Facts read from oncc.org · last checked Nov 7, 2026
60 questions in ONCC's format: four options, one best answer, generic drug names. The mix follows the 2025 outline, so treatment and supportive care get the most questions and professional practice the fewest.
Figure 1.Test content outline drawn to scale: each run is one domain’s weight
Counts per area follow the outline: about a quarter of the set from the cancer continuum, close to half from treatment and supportive care, and the rest from emergencies, psychosocial issues and professional practice. Professional practice questions appear only in this set, since that area has no separate page.
None of these questions repeat the ones on the area pages, so the two can be used one after the other.
The AOCNP set, 60 questions
0 / 60 answered60 questions
Tap an option: why each one is right or wrong appears under it.
Cancer Treatment
A 58-year-old patient with ECOG 0 has recovered 8 weeks after pancreaticoduodenectomy for stage II pancreatic adenocarcinoma. The APRN recommends 6 months of adjuvant:
For fit patients after resection, modified FOLFIRINOX gave the longest survival in PRODIGE 24 and is the preferred adjuvant regimen.
Gemcitabine plus nab-paclitaxel is a metastatic standard but did not meet its primary endpoint in the adjuvant APACT trial.
Gemcitabine alone is the adjuvant option for patients who cannot tolerate combination therapy, not for an ECOG 0 patient.
Capecitabine is used with gemcitabine in some adjuvant regimens, but alone it has no adjuvant role.
A patient with chronic-phase chronic myeloid leukemia has taken imatinib for 6 months. To assess molecular response, the APRN orders:
Molecular response to a TKI is tracked with quantitative RT-PCR for BCR::ABL1 on the International Scale every 3 months, which is sensitive enough to guide treatment decisions.
FISH is less sensitive than qPCR and cannot measure major molecular response.
Routine marrow biopsies are not needed once qPCR is followed; marrow is reserved for loss of response or suspected progression.
A CBC shows hematologic response only and misses residual leukemia that qPCR detects.
A patient newly diagnosed with breast cancer rates distress 6 on the NCCN Distress Thermometer and checks 'worry' and 'sleep' on the Problem List. The APRN's next step is:
Scores of 4 to 6 are moderate distress that already needs action; waiting for 7 or more misses many patients.
On the NCCN Distress Thermometer, a score of 4 or more prompts further evaluation, and the checked Problem List items (worry, sleep) direct the referral.
Prescribing before evaluating jumps from a screening score to a diagnosis that has not been made.
Rescreening later leaves a positive screen unaddressed.
The spouse of a patient with pancreatic cancer reports exhaustion, irritability, and missed personal medical appointments. To measure caregiver strain, the APRN uses the:
The Mini-Cog screens for cognitive impairment; it does not measure strain.
FACT-G is a familiar oncology questionnaire, but it measures the patient's own quality of life.
Karnofsky rates the patient's functional status, not the caregiver's burden.
The Zarit Burden Interview is a validated measure of caregiver strain and helps target respite and support services.
A patient with advanced mycosis fungoides is starting oral bexarotene. The APRN orders baseline and ongoing:
Bexarotene causes marked hypertriglyceridemia and central hypothyroidism, so fasting triglycerides and free T4 (TSH is unreliable) are checked at baseline and during therapy.
Bexarotene is not cardiotoxic, so cardiac biomarkers are not part of its monitoring.
Pancreatitis is a consequence of the triglyceride rise; checking enzymes without lipids misses the modifiable cause.
CK and uric acid are not monitoring targets for bexarotene.
Three months into tyrosine kinase inhibitor therapy for chronic myeloid leukemia, a patient develops exertional dyspnea and a new unilateral pleural effusion. The agent most likely responsible is:
Nilotinib is linked to QT prolongation, hyperglycemia, and arterial occlusive events.
Imatinib causes superficial fluid retention such as periorbital and leg edema rather than pleural effusions.
Bosutinib's dominant toxicity is diarrhea, with liver enzyme rises.
Pleural effusion is a signature toxicity of dasatinib, managed by holding the drug, diuretics or a short steroid course, and dose reduction or a switch.
A patient with hepatocellular carcinoma has sudden abdominal pain, hypotension and falling hemoglobin. CT shows hemoperitoneum from a ruptured liver tumor. After resuscitation, the APRN anticipates:
Draining the hemoperitoneum does not control the bleeding source and can worsen instability.
