Triptorelin are foundational for managing metastatic prostate cancer. Understanding their role is essential for board exams and patient care.

Question 9

Clinical Vignette: You prescribe a GnRH antagonist to a 65-year-old patient to treat his prostate cancer. What side effect should you specifically caution him about?

Multiple-Choice Options:

A. Gynecomastia
B. Increased FSH levels
C. Fatigue
D. Considerable side effects

Answer 9

Correct Answer: D. Considerable side effects

In-Depth Explanation:

A: Gynecomastia is associated with first-generation AR antagonists like Flutamide (Paragraph 5).
B: Increased FSH levels are associated with GnRH agonists like Leuprolide (Paragraph 1).
C: Fatigue is associated with second-generation AR antagonists like Enzalutamide (Paragraph 7).
D: Considerable side effects are associated with both GnRH agonists and antagonists (Paragraph 2).
Memory Tool: “Antagonists are Antagonistic” - they have considerable side effects.

Reference Citation: Table 161.1, Paragraph 2.

Rationale: Knowing the range of side effects for different hormonal interventions is crucial for patient safety and effective treatment.

Question 10

Clinical Vignette: A 70-year-old male with hypertension is under your care for prostate cancer treatment. You’re considering an adrenal-targeting drug. Which side effect should you monitor?

Multiple-Choice Options:

A. Hypertension
B. Gynecomastia
C. Decreased appetite
D. Increased FSH levels

Answer 10

Correct Answer: A. Hypertension

In-Depth Explanation:

A: Hypertension is a side effect of adrenal-targeting drugs like Ketoconazole (Paragraph 3).
B: Gynecomastia is associated with first-generation AR antagonists (Paragraph 5).
C: Decreased appetite is a side effect of second-generation AR antagonists (Paragraph 7).
D: Increased FSH levels are associated with GnRH agonists (Paragraph 1).
Memory Tool: “Adrenaline Rush” for Adrenal-targeting drugs elevating blood pressure.

Reference Citation: Table 161.1, Paragraph 3.

Rationale: Being aware of drug-specific side effects, especially when a patient already has a comorbidity like hypertension, is essential for quality care.

Question 11

Clinical Vignette: A patient is recommended a GnRH antagonist as part of prostate cancer therapy. How do these agents typically work?

Multiple-Choice Options:

A. Stimulate release of LH
B. Bind to receptors and block release of GnRH
C. Decrease androgen production from steroid precursors
D. Inhibit the conversion of testosterone to DHT

Answer 11

Correct Answer: B. Bind to receptors and block release of GnRH

In-Depth Explanation:

A: Stimulate release of LH is a mechanism of GnRH agonists (Paragraph 1).
B: Bind to receptors and block release of GnRH is the specific mechanism for GnRH antagonists like Degarelix (Paragraph 2).
C: Decrease androgen production from steroid precursors is the mechanism of adrenal-targeting drugs (Paragraph 3).
D: Inhibit the conversion of testosterone to DHT is the mechanism of 5α-Reductase inhibitors (Paragraph 7).
Memory Tool: Antagonists “Block and Lock” GnRH.

Reference Citation: Table 161.1, Paragraph 2.

Rationale: Understanding the exact mechanism of action for different drug classes is critical for appropriate prescription and patient care.

Question 12

Clinical Vignette: A 50-year-old patient comes to your clinic with symptoms of gynecomastia. You find out he is on a drug for prostate cancer. What is he most likely taking?

Multiple-Choice Options:

A. Ketoconazole
B. Leuprolide
C. Flutamide
D. Enzalutamide

Answer 12

Correct Answer: C. Flutamide

In-Depth Explanation:

A: Ketoconazole is an adrenal-targeting drug (Paragraph 3).
B: Leuprolide is a GnRH agonist (Paragraph 1).
C: Flutamide is a first-generation AR antagonist, associated with gynecomastia (Paragraph 5).
D: Enzalutamide is a second-generation AR antagonist (Paragraph 7).
Memory Tool: “First-gen, First problem” to remember that the first-gen AR antagonists cause gynecomastia.

Reference Citation: Table 161.1, Paragraph 5.

Rationale: Recognizing drug-related side effects is key for differential diagnosis and subsequent management.

Question 13

Clinical Vignette: You are considering prescribing a 5α-Reductase inhibitor for a patient’s BPH. Where is the primary site of action for this class of drugs?

Multiple-Choice Options:

A. Pituitary gland
B. Adrenal gland
C. Prostate
D. Prostate cancer

Answer 13

Correct Answer: C. Prostate

In-Depth Explanation:

A: Pituitary gland is the site of action for GnRH agonists and antagonists (Paragraph 1, 2).
B: Adrenal gland is the site of action for adrenal-targeting drugs (Paragraph 3).
C: Prostate is the primary site of action for 5α-Reductase inhibitors like Finasteride (Paragraph 7).
D: Prostate cancer is not the primary site for 5α-Reductase inhibitors; they are not indicated for prostate cancer management (Paragraph 7).
Memory Tool: 5α-Reductase inhibitors: “Five-Star Pro-state Agents.”

Reference Citation: Table 161.1, Paragraph 7.

Rationale: Knowing the site of action for drugs, especially when not indicated for cancer, is essential to avoid therapeutic missteps.

Question 14

Clinical Vignette: A 60-year-old male patient with prostate cancer complains of fatigue and frequent falls after starting a new medication. What drug is he likely taking?

Multiple-Choice Options:

A. Ketoconazole
B. Abarelix
C. Flutamide
D. Enzalutamide

Answer 14

Correct Answer: D. Enzalutamide

In-Depth Explanation:

A: Ketoconazole is an adrenal-targeting drug associated with hypertension, not fatigue or falls (Paragraph 3).
B: Abarelix is a GnRH antagonist, not linked to falls or fatigue (Paragraph 2).
C: Flutamide is a first-generation AR antagonist mainly associated with gynecomastia (Paragraph 5).
D: Enzalutamide is a second-generation AR antagonist associated with falls and fatigue (Paragraph 7).
Memory Tool: “Second-Gen, Second Wind” to remember that second-generation AR antagonists can lead to fatigue.

Reference Citation: Table 161.1, Paragraph 7.

Rationale: Side effect profiles differ among drug classes, and recognizing this can inform patient care and symptom management.

Question 15

Clinical Vignette: A patient with prostate cancer is prescribed a medication that acts by inhibiting cytochrome P450 enzymes. Which class of drugs does this medication belong to?

Multiple-Choice Options:

A. GnRH agonists
B. GnRH antagonists
C. Adrenal-targeting drugs
D. Second-generation AR antagonists

Answer 15

Correct Answer: C. Adrenal-targeting drugs

In-Depth Explanation:

A: GnRH agonists act by stimulating the release of LH (Paragraph 1).
B: GnRH antagonists bind to receptors and block the release of GnRH (Paragraph 2).
C: Adrenal-targeting drugs act by blocking cytochrome P450 enzymes to decrease androgen production (Paragraph 3).
D: Second-generation AR antagonists block AR and diminish AR-mediated transcription (Paragraph 7).
Memory Tool: “Adrenaline Drop” to remember that adrenal-targeting drugs drop androgen levels by inhibiting enzymes.

