Implementation of Germline Testing for Prostate Cancer: Philadelphia Prostate Cancer Consensus Conference 2019

Abstract

Purpose: Germline testing (GT) is a central feature of prostate cancer (PCA) treatment, management, and hereditary cancer assessment. Critical needs include optimized multigene testing strategies that incorporate evolving genetic data, consistency in GT indications and management, and alternate genetic evaluation models that address the rising demand for genetic services.

Methods: A multidisciplinary consensus conference that included experts, stakeholders, and national organization leaders was convened in response to current practice challenges and to develop a genetic implementation framework. Evidence review informed questions using the modified Delphi model. The final framework included criteria with strong (> 75%) agreement (Recommend) or moderate (50% to 74%) agreement (Consider).

Results: Large germline panels and somatic testing were recommended for metastatic PCA. Reflex testing-initial testing of priority genes followed by expanded testing-was suggested for multiple scenarios. Metastatic disease or family history suggestive of hereditary PCA was recommended for GT. Additional family history and pathologic criteria garnered moderate consensus. Priority genes to test for metastatic disease treatment included BRCA2, BRCA1, and mismatch repair genes, with broader testing, such as ATM, for clinical trial eligibility. BRCA2 was recommended for active surveillance discussions. Screening starting at age 40 years or 10 years before the youngest PCA diagnosis in a family was recommended for BRCA2 carriers, with consideration in HOXB13, BRCA1, ATM, and mismatch repair carriers. Collaborative (point-of-care) evaluation models between health care and genetic providers was endorsed to address the genetic counseling shortage. The genetic evaluation framework included optimal pretest informed consent, post-test discussion, cascade testing, and technology-based approaches.

Conclusion: This multidisciplinary, consensus-driven PCA genetic implementation framework provides novel guidance to clinicians and patients tailored to the precision era. Multiple research, education, and policy needs remain of importance.

FIG 1.

Variability in prostate cancer–specific multigene panels. Genetic testing registry: As of August 2019. Available at: https://www.ncbi.nlm.gov/gtr/. Courtesy of Saud AlDubayan, MD.

FIG 2.

Framework for prostate cancer (PCA) genetic evaluation and management. (*) See Table 2 for personal history or family history (FH) of cancers indicating genes to test. GINA, Genetic Information Nondiscrimination Act; HBOC, hereditary breast and ovarian cancer; MMR, mismatch repair; NGS, next-generation sequencing; PARP, poly (ADP-ribose) polymerase; PD-1, programmed death 1; VUS, variant of uncertain significance.

FIG 3.

Models of collaboration between genetics and health care practices for prostate cancer genetic evaluation. FH, family history; GC, genetic counseling.