restage with radiographs and scans, evaluate serum testosterone level if less than 50 ng/mL, and discontinue all hormonal therapy (LH-RH analogue and antiandrogen) for 4 to 8 weeks before planning the next therapeutic step.

if the patient is on an antiandrogen in addition to a luteinizing hormone–releasing hormone (LH-RH) analogue, discontinue this for 4 weeks in the case of flutamide/nilutamide and for 8 weeks in the case of bicalutamide.

obtain a serum testosterone level to evaluate adequate gonadal suppression, restage the disease with radiographs and scans, maintain gonadal suppression, and plan the next therapeutic step.

if the patient experiences severe focal bone pain that requires regular use of narcotic analgesics, consider palliative radiation therapy.

if the patient has no symptoms, the workup shows that he has adequate gonadal suppression (serum testosterone <50 ng/mL), and the only evidence of disease progression is a rising prostate-specific antigen (PSA) and scans are unchanged, try a second-line hormonal therapy before chemotherapy is offered.

Assess the PSA doubling time (PSADT): if less than 6 months, consider treatment as soon as possible; otherwise, observation may be reasonable.

Evaluate the adequacy of gonadal suppression (check serum testosterone level) and plan for second-line endocrine manipulations.

Continue follow-up with regular PSA tests and restage when the patient becomes symptomatic.

Send the patient to an oncologist for initiation of chemotherapy.

Radiate the prostatic bed and the pelvis.

Treat aggressively with high-dose bicalutamide, calcium, and vitamin

Wait until he becomes symptomatic.

Administer docetaxel, 75 mg/m2 every 3 weeks, and zoledronate, 4 mg monthly.

Plan for next endocrine treatment approach, including the infusion of zoledronate given 3 times yearly.

Administer a radiopharmaceutical.

order magnetic resonance imaging (MRI) of the spine to rule out cord compression.

give analgesics as needed and consider a workup when the PSA value rises.

add zoledronate to management.

order radiation therapy followed by docetaxel.

consider radiation therapy.

perform a biopsy of the pelvic mass to rule out the neuroendocrine/anaplastic subtype.

send him for a colonoscopy because he probably has another cancer because the PSA value is negative.

administer radiation to the pelvis followed by docetaxel.

treat with bicalutamide because the PSA level is still low.

begin docetaxel because he has castration-resistant prostate cancer (CRPC).

radiation therapy followed by second-line hormonal therapy until progression; then offer chemotherapy.

docetaxel combined with zoledronate.

chemotherapy with carboplatin and etoposide preceded or followed by irradiation.

radiation to the pelvis followed by ketoconazole and hydrocortisone.

a bronchoscopy, because of the histology (small cell carcinoma).

Pain response

All of the above

Quality of life

PSA response

Overall survival

It has significant single-agent activity in CRPC.

It is critical to use it combined with docetaxel.

It adds significant toxicity to docetaxel without an apparent survival benefit.

It has no activity at all in CRPC.

Thromboembolic events are usually prevented by prophylactic anticoagulation.

it may cause modest elevation of liver function test results.

it may cause myelosuppression.

toxicity overrides quality of life benefits.

it may cause edema.

it may cause fatigue and neurotoxicity.

proliferation of osteoblasts.

depletion of osteoclasts.

increased osteoclastic activity.

hypercalcemia

hypocalcemia.

They are mostly lytic, associated with a predominant osteoclastic effect associated with treatment.

There is increasing evidence that growth factors, cytokines, and other proteins may play a role in the development of bone metastases.

Hypercalcemia is common.

They are always osteoblastic, because of growth factor effects.

Pathologic fractures are common.

It rarely may cause osteonecrosis of the jaw in patients who are undergoing dental work.

It is approved for the treatment of hypercalcemia.

It reduces the increase in osteoclastic activity associated with androgen deprivation.

Side effects include anemia and renal dysfunction.

All of the above

All of the above

is seen in about 50% of patients receiving docetaxel treatment.

is usually seen in the first 3 months of treatment.

represents evidence of therapeutic benefit but not necessarily longer survival.

None of the above

It is seen in less than 1% of patients, except when they demonstrate the neuroendocrine phenotype.

It is common in patients progressing rapidly on hormonal therapy.

Routine MRI of the brain should be considered in all CRPC patients.

Brain metastasis associated with small cell histology should be treated surgically.

It is seen in about 25% of patients with CRPC.

They induce BCL2 phosphorylation.

All of the above

They cause radiosensitization in vitro.

They are antimitotic agents.

They are associated with an increased accumulation of cells in the G2M phase of the cell cycle.