Reference Citation: Table 161.1, Paragraph 3.

Rationale: Knowing the mechanisms of different drug classes can help guide appropriate medication choices and improve patient outcomes.

Question 16

Clinical Vignette: You have a 55-year-old male patient with benign prostatic hyperplasia (BPH). Which class of drug could be administered for his condition?

Multiple-Choice Options:

A. GnRH agonists
B. First-generation AR antagonists
C. Adrenal-targeting drugs
D. 5α-Reductase inhibitors

Answer 16

orrect Answer: D. 5α-Reductase inhibitors

In-Depth Explanation:

A: GnRH agonists are primarily indicated for metastatic prostate cancer, not BPH (Paragraph 1).
B: First-generation AR antagonists are not indicated as monotherapy (Paragraph 5).
C: Adrenal-targeting drugs mainly treat prostate cancer (Paragraph 3).
D: 5α-Reductase inhibitors like Finasteride are commonly administered for BPH (Paragraph 7).
Memory Tool: “5α for 55” to remember that 5α-Reductase inhibitors can be used for a 55-year-old patient with BPH.

Reference Citation: Table 161.1, Paragraph 7.

Rationale: Tailoring drug prescriptions to specific conditions like BPH is crucial for optimal treatment.

Question 17

Clinical Vignette: A patient with prostate cancer reports hypertension, edema, and hypokalemia after starting a new medication. What class of drugs could be causing these side effects?

Multiple-Choice Options:

A. GnRH agonists
B. GnRH antagonists
C. Adrenal-targeting drugs
D. Second-generation AR antagonists

Answer 17

Correct Answer: C. Adrenal-targeting drugs

In-Depth Explanation:

A: GnRH agonists are associated with considerable side effects but not specifically hypertension, edema, and hypokalemia (Paragraph 1).
B: GnRH antagonists also have considerable side effects, but not these specific ones (Paragraph 2).
C: Adrenal-targeting drugs like Ketoconazole and Abiraterone can lead to hypertension, edema, and hypokalemia (Paragraph 3).
D: Second-generation AR antagonists are mainly associated with falls, fatigue, and decreased appetite (Paragraph 7).
Memory Tool: “Adrenal Ailments: H-E-H” for Hypertension, Edema, Hypokalemia.

Reference Citation: Table 161.1, Paragraph 3.

Rationale: Being aware of the side-effect profiles of each class of drugs is essential for correct diagnosis and patient management.

Question 18

Clinical Vignette: A 67-year-old male is being treated for metastatic prostate cancer. He’s given a medication that ultimately decreases LH production. What class of drugs has he likely been prescribed?

Multiple-Choice Options:

A. GnRH agonists
B. GnRH antagonists
C. Adrenal-targeting drugs
D. 5α-Reductase inhibitors

Answer 18

Correct Answer: A. GnRH agonists

In-Depth Explanation:

A: GnRH agonists like Leuprolide stimulate the release of LH initially but then ultimately decrease LH production (Paragraph 1).
B: GnRH antagonists bind to receptors and block the release of GnRH (Paragraph 2).
C: Adrenal-targeting drugs act by inhibiting cytochrome P450 enzymes (Paragraph 3).
D: 5α-Reductase inhibitors inhibit the conversion of testosterone to DHT (Paragraph 7).
Memory Tool: “Agonists Act, Then Attract Less” to remember that GnRH agonists initially act by releasing LH, then reduce it.

Reference Citation: Table 161.1, Paragraph 1.

Rationale: Differentiating drug classes by their mechanisms is crucial, especially for conditions like metastatic cancer where specific interventions are needed.

Question 19

Clinical Vignette: You are considering medication options for a 49-year-old man newly diagnosed with prostate cancer. Which of the following is NOT indicated for managing his prostate cancer?

Multiple-Choice Options:

A. Leuprolide
B. Flutamide
C. Finasteride
D. Enzalutamide

Answer 19

Correct Answer: C. Finasteride

In-Depth Explanation:

A: Leuprolide is a GnRH agonist indicated for metastatic prostate cancer (Paragraph 1).
B: Flutamide is a first-generation AR antagonist used for prostate cancer, though not as monotherapy (Paragraph 5).
C: Finasteride is a 5α-Reductase inhibitor and is not indicated for prostate cancer management (Paragraph 7).
D: Enzalutamide is a second-generation AR antagonist used for prostate cancer (Paragraph 7).
Memory Tool: “Fine, No Cancer” to remember that Finasteride is not fine for treating prostate cancer.

Reference Citation: Table 161.1, Paragraph 7.

Rationale: Knowing what NOT to prescribe is just as important as knowing what to prescribe for effective patient care.

Question 20

Clinical Vignette: A 72-year-old male is diagnosed with metastatic prostate cancer. What is considered the mainstay of therapy for his condition?

Multiple-Choice Options:

A. GnRH agonists
B. GnRH antagonists
C. Adrenal-targeting drugs
D. First-generation AR antagonists

Answer 20

Correct Answer: A. GnRH agonists

In-Depth Explanation:

A: GnRH agonists like Leuprolide and Goserelin are considered the mainstay of therapy for metastatic prostate cancer (Paragraph 1).
B: GnRH antagonists, while effective, are not considered the mainstay of therapy for metastatic disease (Paragraph 2).
C: Adrenal-targeting drugs are not the mainstay therapy for metastatic prostate cancer (Paragraph 3).
D: First-generation AR antagonists are not considered the mainstay and are not indicated as monotherapy (Paragraph 5).
Memory Tool: “A-Gone: Metastatic Gone” to remember that GnRH agonists are the mainstay for metastatic prostate cancer.

Reference Citation: Table 161.1, Paragraph 1.

Rationale: Knowing the first-line treatment for conditions like metastatic prostate cancer is crucial for providing optimal care.

Question 21

Clinical Vignette: A 58-year-old man with prostate cancer is started on a new medication to prevent a testosterone surge. Which class of drugs is he likely taking?

Multiple-Choice Options:

A. GnRH agonists
B. GnRH antagonists
C. Adrenal-targeting drugs
D. 5α-Reductase inhibitors

Answer 21

Correct Answer: B. GnRH antagonists

In-Depth Explanation:

A: GnRH agonists initially stimulate the release of LH and are not used to prevent a testosterone surge (Paragraph 1).
B: GnRH antagonists like Degarelix and Abarelix prevent a testosterone surge by blocking the release of GnRH (Paragraph 2).
C: Adrenal-targeting drugs inhibit cytochrome P450 enzymes and are not used for preventing testosterone surges (Paragraph 3).
D: 5α-Reductase inhibitors are not used to prevent testosterone surges; they inhibit the conversion of testosterone to DHT (Paragraph 7).
Memory Tool: “Antagonize to Neutralize Surge” to remember that GnRH antagonists prevent testosterone surges.

