Myriad Live - Let's Talk Genetic Testing Advancements in Urology

Myriad Live episodes are recordings of an open-forum webinar hosted by Dr. Thomas Slavin. The opinions and views expressed in this recording do not necessarily represent those of Myriad Genetics or its affiliates. To participate in a future recording, visit https://myriad.com/live/ for a list of dates, times, and subjects.

Transcript

0:00:13.5 Dr. Thomas Slavin: Welcome. This episode of Inside the GENOME is a recent recording on Myriad Oncology Live, a webinar hosted by me, Dr. Thomas Slavin, Chief Medical Officer for Myriad Genetics. The opinions and views expressed in this recording do not necessarily represent those of Myriad Genetics or its affiliates. To participate in a future recording, please visit Myriad Live for a list of dates, times and subjects. I look forward to exploring the world of genetics with you all.

[music]

0:00:41.3 DS: Hello, everyone. I was waiting for a break in the song, but it just kept going. [laughter] A thing sometimes about jazz. Welcome to Myriad Live. So excited to have you here today. As always, we'll start out with a little housekeeping, hopefully people can see my screen, but we have an exciting Myriad Live today. So we have two special guests, I'll introduce them in a second. We're gonna be talking about genetic testing, advancements in urology. In a few weeks, we are gonna be coming back at the end of February, last day of February, to talk about disparities in cancer genetic testing across populations. So for that one, we're gonna be joined by Gail Tomlinson, so some people might know her, MD, PhD, she is co-Director of Population Sciences and Prevention Program Mays Cancer Center, and UT Health, San Antonio.

0:01:37.2 DS: And March, we're gonna be joined by Terry Sarantou, who is a breast surgeon, and he's gonna be talking about, largely NCABP accreditation. He's got a lot of experience, sits on many different committees, wears different hats, so a lot of people, by caring about accreditation for their own programs and genetics, so that's what really gonna focus on. Other brief housekeeping, we as always put these up on Myriad Lives, if you wanna go to Myriad Live, or sorry, up on Inside the GENOME, I need more coffee. But if you wanna go to Inside the GENOME, you can. Any podcast, Apple, Spotify, whatever you tend to use for podcasting should have Myriad Live up on it, but you can easily go to it. We have tons of content on there, pretty much endless, to be honest, [laughter] and we will put this up in a few weeks for those that might miss it or wanna share it with friends, but I'd definitely take a look. Anything that says Myriad Live is from these podcasts, or these webinars, and then anything that does not say Myriad Live is me sitting down with usually one person going through something specific. Those tend to be about 15 minutes, actually just record a few. I have a few in the pipeline, so some will get sprinkled in here pretty quickly.

0:03:11.7 DS: Otherwise we have... We've also been doing a really nice molecular tumor board, so for those that wanna learn more about the world of tumor genetics, come join us, we have the information here. But you can also listen to old ones that we posted, but we have the February registration up as well as March, so yeah. Tons of educational opportunities for sure. Let me stop sharing and then introduce our special guests. So I'm joined by two special guests today, so can't thank them enough. Also, a lot of coordination by Sunny Yarrish. Thank you, Sunny, for helping. We also have Rob Finch helping today, so he is the medical director of the urology section here at Myriad, and Rob is gonna be running the chat, so if you've been to Myriad Live, you have a feel for how these work. We're here for you, so we're here for education, making sure people understand whatever the topic is. If you do have a burning question off-topic, maybe we can address it, but usually we try to stick to the topics. So today is really urology genetic testing, both germline and tumor, we'll cover the whole span, so I always encourage people to unmute themselves and ask whatever question you want. No question is a dumb question. Thank you.

0:04:45.7 DS: And it always helps with the dialogue, but if you do not want to unmute yourself for any reason, just send them to the chat and we'll make sure that we get them addressed. You can also send them to Rob or Shelly really on the site. I could see Shelly on, thank you, who normally runs the chat. You can send those to the site, we'll make sure they get addressed, so thanks to everyone. I wanna introduce Kara Cossis and Angelo Baccala. Maybe both can do a quick introduction of yourself, what you do in the urology field for your patients, so if you wanna start, Kara.

0:05:26.6 Kara Cossis: Hi, thank you guys so much for attending and for having us today. I'm Kara Cossis, I am the Director of our Advanced Practice Providers in the state of Maryland. We have roughly 30 advanced practice providers. My role as far as prostate cancer is concerned, deals primarily with getting our advanced practice providers who essentially manage most of these advanced clinics up to par, and continuing that educational experience as things are changing. That's really my role way within our practice, so we're a fairly big practice within Maryland, I believe we are somewhere on 80 or so physicians and like I said, 30 advanced practice providers.

