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Gene Testing Criteria in Prostate Cancer
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Angelo A. Baccala Jr., MD: Getting family history is really important, and doing genetic and hereditary cancer testing is predicated upon who is a good candidate. What do you guys do at Michigan Institute of Urology to assess if a patient is a candidate for that?
Jason M. Hafron, MD: Genetic testing starts with a family history. We’ve overlooked this in the past, but we really need to take an accurate family history, for any history of prostate cancer. Within the family, any history of ovarian cancer, colon cancer, ovarian cancer, or pancreatic cancer when you deal with the HBOCs [hereditary breast and ovarian cancers] is also very important. But what’s interesting—and I’m curious, Angelo, you run a large health group and have a big leadership position within your organization—is that we’re seeing with recent approvals that you potentially, similar to what they do in breast cancer, can screen the patients regardless of family history, regardless of Gleason grade, regardless of stage of disease, with BRCA1 and BRCA2 testing—that’s something we started in our practice just recently. This is evolving, and we’re getting the wheels in motion. We have agreed in principle—we’re getting it set up so anyone diagnosed with cancer, regardless of family history, is going to be screened for BRCA1 and BRCA2 cancer. I’m just curious where you guys are at Lehigh with this.
Angelo A. Baccala Jr., MD: That’s a great point. We are right in line with that. We have already started that process. For anyone who has prostate cancer, it’s part of our follow-up. If they’re diagnosed, when they get that discussion of being told that they are, and because it’s now FDA approved to have BRCA1 and BRCA2 testing, we automatically do it for every patient. What’s interesting is we know that for patients with prostate cancer in general, 17% of the metastatic and high-risk and very high-risk patients are going to have germline mutations, but 37% of them are going to meet criteria. When we do germline testing, it’s important to get that history because almost 40% are going to meet criteria for testing, and knowing that information is going to be important. But to your point, we can even jump that and say, “You have prostate cancer. We’re going to go ahead and test you for at least these 2 genes that we know are extremely important.” There’s a lot of downstream effect—which we’ll talk about later—things that are coming out with BRCA1 and BRCA2 for our prostate cancer patients that we can use. Knowing that information is huge. So that’s extremely important, for sure.
Jason M. Hafron, MD: Angelo, we’re similar. I’m part of a large LUGPA [Large Urology Group Practice Association] group, with 55 urologists, and we’ve implemented that plan. But I don’t know if you’ve had this experience where you get pushback from genetic counselors that the urologists shouldn’t be doing this, and I think part of that as we’ve evolved is pregenetic counseling. How do you respond to those criticisms or challenges? Because we’re doing it, how do you do it with that pregenetic counseling when you’re ordering these tests? What do you tell your patients when you’re ordering the germline testing?
Angelo A. Baccala Jr., MD: We partnered with our genetic counselors because, to your point, I think that’s an important aspect. We’re not there to cut them out. We’re there to include this and make this a better experience for our patients. That’s the part that’s oftentimes misunderstood by genetic counselors. Genetic counselors in most facilities are overwhelmed. There’s a lot going on, a lot going on with our cancer institute, so there’s a lot for them to deal with. For us, as these patients come through the door, the FDA approval part of this has been huge because we’ve been able to stand behind that and say, “This is something we should be doing for our patients,” and they understand that. We do have some counseling with the patient. We discuss the importance—like we’re doing right now—of hereditary testing and why it’s important for them in the future. But if they do get a positive result, we work with our genetic counselors to talk about that result with them. Certainly, they’re trained to do that type of thing. As urologists, we’re not. But getting to those patients, we have better access to them at that point because we’ve been able to diagnose them. We’re following these folks, vs getting them to a genetic counselor where, even if you make the referral, just because of timing and their availability, we may lose a percentage of the patients, and that would really be a shame.
Jason M. Hafron, MD: I feel the same way. The patients are in our office. It’s usually a simple blood test, and as urologists, we’re very familiar with consenting patients. We can tell them the risks, the benefits, and why we do that. But your point about if it is a positive test, if it is a VUS [variants of uncertain significance] or a high-risk negative, that’s an automatic referral to the genetic counselor. It’s similar to when you’re screening someone for kidney cancer or whatever, and you order a chest x-ray and the guy has a lung mass. It’s not like we’re experts in lung masses. We’re going to refer that patient out, but we’ll still screen that patient for a lung mass, and I’m totally comfortable with it. To your point, we don’t have genetic counselors—I’m in a different environment from you on staff—but we work with them. We told them what we’re doing—we’re going to be screening patients—and at first they were a little hesitant, but at the end of the day, they don’t have the bandwidth to do all this screening. The key is that these patients are appropriately screened, offered germline testing, and then the positives, the questions, the high-risk negatives, and the VUSs all should be referred to genetic counselors. I’m not trained and you’re not trained, but the genetic counselors can help with that. That’s true cancer care. It’s comprehensive cancer care to offer those services to our patients.