Reference Citation: Table 161.1, Paragraph 2.

Rationale: Accurate understanding of drug mechanisms allows you to select the appropriate medication for specific patient needs.

Question 22

Clinical Vignette: A 64-year-old man is complaining of breast enlargement after starting his new medication for prostate cancer. What class of drugs is he most likely taking?

Multiple-Choice Options:

A. GnRH agonists
B. GnRH antagonists
C. Adrenal-targeting drugs
D. First-generation AR antagonists

Answer 22

Correct Answer: D. First-generation AR antagonists

In-Depth Explanation:

A: GnRH agonists have considerable side effects but not specifically gynecomastia (Paragraph 1).
B: GnRH antagonists are also not specifically associated with gynecomastia (Paragraph 2).
C: Adrenal-targeting drugs have side effects like hypertension but not gynecomastia (Paragraph 3).
D: First-generation AR antagonists like Flutamide and Bicalutamide are associated with gynecomastia (Paragraph 5).
Memory Tool: “First-Gen, First Breasts” to remember that first-generation AR antagonists can lead to gynecomastia.

Reference Citation: Table 161.1, Paragraph 5.

Rationale: Identifying drug classes by their unique side effects can aid in tailoring therapy and managing patient symptoms.

Question 23

Clinical Vignette: A 65-year-old male with prostate cancer is considering various options for androgen deprivation therapy. He is worried about the adverse effects associated with different methods.

Question: Which of the following is NOT a general approach for androgen signaling blockade?
A) Surgical removal of the testicles (orchiectomy)
B) AR antagonism
C) Beta-blocker administration
D) Inhibition of LHRH and/or LH

Answer 23

Correct Answer: C) Beta-blocker administration

In-Depth Explanation:

A) Surgical removal of the testicles (orchiectomy) is indeed an approach for androgen blockade.
B) AR (Androgen Receptor) antagonism is another method for blocking androgen signaling.
C) Beta-blocker administration is not a general approach for androgen signaling blockade.
D) Inhibition of LHRH and/or LH is also a method used in androgen blockade.
Memory Tool: “SOIL” can help you remember the four general approaches: Surgical removal, Orchiectomy, Inhibition of LHRH/LH, and LHRH Agonists.

Reference Citation: Paragraph 1
Rationale: This information is critical to understand the general approaches to treating conditions that necessitate androgen blockade, like prostate cancer.

Question 24

Clinical Vignette: A 58-year-old man undergoing nilutamide therapy complains of having difficulty adjusting to darkness after exposure to bright light.

Question: What percentage of men on nilutamide therapy is likely to note this side effect?
A) About 10%
B) About 25%
C) About 50%
D) About 75%

Answer 24

Question: What percentage of men on nilutamide therapy is likely to note this side effect?
A) About 10%
B) About 25%
C) About 50%
D) About 75%

Correct Answer: B) About 25%

In-Depth Explanation:

A) Incorrect. The side effect is observed in about 25% of men.
B) Correct. About one-quarter of men (or about 25%) on nilutamide therapy note this side effect.
C) Incorrect. The rate is about 25%, not 50%.
D) Incorrect. The rate is about 25%, not 75%.
Memory Tool: Remember the word “Quarter-Nilu” to associate one-quarter (25%) with Nilutamide.

Reference Citation: Paragraph 2
Rationale: Understanding the side effects of specific drugs is essential for patient management and counseling.

Question 25

Clinical Vignette: A group of researchers is reviewing landmark clinical trials on castration-sensitive biochemical recurrent or metastatic setting in prostate cancer.

Question: According to the STAMPEDE trial, what percentage of the patient population had metastatic disease?
A) 20%
B) 41%
C) 52%
D) 61%

Answer 25

Correct Answer: D) 61%

In-Depth Explanation:

A) Incorrect. The trial noted 52% metastatic, not 20%.
B) Incorrect. 41% is not mentioned in the STAMPEDE trial.
C) Incorrect. While 52% metastatic is noted in one STAMPEDE trial, the question asks for the percentage in another.
D) Correct. 61% of the patient population had metastatic disease.
Memory Tool: “STAMPEDE Sixty-one” can help you remember that 61% had metastatic disease in one of the STAMPEDE trials.

Reference Citation: Table 161.3
Rationale: For comprehensive care and evidence-based practice, being familiar with landmark clinical trials is crucial.

Question 26

Clinical Vignette: A 40-year-old man with rising PSA post-radiation asks about the efficacy of orchiectomy in reducing serum testosterone.

Question: By approximately what percentage does serum testosterone decrease within 6 hours post-orchiectomy?
A) 50%
B) 75%
C) 85%
D) 95%

Answer 26

Correct Answer: D) 95%

In-Depth Explanation:

A) Incorrect. The decrease is approximately 95%, not 50%.
B) Incorrect. The decrease is approximately 95%, not 75%.
C) Incorrect. The decrease is approximately 95%, not 85%.
D) Correct. Orchiectomy leads to an approximate 95% decrease in serum testosterone within 6 hours.
Memory Tool: Remember “Orchi-95” to associate orchiectomy with a 95% decrease.

Reference Citation: Key Points, Bullet Point 2
Rationale: This information is key for patient counseling and making informed decisions about treatment options.

Question 27

Clinical Vignette:
A 62-year-old male patient with metastatic prostate cancer is considering treatment options for androgen deprivation. You discuss various mechanisms for achieving this.

Question:
Which of the following is NOT a general approach for androgen signaling blockade?

A. Surgical removal of the testicles (orchiectomy)
B. AR antagonism
C. Inhibition of insulin secretion
D. Inhibition of LHRH and/or LH

Answer 27

Correct Answer:
C. Inhibition of insulin secretion

Explanation:
A, B, and D are established mechanisms for androgen blockade. C is incorrect as insulin secretion inhibition does not play a role in androgen blockade.

Memory Tool:
Remember the acronym “SOIL” for Surgical Orchiectomy, Inhibition of LHRH, and AR antagonism. ‘Insulin’ doesn’t fit.

Reference Citation:
Paragraph 1.

Rationale:
Understanding the mechanisms of androgen blockade is crucial for the appropriate management of prostate cancer patients.

Question 28

Clinical Vignette:
You are reviewing landmark Phase III clinical trials regarding ADT with a colleague.

Question:
According to Table 161.3, which trial showed that intermittent ADT was not inferior to continuous ADT in terms of overall survival?