Spontaneous HCC rupture with hemoperitoneum is controlled after resuscitation by transarterial embolization, the preferred first hemostatic procedure, with surgery in selected patients.
Observation is inappropriate with ongoing bleeding and hypotension.
Systemic therapy has no role in stopping active bleeding.
A patient will receive a single 8 Gy fraction to a painful lumbar vertebral metastasis. To reduce the risk of post-radiation pain flare, the APRN prescribes:
Prophylactic dexamethasone 8 mg on the day of single-fraction bone radiation and for 4 days afterward reduced pain flare in a randomized trial (NCIC SC.23).
Celecoxib has not been shown to prevent post-radiation pain flare; the randomized evidence is for dexamethasone.
A new long-acting opioid patch takes a day or more to reach effect and does not address the transient inflammatory flare.
Gabapentin targets neuropathic pain and does not prevent the inflammatory flare after radiation.
A patient with metastatic breast cancer has received 300 mg/m² of doxorubicin, is responding, and will continue the drug. The APRN adds:
Mesna protects the bladder from ifosfamide and high-dose cyclophosphamide metabolites.
Dexrazoxane is indicated for cardioprotection once cumulative doxorubicin reaches 300 mg/m² in metastatic breast cancer when more anthracycline is planned.
Leucovorin rescues normal cells after high-dose methotrexate.
Amifostine protects against cisplatin nephrotoxicity and radiation xerostomia, not anthracycline cardiotoxicity.
An older adult living alone after total laryngectomy tells the APRN that he feels cut off from others. To quantify how much help and companionship he perceives, the APRN administers the:
Karnofsky rates physical performance status.
The MMSE screens cognition, which is not his concern.
Isolation raises depression risk, but the GDS screens mood rather than measuring support.
The Medical Outcomes Study Social Support Survey measures perceived emotional, tangible, affectionate, and social-interaction support, the deficit this patient describes.
A patient with pancreatic adenocarcinoma has embolic strokes and sterile mitral valve vegetations on echocardiography, with negative blood cultures. The APRN recommends:
This is an infective endocarditis regimen; sterile vegetations with negative cultures point to NBTE.
Warfarin often fails in cancer-associated hypercoagulability, with recurrent emboli despite a therapeutic INR.
Nonbacterial thrombotic endocarditis with embolic strokes in pancreatic adenocarcinoma is treated with therapeutic unfractionated or low-molecular-weight heparin; recurrence is common on warfarin.
Antiplatelet therapy does not prevent the fibrin-platelet vegetations of NBTE from re-forming and embolizing.
After 14 months of osimertinib, a patient's restaging shows one enlarging adrenal metastasis while all other disease remains controlled. The APRN recommends:
Oligoprogression, one progressing site while the rest stays controlled, is treated with local ablative therapy such as SBRT while the effective TKI continues.
Adding bevacizumab does not eliminate the resistant clone in the adrenal lesion.
Changing systemic therapy abandons a drug that still controls most of the disease.
Stopping osimertinib risks a rapid flare at the sites it is still controlling.
On day 7 of ATRA plus arsenic trioxide for acute promyelocytic leukemia, a patient has fever, dyspnea, a 5 kg weight gain and bilateral pulmonary infiltrates. The treatment directed at this syndrome is:
Tocilizumab, an IL-6 receptor blocker, does not treat APL differentiation syndrome; dexamethasone does.
A diuretic is supportive care for the fluid overload; it does not treat the underlying inflammatory syndrome.
Antibiotics are supportive cover while infection is excluded; they do not treat the cytokine-driven differentiation syndrome itself.
Fever, dyspnea, weight gain, and pulmonary infiltrates during ATRA and arsenic trioxide signal differentiation syndrome, treated at first suspicion with dexamethasone 10 mg IV every 12 hours.
A patient with metastatic pancreatic cancer, ECOG 3 and an expected survival of about 2 months, has severe epigastric and back pain despite escalating opioids with limiting sedation. The APRN recommends:
Celiac plexus neurolysis targets the visceral pain pathway of pancreatic cancer, reducing pain and opioid needs, and is the interventional step when opioids cause dose-limiting sedation.
An implanted intrathecal pump is a larger procedure usually reserved for refractory pain with a longer expected survival; neurolysis comes first for pancreatic pain.
TENS lacks evidence for deep visceral cancer pain.
Combination chemotherapy is poorly tolerated at ECOG 3 and would not relieve pain quickly.
