NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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July 14th, 2026
MKSAP 19 Oncology, Question 57
A 53-year-old man is evaluated in the office following hemicolectomy for adenocarcinoma of the colon. He is otherwise healthy, has no symptoms, and takes no medications.
Physical examination is normal.
Presurgical contrast-enhanced CT scan of the chest, abdomen, and pelvis was negative for metastases.
Pathology revealed a 4-cm adenocarcinoma that was poorly differentiated and invading into the submucosa but not into the muscularis. All 17 lymph nodes sampled were negative for tumor. The tumor is staged as T2N0 (stage I). The tumor is negative for KRAS, NRAS, and BRAF mutations.
Which of the following is the most important prognostic factor?
A. Degree of tumor differentiation
B. KRAS, NRAS, and BRAF tumor mutational status
C. Performance status of patient
D. Size of the tumor
E. Stage of the tumor
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: E. Stage of the tumor
Educational Objective: Evaluate cancer prognosis.
Tumor stage (Option E) is usually the most important prognostic factor in determining a patient's outcome. All tumors are staged using the American Joint Commission on Cancer staging system. This involves the TNM system, in which the extent of the tumor (size and/or depth of penetration), nodes (number of local-regional nodes that contain cancer), and metastases (present or absent) are considered. TNM scorings are placed on a scale of stage I though IV, with stage 1 having the best prognosis and stage IV the worst.
Poorly differentiated tumors (Option A) have, in general, a worse prognosis than well-differentiated tumors; however, this too is a modest prognostic factor compared with staging.
Although molecular profiling for driver mutations in genes such as KRAS, NRAS, and BRAF (Option B) may influence prognosis and may have implications for chemotherapy selections in advanced disease, they have far less influence on outcome than tumor stage. In addition, they are not relevant in the management of stage I colon cancer, which has a very favorable prognosis and would not require further therapy after surgery.
Performance status (Option C), which is a designation of the overall medical wellness, or lack thereof, of the patient may have important prognostic implications within a particular stage of disease but is far less significant prognostically than the staging itself. It is important to differentiate patients with a poor performance status who are debilitated due to chronic comorbidities from patients who would otherwise be medically fit but are acutely debilitated by their cancer. The latter situation may warrant an attempt at aggressive treatment because reversing the cancer process is the only option that will improve the patient's overall condition, whereas the former may need to be treated with. less aggressive treatment or possibly no specific anticancer treatment.
Tumor size (Option D) may be a component of the “T” stage, but by itself, it has only modest prognostic significance relative to overall stage.
Key Point
- Staging is generally the most accurate prognostic indicator and largely dictates the therapeutic strategy for patients with cancer.
Bibliography
Daly MC, Paquette IM. Surveillance, epidemiology, and end results (SEER) and SEER-medicare databases: use in clinical research for improving colorectal cancer outcomes. Clin Colon Rectal Surg. 2019;32:61-68. PMID: 30647547 doi:10.1055/s-0038-1673355
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2026 American College of Physicians. All Rights Reserved All Rights Reserved.
June 30th, 2026
MKSAP 19 Nephrology, Question 56
A 44-year-old woman is evaluated during a follow-up visit for chronic hypertension. Over the past month, her average blood pressure measured with home blood pressure monitoring was 145/90 mm Hg. There is no family history of hypertension. She has no other medical problems. The patient adheres to a low sodium diet. Medications are maximum doses of amlodipine and lisinopril.
On physical examination, blood pressure is 148/96 mm Hg, and pulse rate is 64/min; other vital signs are normal. BMI is 26. The remainder of the examination is unremarkable.
Laboratory studies show a serum creatinine level of 0.8 mg/dL (70.7 µmol/L) and normal electrolyte levels. Urinalysis shows no blood, protein, or leukocyte esterase.
Which of the following is the most appropriate next step in management?
A. Add chlorthalidone
B. Measure plasma aldosterone concentration/plasma renin activity ratio
C. Measure plasma fractionated metanephrines
D. Obtain renal artery imaging
Responses Received from Members (631 Responses):
The Correct Answer is: A. Add chlorthalidone
Educational Objective: Treat difficult-to-control hypertension by adding a diuretic.
The most appropriate next step in management is to add chlorthalidone, a thiazide diuretic (Option A). Resistant hypertension is defined as blood pressure (BP) that remains above goal despite concurrent use of three antihypertensive agents of different classes, or BP at goal but requiring four or more medications. One of these medications must be a diuretic. Suboptimal antihypertensive therapy in patients with difficult-to-control hypertension is frequently the result of not including a diuretic agent, which ensures that extracellular volume expansion is prevented or treated.
Therefore, before a diagnosis of resistant hypertension is made or evaluation is initiated for secondary causes of hypertension, the patient should be treated with an appropriate diuretic medication, with attention to effective dose and dosing frequency. Although hydrochlorothiazide is the most commonly used thiazide diuretic, chlorthalidone has a longer half-life, which allows once-daily dosing; some evidence from trials suggests efficacy in reducing cardiovascular events.
Obtaining a plasma aldosterone concentration/plasma renin activity ratio (Option B) is not indicated at this time, as there is no clinical suspicion for primary hyperaldosteronism. Primary hyperaldosteronism should be suspected in patients with sustained hypertension of >150/100 mm Hg on three separate measurements, resistant hypertension (uncontrolled hypertension on a three-drug regimen inclusive of a diuretic), controlled blood pressure on four or more antihypertensives (one of which is a diuretic), hypertension with hypokalemia (either spontaneous or diuretic induced), hypertension and an incidentally discovered adrenal mass, or a family history of early-onset hypertension or stroke at age <40 years. If adding a diuretic does not lead to improved blood pressure control, a subsequent work-up for primary hyperaldosteronism would be appropriate.
Testing for plasma fractionated metanephrines (Option C), which screens for a pheochromocytoma, is not indicated. The following characteristics raise clinical suspicion for pheochromocytoma: resistant hypertension; new-onset hypertension or onset at a young age; paroxysmal hypertension; episodic tachycardia, headaches, and sweating; history of familial syndromes; adrenal adenoma found incidentally on imaging with or without hypertension; or pressor response during invasive procedures or anesthesia. The patient has none of these indications for testing.
Obtaining renal artery imaging (Option D) is not indicated, as there is no clinical suspicion for renal artery stenosis, which includes the onset of severe hypertension in patients >55 years of age, recurrent flash pulmonary edema, refractory heart failure, or acute kidney injury after initiation of an ACE inhibitor or angiotensin receptor blocker.
Key Point
- Resistant hypertension is blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, or blood pressure at goal but requiring four or more medications; one of these medications must be a diuretic.
Bibliography
Braam B, Taler SJ, Rahman M, et al. Recognition and management of resistant hypertension. Clin J Am Soc Nephrol. 2017;12:524-535. PMID: 27895136 doi:10.2215/CJN.06180616
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2025 American College of Physicians. All Rights Reserved All Rights Reserved.