A) NCIC PR.7
B) SWOG-9346
C) GETUG-AFU15
D) LATITUDE

Answer 28

Correct Answer:
A) NCIC PR.7

In-depth Explanation:

A: Correct. NCIC PR.7 showed that intermittent ADT was not inferior to continuous ADT in terms of overall survival (Table 161.3).
B: Incorrect. SWOG-9346 concluded that noninferiority was not established between intermittent and continuous ADT (Table 161.3).
C: Incorrect. GETUG-AFU15 involved ADT and docetaxel; it didn’t compare intermittent and continuous ADT (Table 161.3).
D: Incorrect. LATITUDE involved high-risk metastatic cases and compared ADT plus abiraterone to ADT plus placebo (Table 161.3).
Memory Tool:
NCIC PR.7 = “Non-Continuous Is Comparable, Provided Results 7”

Specific Reference Citation:
Campbell’s Urology, Table 161.3

Rationale:
Understanding landmark trials informs evidence-based treatment choices.

Question 29

Clinical Vignette:
A 70-year-old man with advanced prostate cancer is on aminoglutethimide therapy. The patient starts to experience muscle weakness and fatigue. What is the likely reason?

A. Increased production of aldosterone
B. Increased production of cortisol
C. Reduced production of aldosterone and cortisol
D. Direct muscle toxicity from the drug

Answer 29

Correct Answer: C. Reduced production of aldosterone and cortisol
Explanation:
Aminoglutethimide inhibits a very proximal step in adrenal function, blocking the production of both aldosterone and cortisol. This is equivalent to a total adrenalectomy medically, and thus, cortisone and fludrocortisone replacement is required.
Memory Tool:
Think “Amino-NO-glutethimide” because it stops (NO) the adrenal glands from making aldosterone and cortisol.
Rationale:
Understanding the side effects of medications used in androgen blockade is crucial for patient management.
Reference:
Paragraph 5, Mechanisms of Androgen Blockade (Campbell’s Urology).

Question 30

Clinical Vignette:
A patient with high-risk castrate-sensitive metastatic prostate cancer is undergoing treatment. His oncologist is contemplating between traditional ADT and adding abiraterone plus prednisone to the regimen. What should the oncologist consider based on the LATITUDE trial?

A. There is no statistically significant difference in overall survival between the two approaches.
B. Abiraterone plus prednisone significantly worsens radiographic progression-free survival.
C. Abiraterone plus prednisone significantly extends radiographic progression-free and overall survival.
D. Traditional ADT outperforms abiraterone plus prednisone in all measured outcomes.

Answer 30

Correct Answer: C. Abiraterone plus prednisone significantly extends radiographic progression-free and overall survival.
Explanation:
The LATITUDE trial concluded that abiraterone plus prednisone (along with traditional ADT) was superior in extending median radiographic progression-free (33.0 vs. 14.8 months) and overall survival (not reached vs 34.7 months, HR = 0.62).
Memory Tool:
Think “Latitude gives you more room to move” — more room for survival and freedom from progression.
Rationale:
Choosing an evidence-based treatment approach improves outcomes for high-risk prostate cancer patients.
Reference:
Paragraph 6 and Table 161.3, Mechanisms of Androgen Blockade (Campbell’s Urology).

Question 31

Correct Answer: C. Abiraterone plus prednisone significantly extends radiographic progression-free and overall survival.
Explanation:
The LATITUDE trial concluded that abiraterone plus prednisone (along with traditional ADT) was superior in extending median radiographic progression-free (33.0 vs. 14.8 months) and overall survival (not reached vs 34.7 months, HR = 0.62).
Memory Tool:
Think “Latitude gives you more room to move” — more room for survival and freedom from progression.
Rationale:
Choosing an evidence-based treatment approach improves outcomes for high-risk prostate cancer patients.
Reference:
Paragraph 6 and Table 161.3, Mechanisms of Androgen Blockade (Campbell’s Urology).

Answer 31

Correct Answer: B. Docetaxel significantly improves overall survival and failure-free survival.
Explanation:
The STAMPEDE trial demonstrated that adding docetaxel to standard hormone therapy improved overall survival by 24% and failure-free survival by 40% for men with newly diagnosed metastatic prostate cancer.
Memory Tool:
Think of a “stampede” as an overwhelming force, just like the added benefit of docetaxel in treatment.
Rationale:
Being aware of recent trials like STAMPEDE can help in optimizing treatment plans for high-risk prostate cancer patients.
Reference:
Table 161.3, Mechanisms of Androgen Blockade (Campbell’s Urology).

Question 32

Clinical Vignette:
A 60-year-old man with newly diagnosed metastatic hormone-sensitive prostate cancer comes to your clinic. You contemplate treatment options. What does the CHARTEED trial suggest about the utility of adding chemotherapy to ADT?

A. Combining chemotherapy with ADT does not yield any significant benefit.
B. Adding chemotherapy to ADT improves overall survival.
C. Chemotherapy should only be added for patients with low-volume disease.
D. Adding chemotherapy exacerbates side effects without survival benefit.

Answer 32

Correct Answer: B. Adding chemotherapy to ADT improves overall survival.
Explanation:
The CHARTEED trial showed that the addition of chemotherapy (docetaxel) to ADT improved overall survival in patients with metastatic hormone-sensitive prostate cancer. This is especially true for patients with high-volume disease.
Memory Tool:
Think “CHART the course with ED (Early Docetaxel)” to remember the CHARTEED findings.
Rationale:
Inclusion of evidence-based treatments like those suggested by CHARTEED can provide better outcomes.
Reference:
Table 161.3, Mechanisms of Androgen Blockade (Campbell’s Urology).

Question 33

Clinical Vignette:
A 65-year-old male patient with metastatic prostate cancer has been on Androgen Deprivation Therapy (ADT) for 5 months. His ALP levels are monitored as part of his routine follow-up.

Multiple-Choice Options:
A) ALP levels are monitored to assess liver function
B) ALP levels serve as a surrogate for volume of skeletal metastases
C) ALP levels are unrelated to overall survival in prostate cancer
D) ALP levels are indicative of the patient’s blood calcium levels

Answer 33

Correct Answer:
B) ALP levels serve as a surrogate for volume of skeletal metastases

Explanation:
A) Incorrect. While ALP is often a marker for liver function, in this context it is a surrogate for skeletal metastases.
B) Correct. ALP is the strongest predictor for overall survival and acts as a surrogate for the volume of skeletal metastases in patients with prostate cancer.
C) Incorrect. ALP levels are actually the strongest predictor for overall survival in this case.
D) Incorrect. ALP in this case is not an indicator for blood calcium levels.

Memory Tool:
Think of ALP as “A Link to Prognosis” in metastatic prostate cancer.

Reference Citation:
Paragraph 2; Campbell’s Urology

Rationale:
Monitoring ALP levels in metastatic prostate cancer patients on ADT is essential for assessing prognosis. Understanding this aspect is vital for medical professionals.

Question 34

Vignette:
You are treating a 59-year-old male patient who has just been initiated on Androgen Deprivation Therapy for prostate cancer. What steps should be taken to mitigate the risk of fracture in this patient?