A 55-year-old patient receiving curative R-CHOP for DLBCL without growth factor support develops febrile neutropenia after cycle 1. For subsequent cycles the APRN orders:
Doxorubicin is a key active drug in R-CHOP; dropping it sacrifices efficacy.
Lowering doses in curative-intent R-CHOP reduces the chance of cure when growth factor support can prevent a repeat episode.
R-mini-CHOP is designed for patients over 80 and is not appropriate for a fit 55-year-old.
In curative lymphoma therapy, dose intensity affects cure, so febrile neutropenia after cycle 1 is managed with G-CSF prophylaxis for later cycles instead of dose reduction.
A patient with relapsed follicular lymphoma is starting epcoritamab, a CD20×CD3 bispecific antibody. The APRN explains that its step-up dosing in cycle 1 is designed to reduce:
Subcutaneous epcoritamab can cause mild local reactions, which are not why the schedule ramps up.
TLS prevention relies on hydration and uric acid control, not on the dosing schedule.
Hepatitis B reactivation with CD20-directed therapy is prevented by screening and antiviral prophylaxis.
T-cell–engaging bispecific antibodies cause CRS mainly with the first doses, so cycle 1 uses step-up doses with corticosteroid premedication and monitoring to lower its risk and severity.
A patient has stage II squamous cell carcinoma of the anal canal. The APRN anticipates primary treatment with:
Concurrent radiation with fluorouracil (or capecitabine) and mitomycin cures most anal squamous cancers while preserving the sphincter, so surgery is held for persistent or recurrent disease.
Abdominoperineal resection was the old primary treatment; it costs the sphincter and is now salvage after chemoradiation fails.
This is an adenocarcinoma-style approach; anal squamous cell carcinoma is treated definitively with chemoradiation.
Radiation without concurrent chemotherapy gives worse local control and colostomy-free survival in anal cancer.
A patient had a severe reaction to solvent-based paclitaxel. Which taxane can usually be given without routine corticosteroid premedication?
Re-giving the formulation that caused a severe reaction requires premedication and usually desensitization, not routine use.
Nab-paclitaxel is albumin-bound and free of the Cremophor EL solvent behind most paclitaxel hypersensitivity, so it needs no routine steroid premedication and is the usual substitute after a reaction.
Cabazitaxel also uses polysorbate 80 and requires premedication with an antihistamine, a steroid, and an H2 blocker.
Docetaxel is formulated in polysorbate 80 and is given with dexamethasone premedication for hypersensitivity and fluid retention.
A patient switching from conventional doxorubicin to pegylated liposomal doxorubicin asks how the side effects differ. The APRN explains that the liposomal form causes more:
Cardiomyopathy is lower with pegylated liposomal doxorubicin, one reason it is chosen.
Alopecia is less common with the liposomal form.
Pegylated liposomes circulate longer and concentrate drug in skin, so hand-foot syndrome and stomatitis become dose-limiting, while cardiotoxicity and hair loss are lower.
Hemorrhagic cystitis is caused by ifosfamide and cyclophosphamide metabolites, not anthracyclines.
During an infusion of sacituzumab govitecan, the patient develops abdominal cramping, diaphoresis, and diarrhea. The APRN gives:
Loperamide treats the later secretory diarrhea, not the acute cholinergic reaction during infusion.
Octreotide is reserved for severe or refractory diarrhea.
Sacituzumab govitecan carries SN-38, the active metabolite of irinotecan, so it can cause an early cholinergic syndrome with cramping, sweating, and diarrhea that responds to atropine.
Diphenhydramine treats an allergic infusion reaction, which this cholinergic pattern is not.
At tumor board, a 79-year-old with resectable pancreatic head adenocarcinoma is proposed for pancreaticoduodenectomy. The patient needs help with bathing and has fallen twice this year. The APRN recommends:
Hospice referral is premature before function, goals, and treatment tolerance are assessed in a patient with resectable disease.
Falls and dependence in bathing signal frailty that performance status misses, and a geriatric assessment before a pancreaticoduodenectomy estimates surgical risk and finds deficits to address.
Neoadjuvant chemotherapy is also intensive treatment; starting it without evaluation skips the same step.
Proceeding without assessing frailty risks severe complications and functional loss in a patient who already needs help.
A patient with non-small cell lung cancer has a 2.5-cm tumor (T1c) and metastasis to a single ipsilateral mediastinal nodal station (N2a), with no distant metastasis. Under AJCC version 9 (2025), the stage is:
IIIA is where any T1N2 tumor sat in the 8th edition; version 9 moved T1N2a down to IIB, while T1N2b remains IIIA.
