answers can be found on page 17

Practice Test 1
1. A 46-year-old male smoker presents with hematuria.
The findings of cytologic analysis of a urine sample indicate the presence of malignant cells, and CT demonstrates no masses in the kidney, bladder, or lymph
nodes. An examination under anesthesia and a bimanual assessment reveal no palpable masses, whereas the
endoscopic evaluation indicates a two-centimeter lesion
obscuring the right ureteral orifice. Evaluation of a
biopsy specimen demonstrates grade 2 infiltrating transitional cell cancer of the bladder. Muscle is not present
in the submitted surgical specimen. Results of repeat
urinary cytologic analysis show no malignant cells.
Which of the following would you recommend?
A.
B.
C.
D.
E.

Observation
Evaluation of the ureters and renal pelvis
Administration of intravesical mitomycin C
Administration of intravesical BCG
Cystoscopy and biopsy

2. A 62-year-old man presents with a three-month history

of chronic cough recently associated with scant hemoptysis. He smokes two packs a day and although he has
some fatigue, he continues to work full time as an
accountant. A chest x-ray shows a right hilar mass with
bilateral mediastinal adenopathy that is confirmed by CT
of the chest. PET demonstrates activity in the primary
tumor and the mediastinum bilaterally but nowhere else.
Evaluation of a biopsy specimen of the mass indicates
squamous cell cancer, and the findings of a transbronchial biopsy confirm the presence of squamous cell
cancer within the lymph nodes.

3. A 23-year-old woman presents with a white blood

cell count of 3.2 x 103/!L, with 80% promyelocytes
and blasts; anemia; and a platelet count of 180 x
10 3/!L. The morphology of the blasts is shown in
Figure 1. Cytogenetic analysis shows a 15;17 translocation.
Which of the following is true concerning the use of
all-trans retinoic acid in this case?
A. All-trans retinoic acid is useful as salvage therapy but is
not indicated as front-line treatment
B. All-trans retinoic acid can serve as a substitute for an
anthracycline in initial induction therapy
C. All-trans retinoic acid improves disease-free survival if
added to induction but has no demonstrated role in maintenance therapy
D. All-trans retinoic acid improves disease-free survival when
used as maintenance therapy but has no role in induction
therapy
E. All-trans retinoic acid improves disease-free survival both
when added to induction therapy and when used as maintenance therapy

4. On routine blood screening, a 74-year-old man is

found to have an elevated PSA. He reports no nocturia or
u r i n a ry frequency. On clinical examination, the pro s t a t e
is firm and nodular. The results of biopsy of the pro s t a t e
c o n f i rms adenocarcinoma, with a Gleason score of 4.
The patient is being treated for congestive heart failure
s e c o n d a ry to longstanding hypertension. He has mild
dementia, and because he fell once or twice a month, he
and his wife moved into an assisted living facility.

Which of the following is most likely to yield an improved

survival benefit?
A. Weekly, low-dose paclitaxel and carboplatin administered
concurrently with radiation therapy to the thorax at 60 Gy
over six weeks
B. Weekly, low-dose paclitaxel and carboplatin administered
concurrently with radiation therapy to the thorax at 60 Gy
over six weeks and then continued for another six weeks
after completion of the radiation therapy
C. Standard cisplatin and etoposide followed by radiation
therapy to the thorax at 60 Gy over six weeks
D. Standard cisplatin and etoposide administered concurrently
with radiation therapy to the thorax at 60 Gy over six
weeks

Figure 1. Morphology of the blasts for the patient described in question 3.

Practice Test 1 |

Which of the following would you recommend?

A.
B.
C.
D.
E.

Watchful waiting
Radical prostatectomy
Cryosurgery
Radiation therapy
Brachytherapy

5. A 60-year-old woman with no history of cancer or

other substantial medical problems presents to you for
routine follow-up. She currently takes a multivitamin
with folic acid, aspirin (81 mg daily), a calcium supplement (1,200 mg daily), and an estrogen-progesterone
replacement agent. She exercises three times per week.
She has recently read several articles that have suggested that estrogen replacement is no longer recommended because of the possibility of increased risk of
cancers. She asks you about her steps to prevent
cancer.
Which of the following would you tell her?
A. The multivitamin, aspirin, calcium supplement, and exercise can be continued, but the estrogen-progesterone
replacement therapy should be discontinued because it is
known to increase the risk of breast and colon cancer
B. The multivitamin, aspirin, and calcium supplement, and
estrogen-replacement therapy should be discontinued
because they have no demonstrated benefit for cancer
prevention
C. The multivitamin, aspirin, calcium supplement, hormonereplacement therapy, and exercise have all been associated with a reduced risk of death from colon cancer
D. Exercise has not been shown to help prevent any type of
cancer, but it is helpful in preventing cardiovascular
disease

6. Which of the following drugs has been approved for

treatment of relapsed myeloma?
A.
B.
C.
D.

Bortezomib
Thalidomide
IFN-!
Pentostatin

7. A 39-year-old patient with a history of hemophilia A

presents with a three-week history of an enlarging gland
on the left side of the neck. Infection with HIV was diagnosed five years earlier and treated initially with zidovudine (AZT) and then with combination therapy
containing a nucleoside analogue (D4T) and an HIV
protease inhibitor. The CD4 count increased after the
initiation of multiagent HIV therapy, but decreased to
less than 100/mm3 over the past three years.
2

| Practice Test 1

Physical examination demonstrates a left cervical mass

(six by eight centimeters). The findings on CT and a gallium scan show disease confined to the left side of the
neck. Evaluation of bone marrow and a biopsy specimen show involvement with lymphoma. The morphologic and phenotypic studies of the tissue from the neck
mass confirm the diagnosis of lymphoma.
What is the likely histologic type of lymphoma in this
clinical setting?
A.
B.
C.
D.

T-cell large lymphoma

Large B-cell lymphoma
Non-T cell, non-B-cell lymphoma
NK cell lymphoma

8. Referring to the patient described in question 7,

which one of the following histologic types is most likely?
A.
B.
C.
D.

