Considerations for Genetic Testing in Prostate Cancer

Transcript: Judd Moul, MD: We have to move on to the final section and future trends. We have a few minutes to perhaps discuss the PARP [poly ADP ribose polymerase] inhibitors and other novel immunotherapy. I have a simple question with regard to hereditary cancer testing like BRCA1/2. Neeraj, in your practice, who do you order hereditary cancer testing on?

Neeraj Agarwal, MD: My take on this is that prostate cancer is not a lifestyle cancer. It’s a genetically predisposed cancer like ovarian cancer, breast cancer, pancreatic cancer, and maybe gastric cancer. In our clinic, every single patient with prostate cancer, regardless of the family history, is seen in what we call the genetics clinic. There are multiple ways you can define those clinics. We call it the high-risk genetics clinic.

Families fear saying something that may be unreliable for many of these patients. There is time to take a family history of the past 5 generations, which may still be unreliable. We want all of our patients to be evaluated by a genetic counselor, and then the determination of whether the patient should have germline testing is made by the genetic counselor.

This is our practice right now. Every prostate cancer patient is considered to be possibly carrying the hereditary risk factors unless proven otherwise.

Judd Moul, MD: Alicia?

Alicia Morgans, MD, MPH: I think that many medical oncology practices are taking that approach. In our practice, we’re following the updated NCCN [National Comprehensive Cancer Network] guidelines, which I think have embraced conversations with the genetic counselor and genetic testing. In the metastatic population, family history is not necessarily going to be associated with your risk of these DNA repair defects or other potentially actionable mutations. All metastatic patients are recommended to consider genetic counseling, and whether they get to a counselor or not, to consider having that conversation.

Judd Moul, MD: In your practice, you have 2 varieties. You have the guy who shows up de novo with metastatic disease. He should be tested. What about the guys who have already had treatment for localized disease, have never been tested, and then get to the metastatic state? Should those men be tested, too?

Alicia Morgans, MD, MPH: Yes, I would say those men should be tested, too, because it could be that we’re catching them at an earlier state when they were localized. Still, when we pull out those patients who have metastatic disease, they are enriched for having these heritable mutations. That population was included and does seem to have this higher risk. I think it’s around 11.5% of these patients who will have those mutations. In a localized setting, it is more based on family history. It’s not just based on family history of prostate cancer, but also of breast and ovarian cancer, which can run in these BRCA1/2 families, which we really need to identify. It’s more of a nuanced conversation in the localized setting, but in the metastatic setting, we try to get these patients to genetic counseling.

Judd Moul, MD: Tanya?

Tanya Dorff, MD: I have nothing to add. I think they covered it.

Judd Moul, MD: The only comment I would make is that speaking as a urologist, it’s a little more challenging, simply because we’re seeing tons of men with elevated PSA [prostate-specific antigen]. We’re seeing a lot of men with localized prostate cancer and lower-risk disease, and it’s really difficult. We obviously don’t have the bandwidth to do that testing on everybody. Quite frankly, in our institution we don’t even have the bandwidth and enough genetic counselors, or teams, to send every single metastatic prostate cancer. This is a whole new area. Up until 2 or 3 years ago, I knew nothing about BRCA. I didn’t even think it was important in prostate cancer. We have to recognize that this is so new and a lot of urologists are still struggling with what to do in this situation.

Alicia Morgans, MD, MPH: Medical oncologists are in a similar position, and there are whole groups around just trying to say, “These are strategies of implementation.” I would say this is in its infancy.

Transcript Edited for Clarity