Multiple-Choice Options:
A) Treat only if osteoporosis is diagnosed
B) Ensure adequate intake of calcium and vitamin D3
C) Initiate prophylactic radiation therapy
D) Provide pharmacotherapy for hot flashes

Answer 34

Correct Answer:
B) Ensure adequate intake of calcium and vitamin D3

In-Depth Explanation:

A) Treatment of osteoporosis begins with recognition, but the text suggests proactively ensuring calcium and vitamin D3 intake for all men starting ADT. (Line: “Treatment of osteoporosis begins with recognition.”)
B) All men starting ADT should ensure adequate intake of calcium and vitamin D3 to mitigate the risk of fracture. (Line: “To mitigate risk of fracture, all men starting ADT (regardless of fracture risk) should ensure adequate intake of calcium and vitamin D3.”)
C) Prophylactic radiation therapy is used to prevent or reduce painful gynecomastia, not to mitigate the risk of fracture. (Line: “Prophylactic radiation therapy (10–15 Gy, single fraction) has been used to prevent or reduce painful gynecomastia.”)
D) Treatment of hot flashes is not related to the mitigation of fracture risk. (Line: “Treatment of hot flashes should be reserved for those men who find them particularly bothersome.”)
Memory Tool:
Think of the “D3-Bone Connection” to remember that Vitamin D3 and calcium are essential for bone health in men on ADT.

Reference Citation:
General text for each answer choice.

Rationale:
Recognizing and mitigating the risks associated with long-term ADT, such as fracture risk, are crucial in comprehensive patient care.

Question 35

Vignette:
You have a patient undergoing ADT for metastatic prostate cancer. The patient shows an incomplete response after initiation of ADT. What does this suggest?

Multiple-Choice Options:
A) There is no castrate-resistant cell population present.
B) A significant castrate-resistant cell population is present.
C) Patient is not following the treatment regimen properly.
D) ADT needs a longer duration for a complete response.

Answer 35

Correct Answer:
B) A significant castrate-resistant cell population is present.

In-Depth Explanation:

A) This choice is incorrect as an incomplete or sluggish response to ADT is evidence of a significant castrate-resistant cell population. (Line: “an incomplete or sluggish response is evidence of a significant castrate-resistant cell population.”)
B) An incomplete or sluggish response to ADT implies that there is a significant castrate-resistant cell population in the patient. (Line: “an incomplete or sluggish response is evidence of a significant castrate-resistant cell population.”)
C) The vignette does not provide information regarding the patient’s adherence to the treatment regimen.
D) While duration may influence ADT response, an incomplete or sluggish response specifically indicates a castrate-resistant cell population. (Line: “an incomplete or sluggish response is evidence of a significant castrate-resistant cell population.”)
Memory Tool:
Remember “CRISP” for “Castrate-Resistant Incomplete or Sluggish Response to Prostate treatment” to recall the significance of incomplete or sluggish response.

Reference Citation:
General text for the explanation of each answer choice.

Rationale:
Understanding the implications of an incomplete or sluggish response to ADT is crucial for treatment adjustment and future management.

Question 36

Vignette:
A 65-year-old man on ADT is bothered by hot flashes. What treatment has shown a moderate decrease in hot flashes according to a phase III randomized, double-blind, placebo-controlled trial?

Multiple-Choice Options:
A) Venlafaxine (75 mg/daily)
B) Gabapentin (900 mg)
C) Medroxyprogesterone acetate (20 mg/daily)
D) Cyproterone acetate (100 mg/daily)

Answer 36

Correct Answer:
B) Gabapentin (900 mg)

In-Depth Explanation:

A) Venlafaxine is mentioned but not described as having a moderate decrease in hot flashes in the provided study. (Line: “A randomized trial of 311 men on ADT with hot flashes evaluated venlafaxine (75 mg/daily).”)
B) Gabapentin at a dose of 900 mg decreased hot flashes to a moderate degree according to a phase III trial. (Line: “the highest studied dose of gabapentin (900 mg) decreased hot flashes to a moderate degree.”)
C) Medroxyprogesterone acetate is mentioned but not in the context of a phase III trial decreasing hot flashes to a moderate degree. (Line: “A randomized trial of 311 men on ADT with hot flashes evaluated…medroxyprogesterone acetate (20 mg/daily).”)
D) Cyproterone acetate is mentioned but not in the context of a phase III trial decreasing hot flashes to a moderate degree. (Line: “A randomized trial of 311 men on ADT with hot flashes evaluated…cyproterone acetate (100 mg/daily).”)
Memory Tool:
Think of “Gabapentin for Getting a Break” from hot flashes to remember that gabapentin can moderately decrease hot flashes.

Reference Citation:
Loprinzi et al., 2009 for gabapentin and general text for other options.

Rationale:
Hot flashes can be a bothersome side effect of ADT; knowing the treatment options backed by scientific evidence is essential.

Question 37

Vignette:
A 68-year-old man with metastatic prostate cancer has just initiated ADT. What biomarker is a strong, independent predictor of survival after 7 months of ADT?

Multiple-Choice Options:
A) Hemoglobin
B) ALP
C) PSA
D) LDH

Answer 37

Correct Answer:
C) PSA

In-Depth Explanation:

A) Hemoglobin is associated with treatment response but is not described as a strong, independent predictor of survival after 7 months of ADT. (Line: “In castration-sensitive prostate cancer, treatment response is associated with bone metastases, symptoms, and serum ALP, hemoglobin, and LDH levels.”)
B) ALP is a surrogate for volume of skeletal metastases and a predictor for overall survival, but it is not specifically linked to survival after 7 months of ADT. (Line: “The strongest predictor for overall survival was ALP, a surrogate for volume of skeletal metastases.”)
C) PSA after 7 months of ADT was described as a strong, independent predictor of survival. (Line: “PSA after 7 months of ADT was a strong, independent predictor of survival.”)
D) LDH is associated with treatment response but is not described as a strong, independent predictor of survival after 7 months of ADT. (Line: “In castration-sensitive prostate cancer, treatment response is associated with bone metastases, symptoms, and serum ALP, hemoglobin, and LDH levels.”)
Memory Tool:
Think “7th Heaven for PSA” to remember that PSA after 7 months is a key survival predictor.

Reference Citation:
Hussain et al., 2009 and general text for the explanation of each answer choice.

Rationale:
Knowing which biomarkers to watch can guide clinicians in evaluating the efficacy and potential durability of ADT treatment.

Question 38

Topic: Risk of Fracture

Vignette:
A 55-year-old man has just started ADT. What measure should be considered for all men starting ADT to mitigate the risk of fractures?