High-grade lymphoma
High-grade lymphoma with extranodal sites of disease
Low-grade lymphoma
Follicular lymphoma

9. A 34-year-old woman was recently diagnosed with a

0.83-millimeter thick melanoma. There was no ulceration, and the Clark level was III. The melanoma arose
from the posterior part of the right calf.
In addition to blood work (complete blood count, chemistry panel, and serum LDH), which of the following
staging procedures is appropriate for this patient?
A.
B.
C.
D.

Chest-x-ray
MRI of the brain, CT of the chest, abdomen, and pelvis
PET and MRI of the brain
Bone scan and CT of the chest, abdomen, and pelvis

10. You are the research director of a small biotechnology company that has identified a peptide that elicits a
strong immune response to breast cancer. A newly hired
employee is a protein chemist who recently completed
postdoctorate training in computer-based mapping of
protein structure. She brings you an idea for a novel
approach to vaccine development for prostate cancer.
She argues its effectiveness in influencing a T-cell
response. Among her postulates is a false assumption
about the processes of T-cell recognition of antigen and
subsequent events leading to tumor-cell elimination.
Which of the following statements in the research design
is a false or incorrect assumption?
A. Secretion of IL-2, IFN-", and GM-CSF
B. Recognition of peptides in association with major histocompatibility (MHC) molecules

C. Engagement of costimulator molecules, such as B7 and

CD28, between dendritic cells and CD4+ cells
D. Blockade of activation and signaling by the T cell-CD3
complex on CD4+ T cells by a mutant human leukocyte
antigen (HLA)-A2
E. Stimulation of immunoglobulin production (humoral
response) through cytokines such as IL-4 and IL-10

11. A 59-year-old man presents with a three-month history of hoarseness. He has had no anorexia or weight
loss. His medical history is significant for type 2 diabetes
and hypertension. He continues to work full time. He
has a 20-pack-year history of smoking and has always
abstained from alcohol.
On physical examination, he appears healthy and in no
distress. There is no palpable neck disease. Mirror
examination reveals a nodule in the middle of the left
vocal cord but normal mobility is preserved. S1 and S2
heart sounds are audible with a soft systolic murmur.
Lung fields are clear to auscultation and percussion. No
hepatosplenomegaly or ascites is noted. No clubbing,
cyanosis, or edema is seen in the extremities.
The results of a complete blood count, serum chemistry
tests, and liver function tests are within normal limits. The
chest x-ray shows no card i o p u l m o n a ry disease. CT scan
of the neck reveals a mass on the left vocal cord with no
evidence of supraglottic or extralaryngeal extension; no
pathologic adenopathy is noted in the neck. Examination
under anesthesia documents the vocal cord lesion. The
findings on examination of a biopsy specimen indicate a
moderately to poorly diff e rentiated squamous cell cancer.
Which of the following is the most appropriate therapy
for this patient?
A. Curative-dose radiotherapy to the larynx alone, with surgery reserved for salvage
B. Curative-dose radiotherapy to the larynx and ipsilateral
neck, with surgery reserved for salvage
C. Combination chemotherapy with cisplatin and fluorouracil
followed by curative-dose radiotherapy to the larynx and
both sides of the neck, with surgery reserved for salvage
D. Concurrent cisplatin with curative-dose radiotherapy to the
larynx and both sides of the neck, with surgery reserved
for salvage
E. Hemilaryngectomy and left modified-radical neck
dissection

12. The introduction of a new large-scale screening test

has its greatest immediate effect on which of the following?
A. Mortality rate related to the disease
B. Incidence of the disease

C. Survival rate
D. Morbidity

13. A 20-year-old woman with a one-week history of fairly

intense pelvic pre s s u re is seen by a physician at the student health services at her college. On palpation, the
physician feels a mass, and a CT scan of the abdomen
and pelvis demonstrates a large cyst on the right ovary.
During exploratory surg e ry, perf o rmed by a general gynecologist, a benign cyst is found, but a small portion (less
than 10%) of the mass is found to be an endoderm a l
sinus tumor. There is no evidence of disease outside of
the ovary. Postoperatively, the HCG and alpha-fetoprotein
levels are within normal limits.
Which of the following is the most appropriate next step
in the treatment of this patient?
A. Observation, with monthly monitoring of tumor markers
(HCG, alpha-fetoprotein)
B. Repeat exploratory surgery performed by a gynecologic
oncologist
C. Chemotherapy with BEP
D. Chemotherapy with carboplatin and paclitaxel
E. Chemotherapy with carboplatin and paclitaxel, followed by
high-dose chemotherapy with autologous peripheral stem
cell rescue

14. Of the following patients, all of whom have had complete resection of the tumor with negative margins, which
one is most likely to benefit from adjuvant chemotherapy?
A. 46-year-old woman with an eight-centimeter high-grade
rhabdomyosarcoma of the bladder
B. 33-year-old man with a seven-centimeter desmoid tumor of
the thigh
C. 52-year-old woman with a 10-centimeter high-grade mediastinal liposarcoma
D. 28-year-old man with a nine-centimeter high-grade
leiomyosarcoma arising from the inferior vena cava

15. Which of the following statements is true?

A. There is essentially no difference between CML in lymphoid blast crisis and Ph-positive ALL
B. Differences in the breakpoint of the BCR-ABL translocation
help explain the biologic differences between CML and Phpositive ALL
C. The proportion of patients with ALL who have the Ph chromosome is consistent across age-groups
D. The rate of complete remission for patients with Ph-positive
ALL is almost as high as that for patients have no Ph chromosome, but the likelihood of disease remaining in complete
remission is much lower for patients with Ph-positive ALL
Practice Test 1 |

E. The likelihood of a complete remission is low for patients

with Ph-positive ALL, but once disease is in complete
remission, such patients do as well as patients without the
Ph chromosome

16. A 52-year-old woman presents with severe hot

flashes that affect her quality of life. She has a history of
T1, N1 breast cancer that was diagnosed two years previously. At that time, she was treated with a lumpectomy,
radiation therapy, and adjuvant chemotherapy. She now
takes tamoxifen. She has had no evidence of recurrent
breast cancer since the diagnosis, and the current
history and findings on physical examination do not
suggest any breast cancer-related problems.
The patient reports having five or six hot flashes during
the day in addition to awaking two or three times each
night with drenching night sweats. She has tried vitamin
E, to no avail. She is averse to receiving any estrogen or
progesterone preparation because of concern regarding
the breast cancer.
Which of the following is a reasonable choice for treating her hot flashes?
A. Venlafaxine
B. Amitriptyline
C. Ativan
D. Soy protein

17. Which of the following is not true about mantle cell

lymphoma?
A.
B.
C.
D.
E.

