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The role and place of genetic testing in prostate cancer


Our GU CONNECT experts, Dr Daniel Keizman (Israel), Prof Gert Attard (UK), Dr Neal Shore (USA), Dr Elena Castro (Spain) and Dr Roberto Iacovelli (Italy) provide their thoughts and opinions on the challenging topic of the role and place of genetic testing in prostate cancer.


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Hello, I’m Daniel Keizman, on behalf of GU CONNECT.


We’re going to talk today about the challenging topic, for which there are various opinions which is the role and place of genetic testing in prostate cancer.


Let’s hear the opinion of our experts.


Professor Gert Attard, Medical Oncologist, University College London, UK


When should we perform genetic testing for a metastatic prostate cancer patient? So the rule, when the test is going to inform on a treatment change that the patient has access to, key now is testing for BRCA status in metastatic CRPC progressing on abiraterone or enzalutamide to access PARP inhibitors, but I guess that, as with every good rule, there are exceptions.


In JCO Precision Oncology we published a paper showing that the success rate for a tumour biopsy younger than 8-months old was 92% for targeted NGS but an archival historic sample has a success rate of less than 70%.


So the sooner we perhaps see a patient, the higher the success rate and will genetic information inform on follow-up interval, access to clinical trials, the search for access to expensive drugs? So my view keep genetic testing in mind all the time but ensure you have that information when the patient requires a treatment change.


Dr Neal Shore, Urologist, Carolina Urologic Research Center, USA


So I love this question when should you begin genetic testing. I start germline testing in all of my patients who have high-risk localised disease, metastatic disease, whether de novo or recurrent, and any patient who has a significant family history.


Additionally I do somatic testing in all of my patients with metastatic disease. Some recommendations say wait till their mCRPC but I like getting somatic testing, preferably tissue-based but I’ll also do liquid, for patients that I find additional indications of genetic alterations for approved indications for example now with PARP inhibitors or even checkpoint inhibitors for MSI high as well as TMB high but there’s, in the US, 14 different gene alterations that we can interrogate. The most prominent one being BRCA2.


So that’s my plea for all my colleagues to think about doing genetic testing, to do the right genomic profiling. We have approved indications, we have clinical trials. More gene alterations will come to the surface of our understanding especially with some of the variants of uncertain significance right now. So please test, please think about it. We have indications, clinical trials. Thank you very much.


Dr Elena Castro, Medical Oncologist, Malaga Biomedical Research Institute, Spain


When should we consider genetic testing for patients with advanced prostate cancer? Well now that we have PARP inhibitors available for patients with metastatic castration-resistant prostate cancer, whose disease has progressed to an androgen receptor signalling inhibitor, we should perform tumour testing in all patients who are eligible for a second-line of therapy if we have not performed these tests before, in order to identify the presence of an alteration in BRCA1 or BRCA2 that may predict response to these therapies.


Besides we should also offer germline testing to all patients with metastatic prostate cancer because about 10% of them will carry an inherited mutation in a cancer pre-disposition gene. BRCA2 is the most frequently altered gene and carriers can also benefit from PARP inhibitors. But equally important, this finding will trigger cascade testing and the relatives at-risk could benefit from early detection programs.


Dr Roberto Iacovelli, Medical Oncologist, Fondazione Policlinico Gemelli IRCCS, Rome, Italy


About the question of this newsletter. I generally perform genetic tests for BRCA1 or BRCA2 mutations during second-line of therapy for castration-resistant disease in order to have this result available for the choice of third line of therapy. I test my patient for somatic mutation and eventually for germline mutation.


And another important point in my clinical practice is that the majority of patients have no good quality tumour tissue for this analysis or enough tumour tissue for this analysis. Then when it is possible I try to perform a new tumour biopsy.


Finally my message for you is test your patient during second-line and if it’s possible perform a new tumour biopsy.


Dr Daniel Keizman, Medical Oncologist, Tel Aviv Sourasky Medical Center, Israel


Thank you to the experts regarding their opinion. My personal opinion is that I consider genetic testing of the tumour in various stages.


In early prostate cancer in patients that I consider active surveillance I would try and see if I can do a genetic test to better risk stratify the patient and then when you have a patient after radical prostatectomy where genetic tests might try to help us see whether the patient should get adjuvant radiation therapy if he has negative predictive factors. Then if we have a patient with a biochemical failure, rising PSA after surgery we have genetic testing to try and see what’s the risk and the potential benefit of salvage therapy like radiation therapy.


And finally in patients with metastatic castration-resistant prostate cancer, we do genetic tests to see if, for example, we have a mutation in the BRCA or other DNA repair gene so that we can give the patient targeted therapies like PARP inhibitors.


Thank you very much to our experts and to you for listening today. I’m Daniel Keizman, from GU CONNECT.