Multiple-Choice Options:
A) Regular bone mineral density examinations
B) Adequate intake of calcium and vitamin D3
C) Cessation of smoking
D) All of the above

Answer 38

Correct Answer:
D) All of the above

In-Depth Explanation:

A) Regular bone mineral density examinations are recommended for men on ADT. (Line: “patients should have regular bone mineral density examinations.”)
B) Adequate intake of calcium and vitamin D3 is recommended for all men starting ADT. (Line: “all men starting ADT should ensure adequate intake of calcium and vitamin D3.”)
C) Cessation of smoking is recommended for all men starting ADT. (Line: “be encouraged to quit smoking tobacco.”)
D) All of the mentioned measures should be considered to mitigate the risk of fractures.
Memory Tool:
Think “ABC of ADT Fracture Care” for “All Bone-exams, Calcium/Vitamin D3, and Cessation of smoking.”

Reference Citation:
General text for the explanation of each answer choice.

Rationale:
Understanding preventive measures to mitigate the risk of fractures can help to manage the potential complications of long-term ADT.

Question 39

Topic: Bone Scan Index (BSI)

Vignette:
A clinician is using Bone Scan Index (BSI) to evaluate a patient with castration-sensitive prostate cancer. What is BSI directly and independently associated with?

Multiple-Choice Options:
A) Overall survival
B) Time from castration-sensitive prostate cancer to castration resistance
C) PSA levels
D) Efficacy of ADT

Answer 39

Correct Answer:
B) Time from castration-sensitive prostate cancer to castration resistance

In-Depth Explanation:

A) Overall survival is not specifically associated with BSI in the material provided. (Line: “Bone scan index (BSI), an automated method…”)
B) BSI has been directly and independently associated with the time from castration-sensitive prostate cancer to castration resistance. (Line: “has been directly and independently associated with time from castration-sensitive prostate cancer to castration resistance.”)
C) PSA levels are not specifically associated with BSI. (Line: “Bone scan index (BSI), an automated method…”)
D) Efficacy of ADT is not specifically associated with BSI. (Line: “Bone scan index (BSI), an automated method…”)
Memory Tool:
Think “BSI to Bye-Bye Sensitivity” to remember BSI is linked with moving from castration-sensitive to castration-resistant prostate cancer.

Reference Citation:
Poulsen et al., 2016; Zacho et al., 2017, and general text for each answer choice.

Rationale:
Understanding the utility of BSI can guide clinicians in monitoring progression from castration-sensitive to castration-resistant prostate cancer.

Question 40

Topic: Hot Flashes Treatment

Vignette:
A 60-year-old man on ADT is experiencing hot flashes. Which medication has been shown to decrease hot flashes to a moderate degree?

Multiple-Choice Options:
A) Venlafaxine
B) Medroxyprogesterone
C) Gabapentin
D) Cyproterone

Answer 40

Correct Answer:
C) Gabapentin

In-Depth Explanation:

A) Venlafaxine was studied but was not specifically mentioned to decrease hot flashes to a moderate degree. (Line: “A randomized trial of 311 men on ADT with hot flashes evaluated venlafaxine…”)
B) Medroxyprogesterone was studied but was not specifically mentioned to decrease hot flashes to a moderate degree. (Line: “superiority to medroxyprogesterone and cyproterone.”)
C) Gabapentin at a dose of 900 mg decreased hot flashes to a moderate degree. (Line: “the highest studied dose of gabapentin (900 mg) decreased hot flashes to a moderate degree.”)
D) Cyproterone was studied but was not specifically mentioned to decrease hot flashes to a moderate degree. (Line: “superiority to medroxyprogesterone and cyproterone.”)
Memory Tool:
Think “Cool it with Gabapentin” to remember that Gabapentin moderates hot flashes.

Reference Citation:
Loprinzi et al., 2009, and general text for each answer choice.

Rationale:
Hot flashes can be particularly bothersome, and knowing the moderate effectiveness of Gabapentin can help in patient management.

Question 41

Question 9: Clinical Follow-Up on Hormonal Therapy
Topic: Germline HSD3B1 Variants

Vignette:
A 70-year-old man with prostate cancer is not responding well to Androgen Deprivation Therapy (ADT). What biomarker is suggested to predict response and ultimate resistance to ADT?

Multiple-Choice Options:
A) ALP
B) HSD3B1
C) PSA
D) BSI

Answer 41

B) HSD3B1

In-Depth Explanation:

A) ALP is a predictor for overall survival and volume of skeletal metastases, not specifically for resistance to ADT. (Line: “The strongest predictor for overall survival was ALP, a surrogate for volume of skeletal metastases.”)
B) Germline HSD3B1 variants are predictive biomarkers for response and ultimate resistance to ADT. (Line: “Collectively, the data suggest germline HSD3B1 variants are a predictive biomarker for response and ultimate resistance to ADT.”)
C) PSA is used for measuring the effectiveness of ADT but is not mentioned as a biomarker for resistance. (Line: “After initiation of ADT, the majority of prostate cancer patients exhibit a clinical response…”)
D) BSI is associated with time from castration-sensitive to castration-resistant prostate cancer but is not a biomarker for resistance to ADT. (Line: “Bone scan index (BSI), an automated method…”)
Memory Tool:
Think “HSD3B1 Helps Screen Deception of ADT” to remember that HSD3B1 is useful in predicting resistance to ADT.

Reference Citation:
Text for each answer choice and line numbers.

Rationale:
Understanding biomarkers like HSD3B1 can offer insights into the patient’s potential response to ADT, helping to tailor treatment plans.

Question 42

Topic: Osteoporosis Management

Vignette:
You have a patient who is about to start ADT. What step is recommended for all men regardless of their fracture risk when initiating ADT?

Multiple-Choice Options:
A) Regular bone mineral density examinations
B) Quit smoking tobacco
C) Ensure adequate intake of calcium and vitamin D3
D) Engage in weight-bearing exercise

Answer 42

Topic: Osteoporosis Management

Vignette:
You have a patient who is about to start ADT. What step is recommended for all men regardless of their fracture risk when initiating ADT?

Multiple-Choice Options:
A) Regular bone mineral density examinations
B) Quit smoking tobacco
C) Ensure adequate intake of calcium and vitamin D3
D) Engage in weight-bearing exercise

Question 43

Clinical Vignette: A 65-year-old male patient with locally advanced prostate cancer is under your care. You’re considering the best course of treatment for him.

Question: Which combination of therapies has shown significant improvement in clinical progression, overall mortality, and prostate cancer-specific mortality?

Options:

A. Radiation alone
B. Radiation and orchiectomy
C. Radiation and goserelin
D. Bilateral surgical adrenalectomy

Answer 43

Correct Answer: B. Radiation and orchiectomy

Explanation:

A. Radiation alone showed a high frequency of progression (Line 2, Granfors et al., 1998)
B. Radiation and orchiectomy showed significant improvements in clinical progression, overall mortality, and prostate cancer-specific mortality (Line 4-6, Granfors et al., 1998).
C. Radiation combined with goserelin showed improvement, but in progression-free survival and overall survival, not in clinical progression, overall mortality, and prostate cancer-specific mortality (Line 9-11, Bolla et al., 2010).
D. Bilateral surgical adrenalectomy had failure far outweighing success (Line 18, Huggins and Scott, 1945).
Memory Tool: Think “RO” for Radiation and Orchiectomy to remember the superior treatment outcome.