AJCC version 9 (2025) splits N2 into single-station N2a and multistation N2b, and a T1 tumor with N2a disease is now stage IIB.
In version 9, IIA holds T1 tumors with N1 (hilar or intrapulmonary) nodes; mediastinal N2a disease moves a T1 tumor up to IIB.
IIIB in version 9 requires more nodal or tumor burden, such as T2 with N2b or N3 disease with a small tumor.
A 62-year-old never-smoker has metastatic lung adenocarcinoma with PD-L1 TPS 80%. Broad molecular testing is pending, and the patient is clinically stable. The APRN recommends:
In a stable never-smoker with adenocarcinoma, an actionable driver is likely and predicts poor response to immunotherapy, so treatment waits for the broad molecular results.
Targeted therapy needs a confirmed EGFR mutation; empiric TKI treats a guess.
Starting chemoimmunotherapy in a stable patient trades a short wait for the risk of committing to the wrong first-line regimen.
High PD-L1 tempts immediate immunotherapy, but driver-positive tumors respond poorly, and prior checkpoint inhibitor exposure raises toxicity with a later TKI.
A patient on sunitinib for renal cell carcinoma has BP 154/96 mmHg at two visits and no symptoms. The APRN's plan is:
Discontinuation is reserved for hypertensive crisis or BP that stays uncontrolled despite treatment.
Diltiazem is also a calcium channel blocker, but it inhibits CYP3A4 and raises sunitinib levels.
VEGF-TKI hypertension is treated so the anticancer drug can continue, and a dihydropyridine calcium channel blocker such as amlodipine or an ACE inhibitor is preferred.
BP of 154/96 at two visits is stage 2 hypertension and needs treatment now, especially on a drug that keeps raising it.
A patient vomits in the parking lot before her fourth cycle of AC; nausea was poorly controlled in earlier cycles. The APRN recommends:
Escalating dexamethasone targets chemotherapy-induced emesis, not the learned trigger that starts before treatment.
Adding another serotonin antagonist does not break a conditioned response and adds QT risk.
Vomiting before the fourth cycle after poorly controlled CINV is anticipatory nausea, a conditioned response treated with lorazepam and behavioral techniques such as relaxation and systematic desensitization.
Scopolamine is for motion-related nausea and does not treat anticipatory symptoms.
A 72-year-old with metastatic colorectal cancer has anorexia and weight loss and had a deep vein thrombosis 6 months ago. Per the ASCO 2023 update on cancer cachexia, the APRN prescribes:
Megestrol improves appetite but raises thromboembolic risk, a key concern after a DVT.
Mirtazapine did not improve appetite in its randomized trial in patients with cancer, despite its use for appetite.
ASCO does not recommend dronabinol for cancer cachexia because evidence of benefit is insufficient.
The ASCO 2023 cachexia update added low-dose olanzapine, which improved appetite and weight in a randomized trial, and it avoids the clot risk of megestrol after a recent DVT.
A 30-year-old has facial trichilemmomas, macrocephaly and a multinodular goiter. Which germline gene does the APRN test?
STK11 causes Peutz-Jeghers syndrome, recognized by lip and buccal pigmentation and hamartomatous GI polyps.
Trichilemmomas, macrocephaly, and multinodular goiter are major features of Cowden syndrome, caused by germline PTEN variants, with raised breast, thyroid, endometrial, colorectal, and kidney cancer risk.
RET causes MEN2 with medullary thyroid cancer from C cells; the thyroid finding here is a benign multinodular goiter.
TP53 causes Li-Fraumeni syndrome, with early sarcomas, breast and brain cancers, and no characteristic skin lesions.
A 30-year-old has bilateral renal cysts and a solid renal mass, a retinal hemangioblastoma, and a father who had kidney cancer at 45. Which syndrome does the APRN suspect?
Birt-Hogg-Dubé causes renal tumors with lung cysts, spontaneous pneumothorax, and fibrofolliculomas, not retinal hemangioblastomas.
Tuberous sclerosis causes renal angiomyolipomas with skin, brain, and heart lesions, not hemangioblastomas with clear-cell renal cancer.
Hereditary leiomyomatosis causes skin and uterine leiomyomas with an aggressive papillary-type renal cancer, usually a single lesion.