It is commonly associated with intestinal polyposis

The immunohenotype is CD20+, CD5+, CD23+, CD10It is not curable with CHOP plus rituximab
The median survival is 2.5 to 3.0 years
It is associated with the BCL-1 oncogene

18. Which of the following is true regarding gefitinib and

lung cancer?
A. Patients with overe x p ression of the EGF receptor are more
likely to respond to EGF receptor- t y rosine kinase
inhibitors such as gefitinib than patients without such
overexpression
B. Single-agent gefitinib improves survival for patients with
recurrent lung cancer for whom treatment with one or two
prior chemotherapy regimens failed
C. Single-agent gefitinib improves symptoms for patients with
recurrent lung cancer for whom treatment with one or two
prior chemotherapy regimens failed
D. Single-agent gefitinib is an appropriate option as a firstline treatment for older patients or patients with poor performance status who have non-small cell lung cancer

| Practice Test 1

19. Which of the following is not necessary to select

optimal therapy for metastatic breast cancer?
A.
B.
C.
D.
E.

ER, PR, and HER2 status

Presence or absence of bone metastasis
Extent and location of metastatic disease
Presence, type, and severity of comorbid conditions
Presence or absence of TP53 and BRCA1 mutations

20. Although it was previously thought that androgen

priming could be used to sensitize prostate cancer cells
to radioisotope therapy or chemotherapy, this notion has
not found support from in vitro or clinical studies. It is
now clear that androgen ablation improves the response
rate and the duration of radiation for prostate cancer.
The combined effects of hormone blockade and cytotoxic therapy is likely the result of additive effects on
which of the following?
A.
B.
C.
D.
E.

Transcription
DNA repair
DNA replication
Apoptosis
Translation

21. A 58-year-old woman presents for a routine check-up,

and the physical examination reveals an enlarged two-centimeter left axillary lymph node. She was diagnosed two
years previously with a superficial spreading malignant
melanoma with a depth of 1.6 millimeters. Sentinel lymph
node biopsy at that time was negative for melanoma, and
the wide excision showed no residual melanoma.
Which of the following options would you now advise?
A. Continue with close follow-up
B. Arrange for lymph node biopsy or fine-needle aspiration of
the lymph node
C. Begin treatment with high-dose interferon
D. Begin radiation therapy to the left axilla

22. The incidence of breast cancer varies worldwide

and even within the United States among cultural and
ethnic groups.
Which of the following statements accurately describes
this variation?
A. The incidence of breast cancer is higher among black
women than white women, but the mortality rate is higher
for white women than for black women
B. The highest incidence of breast cancer is found among
American Indian and Hispanic women
C. The incidence of breast cancer is lower among black
women than white women, but the mortality rate is higher
for black women than for white women

D. In 2002, there were more new cases of breast cancer

among American Indian women than among black women
E. The incidence of breast cancer in Asian immigrants to the
United States dropped within 10 years from 160 per
100,000 cases to 120 per 100,000 cases

23. A 64-year-old woman with metastatic breast cancer

who received the fourth cycle of paclitaxel and doxorubicin is admitted to the hospital with neutropenia. An
infectious-disease physician was consulted and antibiotics were administered. The fever resolved over the
next two days. Today, the temperature again rose to
40"C. Clinical examination identifies no localizing site.
Antifungal therapy was started, and the appropriate
antibiotic changes were made as recommended by the
infectious-disease team. The managing intern i s t
believes that the patient may benefit from a colony-stimulating factor (CSF), as neutropenia was persistent
throughout the hospital stay.
Which of the following is true about CSFs?
A. The use of CSF in historically chemosensitive tumors such
as non-Hodgkins lymphoma, small cell lung cancer, testicular cancer, and breast cancer has been shown to improve
survival
B. G-CSFs should routinely be used for individuals with documented neutropenia who are also afebrile
C. G-CSF is an appropriate adjunct therapy for fevers of at
least three days duration and neutropenia, even without a
documented source of infection
D. G-CSF has been associated with myalgias and arthralgias
E. Dose escalation of G-CSF beyond 5 #g/kg per day may be
beneficial in refractory patients

24. A 37-year-old premenopausal woman with large

breasts is found to have mass (three centimeters by
three centimeters) in the upper, outer quadrant of the
left breast. There is also a 1.5-centimeter palpable,
mobile, firm, nontender node in the left axilla. Bilateral
mammography identifies a single spiculated mass, 2.2
centimeters by 2.3 centimeters in largest diameter, corresponding to the clinical finding. No other abnormalities are identified. A fine-needle aspirate showed
malignant cells in the breast mass. The appropriate
staging work-up ruled out distant metastasis.
Which of the following would be the optimal regional
therapeutic option for this patient?
A. Lumpectomy, axillary dissection, radiation therapy
B. Comprehensive radiation therapy to the breast and regional
lymph nodes
C. Lumpectomy alone

D. Bilateral total mastectomy

E. Any of the above

25. Referring to the patient described in question 24,

the primary tumor is removed and axillary staging is performed. The tumor measures 2.2 centimeters by 2.5
centimeters by 1.8 centimeters. Histologic evaluation
indicates poorly differentiated invasive ductal cancer.
The tumor is ER negative and PR negative. Five of 22
lymph nodes are positive for disease.
Which of the following therapeutic options would you
recommend?
A.
B.
C.
D.

