Germline Testing and Genomic Classifiers in Prostate Cancer

The panelists recommend germline and somatic testing for every patient with metastatic prostate cancer and germline testing for more aggressive localized disease, where results primarily inform cascade testing of relatives rather than treatment. They acknowledge ongoing disagreement over testing lower-risk patients and stress a detailed family history of breast, ovarian, and pancreatic cancers and melanoma. The conversation then turns to RNA-based genomic classifiers, which estimate risk of metastasis and cancer-specific mortality but cannot detect BRCA2 or other targetable alterations; a low-risk score does not imply HRR proficiency. The strongest evidence for classifiers lies after prostatectomy, where higher scores support early salvage radiation plus androgen deprivation therapy, and they can help with active surveillance decisions in favorable intermediate-risk disease, but they do not change management of metastatic disease. The panelists discuss emerging data linking high-risk classifier scores to docetaxel benefit and advise prioritizing clinical features and NCCN risk groups when classifier results conflict.