Retinal hemangioblastoma with bilateral renal cysts and a solid renal mass, plus a parent with early kidney cancer, is classic von Hippel-Lindau syndrome, which also causes CNS hemangioblastomas and pheochromocytoma.
A 29-year-old woman who completed ABVD for Hodgkin lymphoma avoids dating because she assumes she can no longer have children. The APRN explains that:
ABVD's only alkylating agent, dacarbazine, is weakly gonadotoxic, so ABVD carries a low risk of lasting infertility; most women keep regular cycles, unlike after escalated BEACOPP.
Advice to delay pregnancy after lymphoma treatment is measured in months to a couple of years for relapse risk, not a decade.
Permanent ovarian failure is a risk of regimens heavy in cyclophosphamide and procarbazine, such as escalated BEACOPP, not ABVD.
Ovarian reserve can be estimated with AMH and antral follicle count once treatment ends.
A 38-year-old Ashkenazi Jewish woman tests negative on a 3-site BRCA founder panel. Her paternal aunt had breast cancer at 45 and ovarian cancer at 55 and is deceased, never tested. The APRN recommends:
Treating a founder panel as a full test is the error; it looks for three variants and misses the rest of BRCA1/2 and other genes.
Ovarian cancer screening with CA-125 and ultrasound has not reduced mortality and does not clarify her genetic risk.
A negative 3-site founder panel lowers but does not exclude hereditary risk when the family history is this strong; non-founder BRCA variants and other genes such as PALB2 or the Lynch genes remain possible.
Germline results do not change with time; repeating the same limited test adds nothing.
A patient receiving durvalumab after chemoradiation for NSCLC has new dyspnea, dry cough, and SpO₂ 88% on room air. To evaluate for immune-related pneumonitis, the APRN orders first:
Chest CT is the first test for suspected checkpoint inhibitor pneumonitis; it shows ground-glass or organizing patterns that plain films miss and can be done as a CT angiogram to exclude PE.
Bronchoscopy with lavage follows imaging when infection must be excluded; it is not the first test.
Pulmonary function testing helps track recovery but does not establish the diagnosis in a hypoxemic patient.
A V/Q scan evaluates only embolism and does not show parenchymal pneumonitis.
A patient with Hodgkin lymphoma is starting ABVD. To reduce the risk of bleomycin's idiosyncratic fever-hypotension reaction, the APRN orders:
H2 blockade belongs to hypersensitivity premedication; this reaction is not IgE-mediated.
Reducing every dose lowers efficacy without preventing the idiosyncratic first-dose reaction.
Lymphoma patients have a small risk of an acute idiosyncratic reaction to bleomycin with fever, hypotension, and confusion, so the label calls for 2 units or less for the first doses, with observation before full dosing.
Prolonged infusion does not prevent the reaction and is not how bleomycin is given in ABVD.
A patient with AML and WBC 190,000/mm³ is comfortable. Arterial PaO₂ is 48 mmHg, but pulse oximetry reads 97%. The APRN recognizes:
Very high blast counts keep consuming oxygen in the blood gas syringe, falsely lowering PaO₂; normal oximetry and comfortable breathing confirm the artifact, which an iced, promptly analyzed sample corrects.
Pulmonary leukostasis causes real respiratory distress and a low SpO₂, neither of which this patient has.
Methemoglobinemia produces the reverse pattern, a low SpO₂ with a normal PaO₂.
Blaming the oximeter assumes the blood gas is right; in hyperleukocytosis it is the PaO₂ that is falsely low.
A 45-year-old patient who lives 200 miles from the cancer center needs 6 weeks of daily radiation and cannot afford a hotel. The APRN refers the patient to:
Hospice respite beds give caregivers short breaks for hospice patients, not housing for outpatient treatment.
Area Agencies on Aging coordinate services in the patient's home community and do not provide lodging at the treatment center.
Ronald McDonald Houses serve families of children receiving care.
American Cancer Society Hope Lodge communities give adult patients and a caregiver free lodging near treatment centers, which fits weeks of daily radiation far from home.
A 42-year-old man whose father and brother had prostate cancer at 58 and 61 asks about screening. Following ACS guidance, the APRN:
ACS advises starting the PSA discussion at 40 for men with more than one first-degree relative diagnosed before 65, which fits a father and brother diagnosed at 58 and 61.
Age 55 is the start of the USPSTF average-risk range; family history moves the conversation much earlier.