Six cycles of classical CMF

Six cycles of FAC followed by five years of anastrozole
Four cycles of AC
Four cycles of AC followed by four cycles of paclitaxel
administered in a dose-dense schedule
E. Goserelin for two years and tamoxifen for five years

26. A 27-year-old man with AML, who initially presented

with a white blood cell count of 42 x 103/!L and blasts
characterized as having trisomy 8, is treated with
daunomycin and standard-dose cytarabine. A complete
remission is achieved with a single cycle of therapy. He
then is treated with three cycles of high-dose cytarabine.
Shortly after completing the third cycle (five months
after diagnosis), a repeat bone marrow examination is
p e rf o rmed because of a declining platelet count.
Although no blasts are seen in the peripheral smear, the
marrow shows 20% myeloblasts, again with trisomy 8.
Repeat induction therapy with daunomycin and cytarabine is proposed.
Which of the following is most important in assessing the
likelihood of achieving a second remission?
A. Duration of the first remission
B. Achievement of the first remission with a single cycle of
induction therapy
C. Age of the patient
D. Cytogenetic characteristics of the leukemia
E. Detection of relapse before there were circulating blasts

27. A 46-year-old woman has kidney transplantation

and is subsequently treated with immunosuppressive
agents in an attempt to prevent graft rejection. After 18
months, she begins to note fevers, night sweats, and
abdominal bloating. A CT scan of the abdomen demonstrates a gastric mass. The results of biopsy indicate an
aggressive lymphoma.
Which of the following would not be a characteristic of
this lymphoma?
Practice Test 1 |

A. Findings on PCR are negative for EBV

B. Withdrawal of immunosuppression may result in resolution
of the lymphoma
C. Polymorphic histologic appearance
D. T-cell origin

28. Resistance to imatinib mesylate is an important

mechanism by which cancers bypass the efficacy of this
targeted therapy.
Which of the following statements about resistance to
imatinib resistance is false?
A. Amplification of BCR/ABL oncogene may be seen in CML
blast crisis cells
B. Point mutations occur in the ATP-binding pocket that interfere with imatinib binding to the BCR-ABL protein
C. Different point mutations can result in various degrees of
reduced binding to imatinib, suggesting that in some
instances an increased drug dose may be useful to overcome relative drug resistance
D. In most cases, mutations reside in resistant clones in
untreated patients and are selected by imatinib treatment
E. Imatinib egress is increased in resistant cells

29. A 35-year-old previously healthy man was seen in

the emergency room after a sudden onset grand mal
seizure that occurred while he was at work. At the time
of evaluation, he is awake and alert, with no symptoms.
The findings on physical examination, including neurologic evaluation, are normal.

Figure 2.

| Practice Test 1

CT of the head, with and without contrast enhancement, shows an isodense mass lesion in the left
frontal lobe and no evidence of intracranial hemorrhage. Anticonvulsant medications are prescribed,
and the patient has no further seizure activity. The
patient also has MRI of the head (Fig. 2). Cytogenetic
analysis of tissue from the lesion obtained by biopsy
demonstrates loss of the short arm of chromosome 1
and loss of the long arm of chromosome 19.
Which of the following is the most likely diagnosis?
A.
B.
C.
D.
E.

Glioblastoma multiforme
Ependymoma
Oligodendroglioma
Low-grade astrocytoma
Metastatic testicular cancer

30. A 58-year-old man is found to have a PSA level of

4.8 ng/mL on routine examination, which is increased
from the level a year previously (3.4 ng/mL). He has no
urinary symptoms or erectile dysfunction. On digital
rectal examination, the prostate appears to be of normal
size with no abnormalities. He was referred for a urologic evaluation, and the findings of a transrectal ultrasound-guided biopsy of the prostate indicated
adenocarcinoma, Gleason grade 6, in two of three cores
from the right, and none of three cores from the left. It
is estimated that 10% of each of the two cores is
involved by cancer. There are no associated medical
comorbidities.

Which of the following would you advise for the patient

at this point?
A.
B.
C.
D.
E.

CT of the abdomen and pelvis only

Bone scan only
CT scan of the abdomen and pelvis and bone scan
Capromab pendetide imaging
None of the above

31. Immunohistochemical analysis is sometimes used

as a surrogate for genetic analysis to gauge the presence of an oncogene mutation.
To which of the following does this not apply?
A.
B.
C.
D.
E.

P53
HER2
RAS
N-MYC
EGFR

32. A 35-year-old premenopausal woman presents after

colonoscopy examination showed a solitary lesion in the
ascending colon, with no other polyps or disease noted.
Evaluation of a biopsy sample obtained during colonoscopy showed adenocarcinoma, poorly differentiated
histology, and no evidence of a pre-existing polyp.
The patient is married and has two children, who are 10
and 6 years old. She plans to have no more children.
Her mother died at age 48 of gastric cancer. Her father
is alive and well. Her 40-year-old sister was diagnosed
with an early stage colon cancer two years ago and has
been followed up with no recurrence of new cancers.
The patient has no other siblings and no other family
history was elicited.
A right hemicolectomy is done. At surgery, the lesion is
determined to be a T3, N1, M0 adenocarcinoma. She
recovered well and presents to you for further recommendations regarding treatment options. She is also
concerned that her children are at increased risk for
colon cancer.
In addition to recommending chemotherapy, which of
the following would you advise?
A. No further surgery is indicated
B. Her children are not at increased risk for colon cancer, but
they should have routine screening procedures
C. The tumor most likely arose from a polyp, and future
screening is likely to detect additional polyps
D. The gastric cancer in her mother is not related to the
patients colon cancer
E. Genetic testing of the patients tumor will support a diagnosis of familial cancer syndrome

33. A 45-year-old man presents with oral sicca and elevated serum levels of liver function tests 90 days after
receiving a transplant from matched sibling for chronic
myeloid leukemia in chronic phase. The preparative regimen involved busulfan and cyclophosphamide. A
pathologically confirmed diagnosis of chronic graft-versus-host disease is made, and prednisone, 1 mg/kg per
day, is added to a stable dose of cyclosporine dose. Ten
days later, CMV antigens are detected in the peripheral
blood for the first time following transplantation, and
treatment with intravenous ganciclovir, 5 mg/kg twice
daily is begun. Ten days later, the granulocyte count has
decreased from a normal value to 0.7 # 103/!L.
Which of the following is the most likely cause of the
granulocytopenia?
A.
B.
C.
D.
E.

