The Role of Germline Testing in Prostate Cancer

In recent years, germline testing in prostate cancer has grown in significance. How does it play a role in improving cancer detection? And, can it affect treatment plans?

During the 2019 Prostate Cancer Consensus Conference: Implementation of Genetic Testing for Inherited Prostate Cancer, Dr. Thomas J. Polascik, a urologic oncologist at Duke University in Durham, North Carolina, spoke with CURE® about the considerations for germline testing in this disease space.

CURE®: Can you give a brief overview of your presentation?

Polascik: I overviewed some of the screening trials for genetics and, most importantly, how we’ve developed a PSA screening initiative for prostate cancer at our university. This is an algorithm that was developed in a multidisciplinary fashion based upon best available evidence and then we deployed it in a system wide manner throughout the health system.

There are three clinical trials, PROFILE, IMPACT AND BARCODE 1, ongoing. Is there anything that you would like to talk about regarding these?

One of the interesting facts with these protocols is how does one know if there is cancer or not cancer? And the question was asked during a discussion section about perhaps getting a biopsy in all men. One of the downsides of the IMPACT trial was that not all men were biopsied either with PSAs above 3 or at end of study because it was optional. But (with) some of these newer trials coming up now, biopsies are going to be mandated.

What are the main considerations for germline testing in prostate cancer?

We look at men with high risk disease, if they have high Gleason scores, metastatic disease or locally advanced disease or those who have a known genetic aberration that runs in the family.

What do you identify as unmet needs that still need to be addressed in this space?

There are several. We don’t really know what all the implications are for these genetic abnormalities. Some lead to potential treatment. Others at this point we have no idea — we’re just gathering data. I think from an institutional point of view, it’s very interesting how people will put this all together. They’re going to have to figure out at their institution how to make it work. There are a lot of moving parts. It’s a collaborative effort. We work very tightly with primary care and you have to devise a system that works for everyone, and specifically you have to respect physicians time because time is short. These clinic visits are very tight and there’s a lot of things that need to get accomplished. And it’s not just about prostate cancer.

Where do you see the future of prostate cancer, specifically in genetic testing, changing?

I think that a lot of things may just be patient driven. Just like a lot of the pharma companies now do direct marketing to patients, so patients are going to hear about 23andMe. Then they’re going to get these tests done and come into the physician’s office and say, “Hey, what does this mean? What’s my risk? And what should I do?” I think a lot of this will be driven on the consumer end of things.

Is there anything else that you would like to add?

I think that as medicine gets more complicated you have to bring in teams. You need different people’s expertise and help. Clinicians have time constraints and limited time to talk with patients about a lot of issues. So maybe the best solution is to send people, for example, to genetics counseling where they have more time to spend on some of these issues or other specialists in that regard, and this way, in terms of the patient experience, they get a very broad view and can interact with many different professionals with different levels of expertise.