Age 50 is the ACS starting point for average-risk men; it ignores two affected first-degree relatives.
Prostate MRI follows an elevated PSA to guide biopsy; it is not a first-line screening test.
A single-center, unblinded RCT (n = 78) of acupuncture for chemotherapy-induced neuropathic pain found a 0.9-point greater pain reduction on a 10-point scale (95% CI 0.05–1.75, p = 0.04). The APRN counsels that the trial shows:
Lack of blinding weakens confidence in a subjective outcome but does not by itself cancel a statistically significant result.
A p value says the result is unlikely to be chance, not how big it is; 0.9 points on a 10-point scale is below the change most patients notice.
Duloxetine is the agent ASCO recommends for established painful CIPN; a small, uncertain acupuncture effect does not justify replacing it.
The result is statistically significant, but a 0.9-point difference with a confidence interval reaching almost to zero, from an unblinded single-center trial, is a small and uncertain effect, so acupuncture can be offered as a low-risk option through shared decision-making.
A patient receiving bevacizumab with FOLFIRI for metastatic colon cancer develops sudden severe abdominal pain, and CT shows free intraperitoneal air. Along with surgical consultation, the APRN:
The 28-day interval applies to elective surgery and wound healing, not to a perforation.
Bevacizumab toxicity is not managed by dose reduction, and continuing it after perforation is unsafe.
GI perforation is a boxed-warning toxicity of bevacizumab, and the drug is permanently discontinued once it occurs; the chemotherapy can resume after recovery.
Holding until symptoms settle treats perforation like a reversible side effect and leaves the patient exposed to recurrence.
After 14 days of methylprednisolone 2 mg/kg/day for acute GVHD, a patient has worsening diarrhea, rising bilirubin, and spreading rash. The APRN recommends:
After 14 days with worsening gut, liver, and skin disease, more waiting only adds organ damage.
Escalating steroids adds infection and metabolic toxicity without improving response.
Progression after 3 days or no improvement after 7 days of high-dose steroids defines steroid-refractory acute GVHD, and ruxolitinib is the approved second-line therapy (REACH2).
Tapering during progression worsens GVHD; steroids are tapered only after a response.
A patient with a metastatic somatostatin-receptor–positive neuroendocrine tumor is starting lutetium-177 dotatate. With each dose, the APRN orders a concurrent infusion of:
Amifostine protects salivary glands during external beam radiation; it is not part of radioligand therapy.
Mannitol is an osmotic diuretic used with cisplatin or for raised ICP, not to protect the kidneys from radioligand therapy.
Bicarbonate alkalinizes urine for methotrexate clearance; it does not block tubular uptake of the radioligand.
Lutetium-177 dotatate is reabsorbed in the proximal tubules, and a concurrent infusion of lysine and arginine blocks that uptake and lowers the kidney radiation dose.
A 68-year-old with diabetes, baseline peripheral neuropathy, and creatinine clearance 48 mL/min will receive a platinum doublet for advanced NSCLC. The APRN recommends:
Hydration reduces cisplatin nephrotoxicity in eligible patients but does not make it safe with reduced clearance and neuropathy.
Duloxetine treats painful established CIPN and is not recommended for prevention.
Cisplatin is nephrotoxic and neurotoxic, so with a creatinine clearance under 60 mL/min and pre-existing neuropathy, carboplatin dosed by the Calvert formula is the safer platinum with similar efficacy in advanced NSCLC.
Magnesium replacement corrects cisplatin-induced wasting but does not prevent kidney or nerve injury.
A 55-year-old's colonoscopy yields 6 SSLs proximal to the rectum, each at least 5 mm and two of them over 10 mm. The APRN recognizes:
Five or more serrated lesions proximal to the rectum, all at least 5 mm with two or more at least 10 mm, meet the WHO 2019 criteria for serrated polyposis syndrome, which calls for short-interval colonoscopy.
Juvenile polyposis causes hamartomatous polyps, often presenting with bleeding in younger patients.
Lynch syndrome causes few, rapidly progressing adenomas and is defined by a germline mismatch repair variant, not by a polyp count.
Attenuated FAP produces adenomas, usually 10 to 100, not serrated lesions.
A 48-year-old premenopausal woman with a Gail 5-year risk of 2.8% and no history of thromboembolism chooses medication to lower her breast cancer risk. The APRN prescribes:
Raloxifene reduces invasive breast cancer risk only in postmenopausal women, so it is not an option for her.