Chronic graft-versus-host disease

CMV infection of the marrow
Ganciclovir toxicity
Recurrence of leukemia
Graft rejection

34. Which of the following describes the difference

between efficacy and effectiveness in the interpretation
of clinical trial results?
A. Efficacy considers the outcomes of a treatment under
carefully controlled conditions, whereas effectiveness
considers the outcomes when applying a treatment in the
routine (real-world) setting
B. Efficacy considers short-term and long-term effects,
whereas effectiveness considers long-term effects only
C. Efficacy considers only the effect of survival, whereas
effectiveness considers all outcomes
D. Efficacy is a clinical measure, whereas effectiveness is
statistical measure

35. A 59-year-old man presents with a history of several

weeks of progressive fatigue and easy bruising. A complete blood count demonstrates pancytopenia, with a
platelet count of 52,000/L and a neutrophil count of
900/L. The hemoglobin is 8.1 g/dL. Evaluation of bone
m a rrow aspirate indicates hypercellularity with occasional
ringed sideroblasts on an iron stain. The diff e rential count
on the bone marrow shows 6% blasts. Cytogenetic analysis identifies an abnormality of chromosome 7.
A c c o rding to the International Prognostic Scoring
System, which of the following describes the likelihood
of disease progressing to AML, with a survival of two
years?
A. He has low risk disease
B. He has intermediate-1 disease
Practice Test 1 |

C. He has intermediate-2 disease

D. He has high-risk disease

36. A 58-year-old Asian man presents with a threemonth history of an enlarging mass on the left side of the
neck. He re p o rts that he has had no anorexia or weight
loss but he has had mild fatigue. On closer questioning,
he says that he has had a mild headache intermittently
over the past month that he attributed to sinus congestion. His medical history is significant for type 2 diabetes
and hypertension. He continues to work full time. He has
a seven-pack-year smoking history but quit 20 years ago.
On physical examination, he appears healthy and in no
distress. On assessment of the neck, there is a two to
three-centimeter, mobile, mass in the upper cervical
lymph node on the left, with no overlying skin changes.
Examination of the tympanic membranes reveals serous
otitis media on the left side. Fiberoptic examination
shows a left-sided nasopharyngeal mass obstructing the
left eustachian tube. S1 and S2 heart sounds are audible with a soft systolic murmur. The lung fields are clear
to auscultation and percussion. No hepatosplenomegaly
or ascites is noted. No clubbing, cyanosis, or edema is
detected in the extremities.
The results of a complete blood count, serum chemistry
tests, and liver function tests are within normal limits.
The chest x-ray shows no cardiopulmonary disease. CT
of the neck confirms a left-sided nasopharyngeal mass
and two enlarged lymph nodes in the left side of the
neck. Erosion of the skull base adjacent to the mass is
noted. Fine-needle aspiration reveals a poorly differentiated tumor. The findings of biopsy of the nasopharynx
are interpreted as lymphoepithelioma.
Which of the following is the most appropriate therapy
for this patient?
A. Nasopharyngectomy, with a left modified-radical neck
dissection, followed by adjuvant radiotherapy to the primary site and ipsilateral neck
B. Induction cisplatin and fluorouracil for three cycles followed by hyperfractionated radiotherapy in a curative dose
to the primary site and to both sides of the neck
C. C o n c u rrent cisplatin with curative-dose radiotherapy to
the primary site and both sides of the neck, followed
by adjuvant cisplatin and fluorouracil for three
cycles
D. Curative-dose radiotherapy alone to the primary site and
the ipsilateral neck
E. High-dose carboplatin-based chemotherapy with stem cell
rescue followed by curative-dose radiotherapy to the primary site and both sides of the neck

| Practice Test 1

37. A 62-year-old woman has lumpectomy and axillary

dissection for a T1, N1, M0 infiltrating ductal cancer of
the right breast. The tumor is found to have the unusual
phenotype: ER positive, PR positive, and HER2 positive
(3+) (according to FISH). The patient has a 30-pack-year
smoking history. She is treated with adjuvant chemotherapy consisting of cyclophosphamide, methotrexate, and
f l u o rouracil followed by local radiation. She refuses to take
tamoxifen. On routine follow-up three years later, a single
one-centimeter peripheral lung lesion is found on CT.
Restaging for breast cancer is otherwise negative. Wedge
resection of the lung mass is done. Several tests are likely
to help determine whether the lung mass is metastatic
breast cancer or primary lung cancer.
Which of the following tests would not be likely to help
discriminate between metastatic breast cancer and
primary lung cancer?
A.
B.
C.
D.
E.

FISH analysis for HER2

Staining for ER and PR
P53 gene mutational analysis
Staining for P53
Mutational analysis of the RAS gene

38. With regard to the patient described in question 37,

the lung mass is determined to be metastatic breast
cancer. The patient now agrees to take tamoxifen. One
year later, there are two new lung masses. She is treated
with trastuzumab and docetaxel. The lung masses
improve, but within three months, ankle edema and
some dyspnea on exertion develops.
Which of the following statements about trastuzumab
and cardiac toxicity is false?
A. Radiolabeled trastuzumab would localize to the heart
B. Discontinuing trastuzumab would very likely resolve the
symptoms
C. After symptoms resolve, docetaxel and trastuzumab may be
reinitiated
D. After symptoms resolve, a good therapeutic choice would
be doxorubicin
E. At any point, a reasonable therapeutic choice would be
capecitabine

39. A 50-year-old man is being treated with gemcitabine

for unresectable metastatic pancreatic cancer. He tolerates the chemotherapy reasonably well but has anorexia
and weight loss. The patient asks for something to help
him gain weight. Because of a history of thromboembolic complications, he and his physician decide not to
use megestrol acetate.
Which of the following agents would be an option, given

that it has been shown, in multiple placebo-controlled

trials, to stimulate appetite?
A. A corticosteroid
B. Dronabinol (a cannabinoid)
C. Fluoxymesterone (an androgen)
D. Eicosopentenoic acid

