Targeting PSMA in Advanced Prostate Cancer - Episode 4

Genomic Testing in mPC: When and How Often?

April 6, 2021
Ulka Vaishampayan, MD

,
Oliver Sartor, MD

Practical considerations for the timing of genomic testing throughout lines of therapy for patients with advanced prostate cancer.

Oliver Sartor, MD: Ulka, when you are thinking about somatic testing, you said you think about it from the beginning. But when do you actually do it? Some people say you’re going to have an evolution in the technology and ascertainment will be better in the future. Should we wait until we need it or do you get it early on and get the landscape? Let me get your thoughts. 

Ulka N. Vaishampayan, MD: For a patient with metastatic disease, I typically get it soon after I see the patient. A lot of patients have not gotten it, and they come to us after having failed a couple of therapies. I get it at that point. But for nonmetastatic disease, if the patient is diagnosed with locally advanced disease or high-risk disease with a high Gleason score, those would be the ones I would get testing on. Of course, if they have family history, that’s pretty significant. I would even offer them germline testing. 

Oliver Sartor, MD: Interesting. So you’re saying early and often. 

Ulka N. Vaishampayan, MD: Yes, pretty much. What are you doing in your practice? Are you typically sending them to genetic counselors, or are you doing the testing first?

Oliver Sartor, MD: That’s a great question. We overwhelmed our genetic counselors initially sending everybody for genetic counseling. They begged, “Please, Dr Sartor, don’t send me 18 more patients tomorrow.” What we did is a little unusual. We actually hired somebody in our clinic. I call them a family coordinator. They do all the family histories, and they annotate things very nicely. When it comes to genetic testing, we talk about the risk of testing, and I’m available as a backup.

We talk about implications of life insurance. We talk about the cost of testing. We talk about implications for health insurance. The good news is we cannot genetically discriminate. We go through all that and then we typically go ahead and get our germline testing right there in the clinic. If there’s a positive, we always offer the genetic counseling. That can be done remotely or in our clinics. We incorporate genetic counselors; not in the pretesting environment but in the post-testing environment.

Ulka N. Vaishampayan, MD: I agree. We’ve had the exact same problem, that we overwhelmed the genetic counselors. Now I have started discussing with patients and giving them a choice if they would like to get tested. Then if they are positive, they see the genetic counselor for a more detailed discussion, get family members involved, etc. Most patients seem to be comfortable with that approach.

Transcript edited for clarity.