Exemestane is also an aromatase inhibitor, a postmenopausal option for the same reason anastrozole is.
Tamoxifen is the risk-reducing drug approved for premenopausal women, and a 5-year Gail risk of 2.8% with no thromboembolic history makes its benefit likely to outweigh harm.
Aromatase inhibitors block peripheral estrogen production but not ovarian estrogen, so they are limited to postmenopausal women.
After lumpectomy and axillary dissection, pathology shows a 2.8-cm invasive ductal carcinoma with 4 of 18 lymph nodes positive, ER-positive, HER2-negative, and no distant disease. The APRN records the pathologic T and N categories as:
pT1c is limited to tumors over 1 cm and up to 2 cm, so a 2.8-cm tumor is too large.
A 2.8-cm tumor is pT2 (more than 2 cm and up to 5 cm), and 4 to 9 positive axillary nodes is pN2a.
pN1a covers 1 to 3 positive axillary nodes; four nodes moves the category up.
pN3a requires 10 or more positive axillary nodes, or infraclavicular nodes.
After upfront surgery, a 2.8-cm grade 3, ER/PR-negative, HER2 3+ breast cancer has 3 of 15 nodes positive. The APRN recommends adjuvant:
Chemotherapy without any HER2-directed agent discards its large reduction in recurrence for HER2 3+ disease.
The paclitaxel-trastuzumab regimen (APT) is for small node-negative tumors, not node-positive grade 3 disease.
T-DM1 is the adjuvant choice for residual disease after neoadjuvant therapy (KATHERINE), not after upfront surgery.
Node-positive HER2-positive breast cancer receives chemotherapy with trastuzumab plus pertuzumab (APHINITY), for example AC followed by a taxane with both antibodies.
Eight weeks into osimertinib, a patient develops new dyspnea, dry cough, and bilateral ground-glass opacities; infection is excluded. The APRN:
Erlotinib is another EGFR TKI with the same class risk of ILD and is less effective.
Dose reduction is used for some osimertinib toxicities, but confirmed ILD requires permanent discontinuation.
Interstitial lung disease from osimertinib is potentially fatal; once infection is excluded, the drug is permanently discontinued and corticosteroids are given.
Infection has been excluded, and antibiotics do not treat drug-induced pneumonitis while continuing the drug keeps the injury going.
A 62-year-old smoker has proximal leg weakness that improves briefly with repeated effort, dry mouth, and reduced reflexes. The APRN orders:
Anti-Hu antibodies cause paraneoplastic sensory neuronopathy or encephalitis, not facilitating proximal weakness with autonomic signs.
Proximal weakness that improves briefly with effort, dry mouth, and reduced reflexes in a smoker is Lambert-Eaton syndrome, confirmed with P/Q-type VGCC antibodies and followed by a search for small cell lung cancer.
Myasthenia gravis worsens with repeated effort, favors ocular muscles, and keeps reflexes, the opposite pattern.
CK rises in myositis, which causes weakness without improvement on repeated effort and without dry mouth.
A patient progresses on osimertinib for EGFR-mutant NSCLC. Rebiopsy shows no new targetable alteration and no small cell transformation. The APRN anticipates next treatment with:
First-generation TKIs do not overcome typical osimertinib resistance.
After osimertinib failure without a targetable resistance mechanism, platinum-pemetrexed is the backbone, and adding amivantamab, an EGFR-MET bispecific antibody, improved progression-free survival in MARIPOSA-2.
Adding pembrolizumab to chemotherapy after EGFR TKI failure did not improve survival in KEYNOTE-789, unlike in driver-negative disease.
Dose escalation does not restore control once resistance has developed.
A patient with newly diagnosed metastatic lung adenocarcinoma has declining performance status and little biopsy tissue left. First-line therapy depends on biomarker results within about a week. The APRN orders:
Comprehensive tissue NGS is ideal, but a 3-week turnaround does not fit a patient whose performance status is declining.
Plasma ctDNA sequencing covers the actionable drivers in about a week without using scarce tissue; a positive result guides first-line therapy and a negative one is followed by tissue testing.
Single-gene testing uses up the remaining tissue and misses ALK, ROS1, BRAF, MET, RET, and other drivers.
Serum tumor markers such as CEA do not identify actionable drivers and cannot guide first-line therapy.
Tumor next-generation sequencing in a 52-year-old man with metastatic pancreatic adenocarcinoma shows a pathogenic BRCA2 variant. The APRN's next step is:
Cascade testing of relatives follows a confirmed germline result; a tumor finding may be somatic.