40. A 61-year-old woman has a nonproductive cough

that is uncontrolled by antitussives and that is accompanied by a low-grade fever and night sweats. After
two weeks, her family physician prescribes a twoweek course of antibiotics with no effect. A subsequent chest x-ray shows a 10-centimeter mediastinal
mass. On physical examination, a right supraclavicular node, 2.0 centimeters by 2.5 centimeters, is
found, as well as small bilateral axillary nodes.
Evaluation of tissue obtained by biopsy of the supraclavicular node demonstrates diffuse large B-cell nonHodgkins lymphoma. Laboratory evaluation indicates
mild anemia, with normal levels of liver enzymes,
include the LDH. The patient is treated with eight
cycles of CHOP plus rituximab. Her symptoms disappear after the first cycle. After completion of therapy,
restaging indicates that all of the nodes are of normal
size. The mediastinal mass has decreased by 80%,
but its location makes it difficult to perf o rm a perc utaenous biopsy. The findings on PET scan are negative; however, no study had been carried out before
therapy.
Which of the following should be the next step?
A.
B.
C.
D.
E.

Radiation therapy to the residual mass

Autologous stem cell transplantation
Change to another chemotherapy regimen
Thoracotomy with biopsy
Repeat CT and PET in two months

41. A 68-year-old woman presents with a three-week

history of abdominal pain and nausea. A CT of the
abdomen and pelvis shows ascites, a large omental
mass, and an enlarged right ovary. During an exploratory
laparotomy, performed by a general surgeon, the patient
is found to have a poorly differentiated adenocarcinoma
of the ovary. After completion of surgery, the largest
residual tumor is less than one centimeter in maximum
diameter.

D. Six cycles of carboplatin (AUC, 6) plus three-hour infusional paclitaxel

E. Six cycles of carboplatin (AUC, 6) plus cyclophosphamide

42. Which of the following is true regarding thymomas?

A. Thymomas are similar to primary lung cancers in that they
tend to occur in patients in the sixth decade of life and
metastasize early
B. Thymomas are similar to primary lung cancers in that they
are often associated with such paraneoplastic syndromes
as hypercalcemia, syndrome of inappropriate excretion of
antidiuretic hormone, and clubbing
C. Like small cell lung cancer, the backbone of treatment for
thymomas is chemotherapy
D. Malignant thymomas and thymic cancers are synonyms for
locally invasive thymic tumors
E. Unlike primary lung cancers, staging (and therefore prognosis) of thymomas is based on the degree of invasion

43. Various factors associated with the re p roductive history

of adult women are associated with different levels of risk.
Which of the following statements about reproductive
risk factors is false?
A. Early onset of menarche, late onset of menopause, and
greater number of years with ovulatory cycles are all
associated with an increased risk of breast cancer
B. First full-term pregnancy before age 20 increases the risk of
b reast cancer, whereas nulliparity has a protective effect
C. The risk of breast cancer is 20% to 30% higher for women
who have their first full-term pregnancy after age 35 than
for nulliparous women
D. Lactation, especially of long duration, has a modest protective effect
E. Early ovarian ablation (before age 45) reduces the risk of
breast cancer

44. A 36-year-old woman with CML in chronic phase

receives imatinib mesylate 400 mg daily and a complete
hematologic response is achieved. On re-evaluation one
year after the start of therapy, disease is in complete
hematologic remission, but the bone marrow continues
to be 70% positive for the Ph chromosome. She has an
HLA-identical brother and is interested in discussing the
risks and benefits of transplantation.

Which of the following would you recommend as the

next course of action?

Which of the following statements about the effects of

the interval from diagnosis to transplantation on outcome is true?

A. Repeat exploratory laparotomy by a gynecologic oncologist

B. Six cycles of cisplatin plus three-hour infusional paclitaxel
C. Six cycles of single-agent carboplatin (AUC, 12)

A. Although an increased interval from diagnosis to transplant

previously had been shown to lead to a worse outcome,
with improved transplant techniques, this is no longer true
Practice Test 1 |

B. The worse outcome associated with a longer interval

between diagnosis and transplantation is largely explained
by the increased pro p o rtion of patients who have transplantation when disease is accelerated phase or blast crisis
C. The worse outcome associated with a longer interval
between diagnosis and transplantation is restricted to
patients treated with busulfan or interferon
D. The worse outcome associated with a longer interval
between diagnosis and transplantation is found with all
therapies so far examined and is not accounted for by
advanced stage of disease

45. A postmenopausal woman is considering using

estrogen and progesterone and asks you for information.
Which of the following do you tell you about the use of
these agents in postmenopausal women?
A. This use has
lar disease
B. This use has
cancer
C. This use has
D. This use has

been shown to lower the risk of cardiovascubeen shown to lower the risk of colorectal
been shown to lower the risk of breast cancer
been shown to improve cognition

46. A 45-year-old man presents with mid-thoracic back

pain, which he describes as sharp and band-like around
the chest. There are no other radicular symptoms, but a
sensory level is apparent at T12. Babinski reflexes are
present, and there is symmetrical hyperreflexia of both
lower extremities. He reports a history of stage III renal
cell cancer that was completely resected four years earlier. The findings on interval examinations, including
imaging studies, have been normal. He also has a
smoking history of 40 pack-years.
A metastatic work-up shows no evidence of a local
recurrence in the renal bed. However, there is a 2.5centimeter lesion in the left lower lobe of the lung is
found that was not visible on studies done eight months
earlier. A complete blood count and screening profile
are within normal limits, except for an elevated serum
alkaline phosphatase level.
Which of the following is not indicated?
A.
B.
C.
D.

