Optimizing Management of mHSPC: Multimodality Care and Genetic Testing


A brief review of the respective roles of multidisciplinary care and genetic testing in patients diagnosed with metastatic hormone-sensitive prostate cancer.


Evan Y. Yu, MD: I don't know if you have a multi-disciplinary clinic or not, but it would be great if you could describe that. What suggestions do you have for providers in the community as there's increasing data for a multi-disciplinary team approach.

Andrew J. Armstrong, MD, MSc: Thank you. Particularly during COVID, it's been challenging to bring people together in person. What we've done is we have 3 virtual tumor boards now per month. One is a more formal presentation put on by the fellows with some teaching points and CME type presentations. Two are practical where we run through all the tough cases. We try to arrive at consensus from both a pathology radiology but also the treating doctors, the urologists, radiation and medical oncologists who arrive at consensus. In a case like this, we would discuss treatment of the primaries in addition to either triple therapy or double therapy. Certainly, it's no longer standard of care to offer ADT [androgen deprivation therapy] to a patient like this. As long as you're intensifying therapy you're providing strong survival benefits to this patient. Radiation to the primary would be part of that discussion.

Pedro C. Barata, MD, MSc: If I may, this is great so far. Thank you for that. As Evan is asking, how do we approach a patient like this. One of the other things perhaps we've considered this time is genetic testing. I'm referring to of course, for 2 types, germline and somatic. Often for patients who present are newly diagnosed and oftentimes we can biopsy the prostate. He will have tissue available. That's the somatic piece. When it's not available, we still do for treatment of naïve patients we can do weakened biopsy if you will. Then the second piece is the germline. The reason why that's important to do it up front is 2-fold. Number 1, he helps us to understand what genes we were born with, and whether there's alteration you can act on with time. It's called cascade testing. For patients who present with BRCA, for instance, germline BRCA, we can go after the family. We have time. We know these therapies are very effective. We are probably going to control the disease. We can work on the family from that perspective and then of course, opens the door for us to think ahead. As we start planning and sequencing these treatments, because unfortunately we cannot cure this patient population. We can start thinking ahead what kind of therapies we can consider when at that point of progression. Doing the genetic testing is something I do consider and at this point it's included in the guidelines. I like that as a point-at some point when we're seeing these patients who present with metastatic or disease to think about genetic testing.

Evan Y. Yu, MD: Thanks for bringing that up. It's an important point. I do and I'm guessing everybody here does germline testing for metastatic prostate cancer upon presentation. I always remind the patients, just like what you said, there's really 2 reasons to do it. One, is the data might help guide your treatment down the road. Certainly, could provide prognostic information but also treatment information down the road but also for your family members and loved ones. If you test positive and they go get tested and they're positive, their doctors might do cancer screening for them very differently. Not just prostate cancer, but breast, ovarian, pancreatic cancer. A lot of different cancers. Our goal with all this is to save a lot of lives down the road. I think it's super important and I'm grateful that you brought that up.

Transcript edited for clarity.

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