Rationale: Understanding the best treatment combination is essential for optimum patient care.

Question 44

Clinical Vignette: A 72-year-old man diagnosed with metastatic castration-sensitive prostate cancer (mCSPC) presents with a Gleason score of 9 and multiple bone metastases.

Question: Which combination therapy has shown a significant improvement in overall survival for patients like the one in the vignette?

Options:

A. ADT alone
B. ADT with goserelin
C. ADT with abiraterone acetate
D. ADT with docetaxel

Answer 44

Correct Answer: C. ADT with abiraterone acetate

Explanation:

A. ADT alone is less effective compared to combinations (Line 32, Fizazi et al., 2017).
B. ADT with goserelin is not specifically mentioned for mCSPC with high-risk features (Not in material).
C. ADT with abiraterone acetate showed a significant improvement in overall survival, especially for high-risk mCSPC (Line 31-33, Fizazi et al., 2017).
D. Docetaxel with ADT is a standard, but not specifically highlighted for superior overall survival in high-risk mCSPC (Line 39).
Memory Tool: A.B.I. for A Better Improvement with ADT and Abiraterone in mCSPC.

Rationale: Making evidence-based choices for mCSPC treatment is crucial.

Question 45

Clinical Vignette: A 60-year-old male is diagnosed with high-risk localized prostate cancer and is consulting you for treatment options.

Question: According to standard care guidelines, what treatment should be considered for this patient?

Options:

A. Presurgical hormonal therapy with surgery
B. ADT concurrent with and after radiation
C. Abiraterone acetate with standard medical castration
D. Docetaxel chemotherapy with ADT

Answer 45

Correct Answer: B. ADT concurrent with and after radiation

Explanation:

A. No proven role for presurgical hormonal therapy in combination with surgery (Line 34).
B. ADT concurrent with and after radiation is the standard care for high-risk localized disease treated with radiation (Line 35).
C. & D. These are standards for metastatic forms but not specified for high-risk localized disease (Line 37 & 39).
Memory Tool: Remember “High Rad” for High-risk and Radiation + ADT.

Rationale: Adhering to standard care guidelines improves treatment outcomes.

Question 46

Clinical Vignette: A 68-year-old male with locally advanced prostate cancer is looking at treatment options. You’re discussing the long-term effects of various combinations.

Question: Which treatment combination showed a dramatic improvement in progression-free survival and overall survival when compared to radiation alone?

Options:

A. Radiation and docetaxel
B. Radiation and goserelin
C. Radiation and orchiectomy
D. Radiation and abiraterone

Answer 46

Correct Answer: B. Radiation and goserelin

Explanation:

A. Radiation and docetaxel isn’t highlighted for dramatic improvements in the material (Not in material).
B. Radiation and goserelin showed dramatic improvement in progression-free and overall survival (Line 10-11, Bolla et al., 2010).
C. Radiation and orchiectomy showed improvements, but the focus was not on progression-free survival and overall survival (Line 4-6, Granfors et al., 1998).
D. Radiation and abiraterone isn’t specifically mentioned in relation to progression-free and overall survival (Not in material).
Memory Tool: “Go Radiant!” - “GOserelin” makes “RADIation” more effective.

Rationale: Knowledge of the long-term effects of treatments aids in better patient management.

Question 47

Clinical Vignette: You are discussing recent clinical trials with a colleague, focusing on studies that have solidified treatment protocols for metastatic castration-sensitive prostate cancer.

Question: What was a unique feature about the STAMPEDE trial’s inclusion criteria compared to other landmark studies?

Options:

A. Focused only on high-risk disease
B. Allowed advanced CSPC with a variety of disease stages
C. Limited to patients with a Gleason score of 8 or higher
D. Excluded patients with bone metastases

Answer 47

Correct Answer: B. Allowed advanced CSPC with a variety of disease stages

Explanation:

A. Focused on high-risk disease was a feature of another landmark study (Line 31, Fizazi et al., 2017).
B. STAMPEDE trial had looser inclusion criteria allowing advanced CSPC in different stages (Line 35-36, James et al., 2017).
C. & D. These were not the unique features of the STAMPEDE trial (Not in material).
Memory Tool: Think “STAMPEDE lets everyone in” to remember its diverse inclusion criteria.

Rationale: Understanding the inclusion criteria of trials helps interpret the applicability of findings.

Question 48

Topic: Timing of Androgen Deprivation Therapy (ADT) in Primary Treatment

Clinical Vignette:
A 67-year-old male patient has been diagnosed with clinically localized prostate cancer. The urologist is considering whether to administer primary ADT as the sole therapy.

Multiple Choice:
A) Primary ADT significantly improves overall survival in all men over 65 with clinically localized prostate cancer.
B) Primary ADT significantly lowers the risk of prostate cancer-specific mortality in all men with clinically localized prostate cancer.
C) Primary ADT significantly lowers the risk of all-cause mortality only in men with high risk of prostate cancer progression.
D) Primary ADT significantly lowers the risk of all-cause mortality in all men with clinically localized prostate cancer.

Answer 48

Correct Answer:
C) Primary ADT significantly lowers the risk of all-cause mortality only in men with high risk of prostate cancer progression.

In-depth Explanation:
A) Incorrect. According to the material, primary ADT does not significantly improve overall survival for most men with clinically localized prostate cancer.
B) Incorrect. Primary ADT did not alter the risk of prostate cancer-specific mortality according to a retrospective cohort study (Potosky et al., 2014).
C) Correct. Primary ADT is associated with decreased risk of all-cause mortality only in men at high risk of prostate cancer progression.
D) Incorrect. Primary ADT did not alter the risk of all-cause mortality for all men with localized prostate cancer.

Memory Tool:
Remember “High-C Primary ADT” to recall that Primary ADT is effective in lowering all-cause mortality for men at “High risk” of prostate “Cancer” progression.

Reference Citation:
(Potosky et al., 2014)

Rationale:
This question addresses the nuanced use of primary ADT in the context of age and risk stratification. Knowing when to administer primary ADT is essential for optimal patient care.

Question 49

Topic: Biochemically Recurrent Prostate Cancer

Clinical Vignette:
A 55-year-old male patient shows a rising PSA level after curative-intent local therapy but does not present with clinical or radiographic evidence of metastatic disease. The urologist is considering whether to initiate ADT immediately or to delay it.

Multiple Choice:
A) Delaying ADT is always the best option for biochemically recurrent prostate cancer.
B) Immediate ADT offers no survival advantage in biochemically recurrent prostate cancer.
C) Immediate ADT has an overall survival advantage in some patients with biochemically recurrent prostate cancer.
D) Immediate ADT worsens the prognosis of biochemically recurrent prostate cancer.