Treatment with high-dose dexamethasone acetate

Consultation with a radiation oncologist
Treatment with IL-2 and IFN-!
Neurosurgical consultation for consideration of resection
of the vertebral body
E. MRI of the entire spine

47. Which of the following cell types does not play a substantial role in the human immune response to cancer?
10

| Practice Test 1

A.
B.
C.
D.
E.

CD3+ T cells
CD66+ neutrophils
CD14+ dendritic cells (monocyte derived)
CD20+ B cells
CD56+ NK cells

48. Which of the following is the deletion of a single

nucleotide in the coding region of the more than 3,000nucleotide BRCA1 gene likely to cause?
A.
B.
C.
D.
E.

Premature termination of translation

Have no effect
Sensitization of the cells to radiation
Microsatellite instability
Congenital sensitivity to ultraviolet light

49. Which of the following statements is true regarding

the use of interferon in the adjuvant setting for patients
with high-risk melanoma?
A. High-dose interferon improves relapse-free survival by
approximately 10% and possibly overall survival
B. Low-dose interferon improves both relapse-free survival
and overall survival by approximately 10%
C. There is no difference in the side-effect profile between
low-dose and high-dose interferon regimens
D. Clinical trials with peptide-based melanoma vaccines show
improved relapse-free survival compared with high-dose
interferon

50. A 62-year-old woman presents with a six-year history of ovarian cancer. At the time of the initial diagnosis, she had an initial-stage exploratory laparo t o m y
with debulking, followed by platinum-based
chemotherapy. Two years later, disease re c u rred and
she had re c u rrent laparotomy with a debulking. She
also received chemotherapy with topotecan. Over the
past year and a half, she has had intermittently progressing ovarian cancer signaled by rising CA-125 levels, despite treatment with hexamethylmelamine and
tamoxifen on an intermittent basis. She now has
symptoms suggestive of small bowel obstruction. She
has never taken narcotics and has never had
constipation.
The findings on physical examination are remarkable for
mild cachexia and a distended abdomen with quiet
bowel sounds. There is no evidence of rebound or tenderness. A radiograph of the abdomen shows a classic
pattern of small bowel obstruction. A nasogastric tube is
inserted. Surgeons have been consulted and have recommended against any surgical procedure. Clamping of

the nasogastric tube after five days results in recurrent

symptoms of nausea and vomiting. The patient has had
no flatus.
Which of the following medications is reasonable to
t ry, given relatively recent information suggesting its
benefit?
A. Amoxicillin
B. Senna laxative
C. Octreotide
D. Narcan

51. You are treating a 55-year-old woman with carboplatin and paclitaxel for adenocarcinoma of the lung
with pulmonary metastases. At presentation, the patient
had presented with a peripheral, three-centimeter mass,
mediastinal adenopathy, and bilateral pulmonary nodules. Both the primary tumor and the pulmonary metastases have partially responded to two cycles of therapy,
and disease stabilized after four cycles. She is tolerating
the chemotherapy well, with minimal reports of nausea
or fatigue and has had no problems with neuropathy or
complications from myelosuppression. Her performance
status is ECOG 0 to 1; she does not report pain, shortness of breath, or cough.
Which of the following is the most appropriate treatment
for this patient?
A. Stop therapy and start chemotherapy at the time of disease
progression
B. Continue with maintenance therapy of weekly paclitaxel
until the time of disease progression
C. Continue carboplatin and paclitaxel until disease progression
D. Begin maintenance therapy with gefitinib until disease
progression
E. Begin radiation of the primary tumor

D. Monthly breast self-examination reduces breast cancer

mortality by 25%, especially if a biopsy is done on every
physical abnormality that is identified
E. Mammograpy screening is associated with a marked
increase in the risk of radiation-induced breast cancer

53. The hospital tumor board asks you to review the

findings of a phase III trial that was recently published in
a respected peer-reviewed journal. The authors claim
that the new treatment is superior to the current standard of care and should become the treatment of choice
for patients with this disease. The trial enrolled 300
patients (150 on each study arm) in 60 centers across
North America including Canada and Mexico. The two
arms were evenly balanced for the important disease
characteristics. The trial was designed to detect an
improvement in time to disease progression of 50%
(median time to disease progression with the standard
of care, six months; median time to disease progression
with the new treatment, nine months) with 0.80 power
at a statistical significance level of 0.05 (two-sided test).
Secondary endpoints included overall survival, cost,
quality of life, and toxicity. The investigators claim a significant result, with a median time to disease progression for the new treatment of x months compared with a
median time to disease progression of y months for the
standard of care (p = 0.02).
Which of the following conclusions can you draw from
the results of this trial?

52. The effects of periodic screening techniques on

breast cancer-related mortality have been assessed in
prospective randomized trials.

A. The trial is too small to make any conclusions, regardless

of the p value
B. Time to progression is not a valid endpoint and, therefore,
the results are meaningless
C. The difference in the time to disease progression of three
months is not a clinically meaningful difference and, therefore, the results are invalid
D. Differences in clinical research practices in different countries make this trial impossible to interpret
E. The new treatment is a reasonable option for treatment and
may be used as a new standard of care

Which of the following is the most appropriate description of these effects?

54. In the trial described in question 53, the 0.80 power

means which of the following?

A. Mammography is useful only for women with small breasts.

Women with large breasts should have screening with
annual breast sonography
B. Mammography done every one to three years reduces
breast cancer-related mortality by 25% to 30% among
women 50 to 69 years old
C. Because mammography is more sensitive in dense breasts,
it is more effective for premenopausal women

A. The probability of achieving a significant result in the trial

is 0.8
B. If the outcome of the trial is that the median time to disease progression with the new treatment is three months
longer than that with the standard of care treatment, the
results will be significant at p = 0.05
C. In the 60 centers in the study, at least 80% of them (48 or
more) should have results in which a median time to disPractice Test 1 |

11

ease progression with the new treatment is at least three

months longer than that with the standard of care treatment
D. If the true median time to disease progression with the new
treatment is nine months and that with the standard of care
is six months, enrolling 300 patients and conducting the
study as planned means that the probability is 0.8 and that
the actual trial will achieve a statistically significant result
at the 0.05 level (two-sided test)
E. Patients receiving the new treatment have an 80% chance
of having a longer time to disease progression than
patients receiving the standard treatment

55. A 65-year-old woman with stage III ovarian cancer

has a clinically defined complete response following
surgery and treatment with carboplatin and paclitaxel.
Other than moderate fatigue, the patient tolerated the
chemotherapy regimen without major side eff e c t s ,
such as emesis, neuropathy or arthralgias/myalgias.
T h ree years after the completion of primary
chemotherapy, the patient has intermittent diffuse
abdominal discomfort. Repeat computerized tomography demonstrates moderate ascites and possible
small peritoneal implants. The CA-125 antigen level is
575 U/mL. The gynecologic oncologist does not
believe that repeat surgery will be of any clinical
value.
Which of the following treatment strategies would you
recommend for this patient?
A.
B.
C.
D.
E.

