Genomics coming of age In late October 2014, the National Comprehensive Cancer Network (NCCN) announced that molecular testing would be included in the latest edition of the prostate cancer treatment guidelines, version 1.2015. Through our care of prostate cancer patients, many of us are already familiar with these tests, Prolaris and OncotypeDX, which aim to help further stratify risk in localized disease. Before these tests, treatment decision-making in prostate cancer was very complex, as most men had multiple viable choices (including active surveillance) even when stratified by T-stage, PSA levels, Gleason score, and other clinical aspects.
At a very basic level, molecular testing of prostate tumor tissue is a genomic analysis assigning a number to how overactive the cells are, compared with normal tissue. By looking at RNA expression levels in genes responsible for pathways such as cell cycle progression, cellular organization, androgen signaling, and other selected genes* in the tumor tissue.
In clinical decision-making, this type of information could help a man with localized, low-risk prostate cancer choose between active surveillance or treatment. But these tests do not help answer the question of surgery vs radiation vs other. Perhaps the testing will soon be helpful in decisions for men with biochemical recurrence after surgery.
First-hand experience For the men who have undergone this type of testing here in my practice, they still use the conventional variables (PSA, Gleason score) and their physicians’ advice to narrow down the treatment choices. If they are candidates for active surveillance, then likely the genomic tests come into play. With a low/less aggressive score or a middle-of-the-road score, men seem to be more inclined toward staying with active surveillance. With a high/aggressive score, men on the fence between active surveillance and treatment, often choose treatment. These scores are not appearing to cause any major drastic decisions, but rather gave men some peace of mind about the decision they were leaning toward.
In explaining the meaning of these tests to patients, I’ve often said that genomic testing is like a magnifying glass on your cancer. Low risk is still low risk. Overall success of treatment is still based mainly on what we know (PSA, Gleason score, stage). By looking more closely through the magnifying glass of genomics, perhaps we can somehow gauge if the cancer is a less aggressive low-risk cancer that is okay to just watch, versus a more aggressive low-risk cancer that would benefit from treatment sooner than later.
Developing the navigator role in personalized medicine Hopefully, as we learn more about these technologies, we can figure out how to best incorporate the data into health care decision making. As navigators, our roles of teacher and advocate are crucial in caring for men dealing with treatment decision making that involves new variables such as genomic testing. Particularly in settings yet to incorporate genomics into daily practice, the navigator can gather updated information on the technologies to share with both providers and patients, even more important as entities such as NCCN are bringing more credibility to emerging technologies. And finally, navigators can help other navigators. The shared experience among navigators is extremely valuable; as an early adopter, I learned so much from fellow providers outside my institution as we learned together how to counsel patients—and providers—around these new technologies.
Now having more experience, it is a joy to share my experiences with colleagues new to the processes around molecular testing and personalized medicine. Ultimately, our patients benefit in ensuring quality and cutting-edge cancer care, as navigators connect the dots from technology to the reality of people dealing with the disease, day to day.
*A side note, genes in these analyses are not hereditary genes (such as BRCA1/2 and the Lynch Syndrome genes) that are passed from parent to child, but rather genes in the tumor itself, not thought to be heritable. Through the Cancer Genome Atlas project, we found that different tumors have their own genomic identity, which led to so many advances in personalized or precision medicine today. While hereditary GENETIC testing involves an analysis of an individual’s blood or saliva to see if they carry a gene mutation that can be shared with family, molecular testing (or genomic testing) looks at the tumor tissue itself to help stratify risk and even help determine treatment options.
Frank dela Rama is a clinical nurse specialist, oncology/genomics, and prostate cancer navigator at Palo Alto Medical Foundation in Palo Alto, California.