Ignoring the finding misses a possible hereditary syndrome and a treatment-relevant biomarker.
Olaparib is approved as maintenance after response to platinum in germline BRCA carriers, not as first-line therapy.
A BRCA2 variant on tumor sequencing may be inherited, and NCCN recommends germline testing for everyone with pancreatic adenocarcinoma; the result guides platinum use, olaparib maintenance, and family testing.
A woman who completed doxorubicin, cyclophosphamide, trastuzumab, and left chest wall radiation 18 months ago reports new exertional dyspnea and bilateral ankle edema. The APRN first orders:
Radiation can injure the lung, but pulmonary disease does not explain bilateral ankle edema.
Anthracycline, trastuzumab, and left-sided chest radiation all add to cardiomyopathy risk, and exertional dyspnea with bilateral edema suggests heart failure, so LVEF is measured first.
Tumor markers are not used to evaluate new symptoms in early breast cancer survivors and would not explain heart failure.
Restaging for recurrence comes after the likely cardiac cause is evaluated.
A 44-year-old treated for endometrial cancer is found to carry a pathogenic MLH1 variant (Lynch syndrome). Per NCCN, her colorectal cancer surveillance is colonoscopy:
Stool testing is not adequate surveillance for hereditary colorectal cancer syndromes; colonoscopy is required.
Carriers of MLH1 (and MSH2) variants develop colorectal cancer young and fast, so NCCN advises colonoscopy every 1–2 years, starting at 20–25.
Ten years is the average-risk screening interval and far too long for a mismatch repair carrier.
A 3–5-year interval fits some post-polypectomy surveillance; in Lynch carriers, interval cancers occur at that spacing.
A patient with metastatic prostate cancer has 2 weeks of worsening thoracic back pain and new leg weakness. After dexamethasone is given, the APRN orders:
Plain films miss early vertebral metastases and never show the spinal canal, so normal films do not exclude cord compression.
Epidural metastases are often multilevel, so the whole spine is imaged with MRI; finding a second, silent level of compression changes the radiation fields and the surgical plan.
A bone scan shows skeletal metastases but not the epidural tumor or the cord, so it cannot confirm or exclude compression.
Imaging only the painful segment is the classic shortcut; it misses noncontiguous compression elsewhere, which is common in metastatic disease.
A woman with weeks to live from metastatic pancreatic cancer says her life now feels meaningless and worries that her grandchildren will not remember who she was. Depression screening is negative. The APRN offers:
Palliative sedation is reserved for refractory physical symptoms at the very end of life, not for existential distress in an alert patient who wants to talk.
Long-term insight-oriented therapy does not fit a prognosis of weeks; brief, meaning-focused work does.
Dignity therapy is a brief bedside intervention near the end of life: the patient's recorded reflections become a written legacy document, which addresses loss of meaning and the worry about being remembered.
Depression screening is negative, and an SSRI takes weeks to act; treating existential distress as depression medicalizes it.
A patient with refractory metastatic colon cancer is consenting to a phase I trial of a new agent and says, "This drug is going to shrink my tumor." The APRN clarifies that the trial's primary purpose is to:
Phase I trials exist to find a safe dose and schedule and to describe toxicity; tumor shrinkage can happen but is not the goal, and correcting this therapeutic misconception is part of valid informed consent.
Randomized comparison with standard therapy is the design of phase III trials, which come after safety and activity are established.
Measuring tumor response rate is the primary aim of phase II trials; in phase I it is recorded only as a secondary observation.
Long-term effectiveness and rare harms are studied after approval, in phase IV post-marketing studies.
A running total sits here; it fills in after your last pick.
What your score can and cannot tell you
Your actual result will be scaled, and the board gives no table converting percent correct into it, so treat a practice percentage as a rough signal only. Group the questions you missed by area, then study that area's page. Misses spread thinly across every area suggest pacing or reading errors; misses bunched in one area suggest a content gap worth a week.
ONCC's own practice tests
The board offers a free 50-question ONCC practice test and a paid 100-question test, each with 14 days of access (practice tests). The free one shows the same 50 items in a new order each time, so a second run tests memory; the paid one draws 100 at random from a larger pool on each use.
Pacing for 165 questions
The 3 h of seat time include a tutorial and a survey, which leaves about a minute per question. No breaks are scheduled, and any break you take is counted against the session.