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Prostate Ca Q&A
Nurse Expert Answers to APP Questions on Prostate Cancer

Released: May 18, 2023

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Key Takeaways
  • Refer patients for genetic testing and counseling.
  • Genetic testing looks for mutations that affect relatives’ risk of cancer as well as patient eligibility for PARP inhibitors.

In this commentary adapted from a live presentation on poly (ADP-ribose) polymerase (PARP) inhibitors in prostate cancer, Frank dela Rama, RN, MS, AOCNS, AGN-BC, answers questions from advanced practice providers (APPs) on genetic testing, tissue sampling, treatment selection for localized disease, and PSMA scans.

In your experience, what is the biggest barrier to patients getting genetic testing?
Sometimes it is just not knowing—and that includes healthcare providers. At my institution, we have trained our colleagues in primary care to keep an eye out for patients with a family or personal history of cancers of the breast, prostate, etc.

It is also critical for providers to have a genetics professional who is accessible; when providers have to order genetic testing independently, that adds to the workload and makes it more likely that genetic testing will not get done. If you are counseling a patient, tell them to ask questions about genetic counseling because some physicians may be less likely to bring it up, simply because they are covering so many other things.

Fortunately, genetic counseling is usually available and covered by insurance. Testing is helpful in guiding treatment, and it can provide critical information on cancer prevention to relatives if a patient does have a germline mutation. For patients who go on to develop metastatic castrate-resistant disease, genetic testing will let us know if they have HRR mutations and may be eligible for olaparib, and/or if they have BRCA mutations and may be eligible for rucaparib.

How do you define “younger” for patients with prostate cancer?
In prostate cancer, “young” is vaguer than, for example, breast cancer. We do not have concrete guidance on this. Because the median age at prostate cancer diagnosis is about 67 years, I would say that being diagnosed before the age of 67 is what we would call younger.

This age category is quite relevant to genetic testing. If you see a younger patient with prostate cancer, it is important to ask questions about family history and pursue germline or somatic testing. We are more likely to identify BRCA2 or other HRR mutations in younger patients with prostate cancer.

When considering germline testing, the genetics professional (CGC, APRN, or MD) will use guideline criteria to determine eligibility for testing. Often, the patient’s age at diagnosis is not the main concern for patients with a personal history of prostate cancer, but rather if it is high-grade (Gleason 8+) or metastatic disease, which meets criteria for BRCA1/2 testing. For patients with a personal history of low- or intermediate-risk cancer who do not meet criteria themselves, they may meet criteria related to family history of cancer regarding age at diagnosis, such as a breast cancer diagnosed at age 50 years or younger or multiple relatives with certain cancers.

Can we do somatic testing on the initial biopsied prostate tissue if it was done years ago?
This is quite a dilemma and depends on the lab you are working with. I have seen somatic tissue tested 1 to 2 years after collection. If it has been a long time, the question instead might be whether we can biopsy a metastatic site or perform a blood test to look at circulating tumor DNA. I would be concerned about using that older tissue because the cancer could have changed after the initial biopsy.

How do you choose between radiation vs chemotherapy for patients with localized prostate cancer?
Our decision largely depends on risk stratification along with how tolerable we think the regimen will be for the patient. We want to make sure that we are not overtreating the patient and exposing them to side effects without additional benefit.

For patients with localized disease who are intermediate or low risk, we are usually deciding between surgery or radiation. For those who are high-intermediate and high risk, we usually recommend androgen deprivation therapy (ADT) plus radiation and sometimes add docetaxel. When we get into the very high–risk category, we often recommend radiation plus ADT plus chemotherapy.

Radiation may sometimes be used for pain treatment in, for example, a patient with recurrence of castrate-resistant disease and a solitary bone metastasis. Radiation is not appropriate for untreated oligometastatic sites but can be considered for oligometastatic sites post treatment.

Do you use PSMA scans to look for metastatic disease in your practice?
Yes, we do use this newer technology that is growing more available. When we do a PSMA (prostate-specific membrane antigen) scan as opposed to a standard CT PET, the images are cleaner and the areas that light up are specific to the PSMA on prostate cancer cells. We use PSMA scans to look for metastases in higher-risk patients and also to follow changes in patients with metastatic disease.

The main barrier is insurance, unfortunately. This technology is relatively expensive, but some plans are covering it. We will do our best to get this covered because it is a great tool.

Your Thoughts?
What have been your biggest challenges with genetic testing for patients with prostate cancer? Join the discussion by leaving a comment.