Dr Elena Castro is a Consultant Medical Oncologist at Hospital Universitario 12 de Octubre in Madrid, Spain.  She treats patients with advanced bladder and prostate cancer, most of them within the context of clinical trials. She studied medicine and obtained a PhD from the University of Salamanca, Spain.  After training in medical oncology, she completed a four-year fellowship in Cancer Genetics at the Institute of Cancer Research, UK.   Later, she joined the Spanish National Cancer Research Center as a clinician-scientist.  Her research has focused on addressing the clinical implications of genetic and genomic variants in prostate cancer, receiving several awards for her work. She has also authored numerous articles published in international peer-reviewed journals including some relevant papers on the impact of germline variants in prostate cancer.   

Dr Elena Castro has received financial support/sponsorship for research support, consultation, or speaker fees from the following companies:

AstraZeneca, Bayer, Janssen, MSD, Novartis, Pfizer, Synlab and Telix. 

Neal D. Shore, MD, FACS is the Medical Director for the Carolina Urologic Research Center. He practices with Atlantic Urology Clinics in Myrtle Beach, South Carolina. Dr Shore has conducted more than 350 clinical trials, focusing mainly on GU Oncology, and serves on the Executive Boards of: Society of Urologic Oncology Board, Bladder Cancer Advocacy Network, and is Immediate Past President, Large Urology Group Practice Association. He is a founder for both: CUSP Clinical Trials Consortium, as well as for DASHKO, large urology practices data registries. He serves as the National Urology Research Director for 21st Century Oncology. He has served on the AUA Male Health Committee and the AUA Data Committee, the SITC Task Force for Prostate Cancer, the Bladder Cancer Advocacy Think Tank and the editorial boards of Reviews in Urology, Urology Times, Chemotherapy Advisor, OncLive, PLOS ONE(Academic Editor), Urology Practice, World Journal of Urology, and serves as Editor, Everyday Urology-Oncology. He has more than 200 peer reviewed publications and numerous book chapters; he performs peer review for Lancet Oncology, New England Journal of Medicine, European Urology, Journal Urology, Urology, BJUI, PCPD, and numerous other high impact scientific journals. A graduate of Duke University and Duke University Medical School, Dr Shore completed a 6-month clinical research fellowship in Pretoria, South Africa, and then completed his General Surgery/Urology training at New York Hospital Cornell Medical Center and at Memorial Sloan-Kettering Cancer Center in New York City. He is a Fellow of the American College of Surgeons.

Dr Neal D. Shore has received financial support/sponsorship for research support, consultation, or speaker fees from the following companies:

Abbvie, Astellas, Amgen, AstraZeneca, Bayer, BMS, Boston Scientific, Clarity, Clovis Oncology, Cold Genesys, Dendreon, Exact Imaging, Exact Sciences, FerGene, Foundation Medicine, Genesis Care, Invitae, Janssen, Lantheus, Lilly, MDxhealth, Merck, Myovant, Myriad, Nymox, Pacific Edge, Pfizer, Phosphorous, Photocure, Propella, PreView, Sanofi Genzyme, Sema4, Speciality Networks, Sesen Bio, Telix, Tempus, Tolmar and Urogen, Vaxiion.

Dr Keizman is an expert in Genitourinary Oncology, particularly in prostate, bladder, kidney and testicular cancer; and at present serves as the head of the Genitourinary Oncology service at Meir Medical Center, Israel. He graduated from The Sackler Faculty of Medicine, Tel Aviv University, and then completed his residency in Internal Medicine (at the Tel-Aviv Medical Center), Medical Oncology (at the Tel-Aviv Medical Center) and a Post Doctoral Clinical Fellowship in Genitourinary Oncology at the John Hopkins Hospital, Kimmel Cancer Center, Baltimore, USA. He is the author of numerous studies and review articles published in medical journals, and a reviewer of numerous medical journals. He presented numerous studies in international meetings. His current research activity focuses on genitourinary oncology.

Prof. Attard is a Cancer Research UK Clinician Scientist and Team Leader at The Institute of Cancer Research and an Honorary Medical Oncology Consultant at the Royal Marsden NHS Foundation Trust, London, UK. He graduated with a degree in Medicine from the University of Malta in June 1999 and obtained a PhD in Medicine from the University of London (ICR) in 2010. His main research interest is dissecting treatment resistance, currently with a focus on plasma DNA analysis, in order to inform on the development of novel therapeutics and biomarkers for castration-resistant prostate cancer (CRPC). He is an experienced clinical trialist in CRPC and a co-author of more than 100 peer-reviewed manuscripts, including several important papers on advanced prostate cancer. Prof. Attard’s many awards over the years include the ASCO Foundation Annual Merit Award in 2007, Prostate Cancer Foundation Young Investor Award in 2008, the AACR-GlaxoSmithKline Outstanding Clinical Scholar Award in 2009, the Medical Research Society/Academy of Medical Sciences Sue McCarthy Prize in 2010 and the McElwain award in 2010. Prof. Attard sits on a number of advisory boards and the editorial board of Annals of Oncology.

Prof. Gerhardt Attard has received financial support/sponsorship for research support, consultation, or speaker fees from the following companies:

Astellas, AstraZeneca, Bayer,  Janssen, Novartis and Pfizer. 

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