Single-agent cisplatin
Single-agent carboplatin
Carboplatin and paclitaxel
Whole abdomen radiation therapy
A nonplatinum-containing chemotherapy regimen

56. A 28-year-old man with a four-month documented

h i s t o ry of anemia presents with fever and bleeding
gums. The results of laboratory studies include a
white blood cell count of 60 x 103/!L, of which most
are leukemic blasts. Immunophenotyping shows the
blasts to express myeloid antigens CD33 and CD13
and to coexpress the B-cell antigen, CD19.
Cytogenetic analysis shows inv(16) in 20 of 20
metaphases.
Which of the following is most important for estimating
the likelihood of achieving a sustained complete
response with chemotherapy?
A. Age of the patient
B. Cytogenetic features of the blasts
C. Four-month history of anemia

12

| Practice Test 1

D. White blood cell count at the time of presentation

E. Presence of a lymphoid marker on the myeloblasts

57. A 55-year-old man presents because of an elevated CEA level (15 ng/mL) at his last routine visit.
The patient has a history of a T3, N1, M0 adenocarc inoma of the colon, which was diagnosed 24 months
previously. The tumor was resected with primary
reanastomosis, and the patient received postoperative
treatment with bolus fluorouracil and leucovorin for six
months. He tolerated the chemotherapy well and has
re t u rned regularly for follow-up visits every six
months. Previous CEA levels had all been less than 2
ng/mL.
At the present time, the findings on physical examination are normal, with no hepatosplenomegaly. There are
no abnormalities noted on chest x-ray. Findings on CT
show a three-centimeter lesion in the right lobe of the
liver. PET demonstrates a positive signal correlating precisely with the lesion seen on the CT scan and no other
uptake. The patient has a history of hypertension that is
controlled with medication.
Which of the following would you recommend?
A. Chemotherapy with fluorouracil, leucovorin, and irinotecan
for the treatment of metastatic colon cancer
B. Biopsy of the liver lesion to confirm a diagnosis of
metastatic colon cancer
C. Referral to a surgeon for consideration of resection of the
liver lesion
D. No treatment because of the lack of symptoms and
indication for palliative chemotherapy at this point

58. A 52-year-old woman notices several new, enlarged

inguinal lymph nodes but otherwise has no symptoms.
On physical examination, she is found to have bilateral
e n l a rged cervical and axillary nodes as well. There is no
hepatosplenomegaly. The results of excisional biopsy of
the lymph node are consistent with the diagnosis of follicular non-Hodgkins lymphoma. She is evaluated again
in three months. The nodes have increased in size and
she reports that she has begun to have night sweats.
Treatment is initiated with CVP, which she receives for six
months with resolution of symptoms and lymphadenopathy. However, in approximately one year, the
nodes become enlarged again and she re p o rts having
fevers, sweats, and weight loss. Physical examination at
that time demonstrates splenomegaly three centimeters
below the left costal margin. The laboratory evaluation is
remarkable for a LDH level of 1,700 U/L. CT of the

abdomen demonstrates a six-centimeter mass surro u n ding the aorta. The results of biopsy of one of the peripheral nodes again indicates follicular non-Hodgkins
lymphoma. You decide that therapy is again indicated.
Which of the following therapeutic approaches is appropriate?
A.
B.
C.
D.
E.

A repeat course of CVP

Single-agent rituximab
Single-agent fludarabine
IFN-!
CHOP with rituximab

59. A 27-year-old man presents with a left testicular mass.

A radical orchiectomy is done, and pathologic evaluation
indicates embryonal cancer with yolk sac elements and
mature and immature teratoma. Postoperatively, the physical examination is normal. The alpha-fetoprotein level is
400 ng/dL and the HCG level is 25 mIU/mL. CT scans of
the abdomen and pelvis demonstrate an eight-centimeter
para-aortic mass with minimal hydro n e p h rosis. Standard
cisplatin-based chemotherapy is started. On day 22, the
alpha-fetoprotein level is 248 ng/dL and the level of HCG
is undetectable. At that time, a mass is palpated in the left
upper quadrant. Repeat CT scans of the abdomen and
pelvis show a 17-centimeter para-aortic mass deviating
the aorta medially, with moderate hydro n e p h rosis extending inferiorly to the bifurcation of the aorta.

Which of the following is the most appropriate treatment?

A. Change in chemotherapy regimen to ifosfamide plus cisplatin
B. Dissection of the retroperitoneal lymph nodes
C. High-dose chemotherapy with peripheral stem cell support
D. Continuation of standard treatment
E. Radiation therapy for palliation

60. Which of the following is true regarding genetic

mutations associated with lung cancer?
A. The tumor suppressor gene TP53, once mutated,
suppresses tumor formation by enhancing apoptosis,
increasing cell-cycle checkpoint control, and decreasing
movement of the cell through the cell cycle
B. Although TP53 mutations correlate with survival, they
should not be measured for patients with non-small cell
lung cancer because such measurement is not costeffective in directing therapy
C. K-RAS mutations are more frequently found in patients with
small cell lung cancer than in patients with non-small cell
lung cancer
D. Overexpression of K-RAS results in enhanced prostaglandin
synthesis, which leads to anti-apoptosis, angiogenesis, and
activation of carcinogens
E. Overexpression of tumor microvasculature and VEGF levels
has been shown to correlate inversely with prognosis in
non-small cell lung cancer

Practice Test 1 |

13