Answer 49

Correct Answer:
C) Immediate ADT has an overall survival advantage in some patients with biochemically recurrent prostate cancer.

In-depth Explanation:
A) Incorrect. According to a study by Duchesne et al., immediate ADT has shown an overall survival advantage (HR=0.55, P=0.047).
B) Incorrect. The same study suggests that immediate ADT can offer a survival advantage.
C) Correct. The study suggests early ADT may be of value for some patients with recurrent disease.
D) Incorrect. Immediate ADT has shown an overall survival advantage in the study.

Memory Tool:
Think “I-ADT can be ICY” where “I-ADT” stands for Immediate ADT and “ICY” stands for “Immediate Can Yield” benefits.

Reference Citation:
(Duchesne et al., 2016)

Rationale:
The question aims to clarify the timing of ADT initiation in the setting of biochemically recurrent prostate cancer, which is a topic often confronted in clinical practice.

Question 50

Topic: Timing of Therapy
Vignette:
A 67-year-old male patient is diagnosed with clinically localized prostate cancer. He asks you about the benefits of primary androgen deprivation therapy (ADT).

Question:
What is the most appropriate recommendation regarding primary ADT for this patient?

Answer 50

Options:
A) Recommend primary ADT to reduce all-cause mortality
B) Recommend against primary ADT as it does not provide a survival benefit
C) Recommend primary ADT to reduce prostate cancer-specific mortality
D) The use of primary ADT is independent of age

Correct Answer:
B) Recommend against primary ADT as it does not provide a survival benefit

Explanation:
Primary ADT does not provide a survival benefit for most men with clinically localized prostate cancer, particularly those over 65 (Shahinian et al., 2006; Potosky et al., 2014).

Memory Tool:
Think “Primary ADT = Primarily Not Helpful” for localized prostate cancer in elderly men.

Reference:
Shahinian et al., 2006; Potosky et al., 2014

Rationale for the Question:
This question tests your knowledge on the appropriate timing and efficacy of primary ADT, especially in older patients.

Question 51

Topic: Timing of Therapy
Vignette:
A 60-year-old male with pN1-3M0 prostate cancer is unsure about when to start ADT. He is also interested in the associated survival benefits.

Question:
Based on a prospective, randomized study, what is the median overall survival difference between immediate and delayed ADT in pN1-3M0 patients?

Options:
A) No difference in median overall survival
B) 1.5 years
C) 2.0 years
D) 3.0 years

Answer 51

Correct Answer:
B) 1.5 years

Explanation:
The median overall survival in the immediate ADT group was 7.6 years vs. 6.1 years in the delayed ADT group (Schroder et al., 2009).

Memory Tool:
Think “Immediate gives you a ‘One-and-a-Half’ year bonus” to remember the 1.5-year advantage.

Reference:
Schroder et al., 2009

Rationale for the Question:
This question explores the difference in survival benefits between immediate and delayed ADT, a crucial clinical decision point.

Question 52

Clinical Vignette: A 55-year-old man presents with a rising PSA post-prostatectomy. There is no evidence of metastatic disease.

Multiple Choice Options:
A. Immediate ADT should not be considered for this patient.
B. Immediate ADT is recommended for this patient.
C. PSA doubling time is irrelevant for initiation of ADT.
D. Immediate ADT has shown an overall survival advantage in such scenarios.

Answer 52

Correct Answer: D
Explanation:

A: Incorrect. Immediate ADT may be considered, depending on multiple factors like PSA doubling times (Dale et al., 2009).
B: Incorrect. The decision for immediate ADT depends on various factors like PSA levels, doubling times, and patient anxiety (Dale et al., 2009).
C: Incorrect. PSA doubling time is one of the factors considered for initiation of ADT (Dale et al., 2009).
D: Correct. Immediate ADT has shown an overall survival advantage (HR = 0.55, P = 0.047) (Duchesne et al., 2016).
Memory Tool: “ADT ASAP” can improve overall survival in biochemically recurrent prostate cancer.
Reference Citation: Duchesne et al., 2016
Rationale: Knowing when to initiate ADT in biochemically recurrent prostate cancer can significantly affect patient outcomes.

Question 53

Topic: Primary ADT in Prostate Cancer

Clinical Vignette: A 67-year-old male patient has been diagnosed with clinically localized prostate cancer. You’re considering administering primary Androgen Deprivation Therapy (ADT).

Multiple Choice Options:
A) Primary ADT significantly reduces all-cause mortality for men with localized prostate cancer.
B) Primary ADT reduces prostate cancer-specific mortality.
C) Primary ADT has been shown to be effective only in men with high risk of prostate cancer progression.
D) Primary ADT increases overall survival for all men older than 65.

Answer 53

Correct Answer: C
In-Depth Explanation for Each Answer:
A) Incorrect. A retrospective study found that primary ADT did not alter the risk of all-cause mortality (Potosky et al., 2014).
B) Incorrect. Primary ADT was also found not to alter prostate cancer-specific mortality (Potosky et al., 2014).
C) Correct. Primary ADT was associated with a decreased risk of all-cause mortality only in men at high risk of prostate cancer progression.
D) Incorrect. Up to 40% of men over 65 have received ADT, but it is not beneficial for overall survival (Shahinian et al., 2006).

Memory Tool: Think “High Risk, High Reward” - Primary ADT is beneficial only for high-risk cases.
Reference Citation: Potosky et al., 2014; Shahinian et al., 2006.
Rationale: Knowledge about the limitations of Primary ADT is crucial for appropriate treatment planning and patient counseling.

Question 54

Clinical Vignette: You’re treating a 55-year-old male patient with pN1-3M0 prostate cancer. You’re considering the timing for Androgen Deprivation Therapy (ADT).

Multiple Choice Options:
A) Immediate ADT confers a median overall survival advantage of more than 2 years compared to delayed ADT.
B) There is no difference in the 10-year cumulative incidence of death from prostate cancer between immediate and delayed ADT.
C) The study by Schroder et al. was designed to show the superiority of immediate ADT.
D) Delayed ADT is proven to be noninferior to immediate ADT.

Answer 54

Correct Answer: B
In-Depth Explanation for Each Answer:
A) Incorrect. The median overall survival for immediate ADT was 7.6 years versus 6.1 years for delayed ADT, which is not more than a 2-year difference (Schroder et al., 2009).
B) Correct. The 10-year cumulative incidence of death was 55.6% in the delayed group and 52.1% in the immediate group, showing no significant difference (Schroder et al., 2009).
C) Incorrect. The study was not designed or powered to show the superiority of immediate ADT.
D) Incorrect. Noninferiority was not established in the study.

Memory Tool: Think “Immediate or Delayed, Death’s Still Played” - Immediate vs. delayed ADT didn’t significantly alter the 10-year death rate.
Reference Citation: Schroder et al., 2009
Rationale: Understanding that noninferiority was not established helps in making evidence-based decisions on timing of ADT.