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Survey Shows Growing Use of Genetic Testing in Prostate Cancer Management in the Community

Nichole Tucker
Published Online:3:56 PM, Mon October 28, 2019
Raoul S. Concepcion, MD
Raoul S. Concepcion, MD
It is known that genetic testing plays a role in the management of prostate cancer, but community practices are still trying to understand and overcome the challenges for increased adoption and find better ways to decide which patients require hereditary testing, how to utilize the test information, and when genetic counseling is needed. Raoul S. Concepcion, MD, covered this topic during a presentation at the 2019 Prostate Cancer Consensus Conference.
In a survey analysis sponsored by Invitae, which included 52 community urology practices, one-third of the practices responded to 8 survey questions. The responses revealed that most community practices are aware that the Society of Urologic Oncology (SUO) released a statement endorsing the use of genetic testing and counseling in the management of prostate cancer. Sixty-six percent of the responders stated that they were already implementing genetic testing in their practice, and 25% said they were in the process of developing in-house genetic testing programs. Concepcion commented that the feedback is positive and now hopes to solve some of the challenges that still exist with making genetic testing and counseling more widely used among urologists.
One key challenge is the lack of genetic counselors who have expertise in oncology. Roughly 40% of the 5000 genetic counselors in the country specialize in oncology, Concepcion stated. Currently, many practices have taken to utilizing tele-counseling methods to access these certified genetic counselors. 
“I think people are starting to understand that with only 5000 genetic counselors in the United States and only about 40% of those are dedicated to oncology, there has to be alternative mechanisms for post-test counseling,” he said.
In an interview with Targeted Oncology, Concepcion, assistant clinical associate professor, Vanderbilt University School of Medicine, and clinical medical director of urology, Integra Connect, discussed the existing challenges with implementing genetic testing and genetic counseling in community practices and how they can potentially be addressed.
TARGETED ONCOLOGY: Can you provide an overview of your presentation at the 2019 Prostate Cancer Consensus Conference?

Concepcion: Over the past few years, the realization that lethal prostate cancer has a hereditary component has caused urologists, whether it be in community practice or academic practice, to identify appropriate patients for hereditary testing. 

This is the second Philadelphia Consensus Conference looking at the role of hereditary testing in patients with prostate cancer. I was asked to present on how hereditary testing would be utilized and embraced in community practices here in the United States.

TARGETED ONCOLOGY: What are the current testing patterns that are being utilized? 

Concepcion: In big urology practices, the one thing that people don't recognize is the large number of patients both existing and newly diagnosed that are being seen in the community. My charge was to identify how these practices would embrace hereditary testing, knowing that there are certain things that you need to do to operationalize this. As opposed to taking comments and talking to colleagues and friends, I decided to come at this in a more structured way. 

Through an unrestricted research grant from Invitae, which is a molecular testing company in California, I constructed an 8-question online survey that we submitted to all Large Urology Group Practice Association (LUGPA) member groups. There are about 149 member groups within LUGPA and we got responses from about 52 of the groups or one-third. Then, I was able to document what they felt were some of the challenges to overcome. We were also able to look at their access to genetic counseling. 

What we found was that the majority of practices (95%) were aware of the statement from SUO supporting hereditary testing. About two-thirds of the practices who responded were already incorporating hereditary testing in the appropriate patients and another 25% were in the process of developing an in-house testing program. Those are all positives.

We knew that the paucity of genetic counseling that is available to patients post-testing was going to be a problem. Of those practices that were already ordering testing, the majority of them utilize counseling that's made available to them through the testing companies, whether it be through telemedicine or [another source]. A few of the practices do have relationships with certified genetic counselors. The majority of the practices have genetic counselors in their area within a 20-mile distance. I suspect the reason why those don't get used as much is because of the wait time. We didn't ask that question specifically, but the fact the majority of the practices are still using tele-counseling speaks to that.

We recognize that post-counseling is very critical, and I think this will always be an issue. We gave a list of about 7 challenges that need to be addressed and the top 3 challenges recognized for the urology practices were medical-legal liability—based on if there was a discovered mutation that went unaddressed, out-of-pocket expense to the patient and reimbursement—some of that is an extension of somatic and tissue-based testing, and third was the complexity of trying to obtain a good family history and put that into the electronic health record.

TARGETED ONCOLOGY: How do you go about addressing those barriers moving forward?

Concepcion: Overcoming some of these challenges is just going to take time. The good thing is that there's more and more information that's being disbursed. I think urology practices will more than likely create champions. 

[There's still a huge unmet need that we must address.] The question is, does every patient post-test who has an identified mutation require certified genetic counseling, or can it be done in an alternative way? There were a couple presentations during the conference that addressed that. 

A couple of people are trying to develop online aps and courses in genetic counseling. I think people are starting to understand that with only 5000 certified genetic counselors in the United States and only about 40% of those are dedicated to oncology, there has to be alternative mechanisms for post-test counseling. Pre-test counseling doesn't necessarily need to be done by a genetic counselor, but it does require a provider who at least has expertise in identifying which patients are appropriate for testing. 

The optimal solution for appropriate genetic testing would be using artificial intelligence in electronic health records, if there is a good family history [for the patient], that would automatically be flagged in the electronic health record to indicate that a patient should be considered for hereditary testing.

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