0:06:16.0 DS: Yeah, thanks, Kara. And I said Cossis, so you can call me Slavin if you want.

[laughter]

0:06:22.3 DS: I probably should have confirmed how you say your name yesterday.

0:06:25.6 KC: I'll respond to almost anything, all right.

0:06:29.5 DS: Well, Dr. Baccala, you wanna introduce yourself to the audience? 

0:06:33.4 Angelo Baccala: Sure, thank you. My name is Angelo Baccala, I wanna say thank you to everyone for having us come out and do this, this talk today and discussion. I look forward to it. I am the Division Chief of Urology for Lehigh Valley Health Network. We're in Northeastern Pennsylvania, right around Allentown is where we are situated, and we've spread out quite a bit from there both North and South and West. We're just about an hour north of Philadelphia, big weekend coming this weekend. Obviously, with the Philadelphia Eagles, everyone's very excited around here, if you're a Phillies fan, or a Philadelphia fan. As a Division Chief, I also run our Center for Robotics and Oncology, and so one of my goals is in addition to running the entire practice, is specifically in oncology, I operate and do urologic oncology procedures as well as make sure that we have pathways set up for all of our oncology disease states, of course one of which is prostate. And so we've been very engaged in promoting genetics for prostate cancer, all various reasons, which we're gonna discuss today, and so that is pretty much my role there.

0:07:53.2 DS: Yeah, no, great, thank you both for coming on. I'm sure the audience wants to hear a little bit about the perspectives of what's new in the genetic testing world for urology. One thing I wanted to start with is, there was a recent article or really an annual report from the American Cancer Society around prostate cancer, facts and figures. It was showing that they're... The incidence of prostate cancer is on the rise, just wondering your perspectives on that, just to ground everyone on the impact of the importance of coming up with really solid treatment plans for individuals with prostate cancer.

0:08:36.2 AB: I think we're gonna obviously be seeing more and more of this, and it makes me wonder whether this is a blip or this is gonna just continue in that trend. A lot of people wonder if it's just a delayed effect from COVID and patients not following up with their primary care docs and then now getting the diagnosis and they're coming at once, people are resuming their care that maybe missed before. That could be, but it could also obviously just be an increase that we're seeing. And so for us, this poses a lot of challenges, we wanna make sure that we have the bandwidth to make sure we take care of these patients as more are gonna be coming through our office space, and so we've tried to find some ways to work around that. But also making sure that we have our current pathways as we've mentioned in lines, that we have the right care that we can deliver it to all of our patients.

0:09:24.5 AB: And so, that includes our testing and whether we're talking about figuring out who needs to be tested, who need to be biopsied, once we find these cancers, and we know that there's gonna be more of them, do we have the right treatment options available for them? How do we determine what the right treatment options are? That's where genetic testing plays an important role in that. So, it's interesting data, I know Pennsylvania when it's broken down, Pennsylvania is one of the bigger states actually that's involved in that too, so we're gonna be seeing a big surge in this area specifically.

0:09:55.7 DS: Yeah, yeah. Has that been affecting you Kara? Have you been noticing anything? 

0:10:00.7 KC: I guess, I would say yeah, the COVID phenomenon is certainly profound as far as the delay of care. I think there could even be consideration to dating back to some earlier things. For people who aren't aware, I believe it was around 2007-ish. There were some recommendations that were made by the US Preventative Task Force. They're the organization that gives these guidelines based on high levels of evidence, when colonoscopy should be done when the... What do you call them? Like breast...

0:10:43.6 DS: Mammograms.

0:10:44.2 KC: Mammograms, thank you. But anyway, there was some changes as far as the routine PSA screenings, and so I think part of what came out too, is that some people are being diagnosed in a more advanced state, so whether it has to do from a delay of care or simply not being picked up. But it's challenging because there was a lot of things, and I think we probably came out at similar times. Once upon a time not too long ago, if your PSA was elevated or you had an abnormal digital exam, you moved on to biopsy, and so we were definitely over-biopsing people a lot, but now there is this, a lot of shared decision making and people don't move on to biopsy right away. Sometimes they're risk stratifying or they're getting a prostate MRI to decide how they should move on, so really, I think things have just changed a lot as far as where they were even coming from and patients being so involved. But with that being said, there still are a lot of challenges to patients even having access to care and doing that.

0:11:51.3 KC: So when we see people are coming in, in these advanced states through the ER, they're coming with extremely high PSAs that weren't necessarily picked up before with potential routine screenings or because of these barriers with the COVID phenomenon as well.

0:12:11.4 DS: Yeah, and that's a big shift, just to dig in a little bit on the whole concept of active surveillance. Yeah, I remember... And you both probably know much better than me, but I remember in medical school that that was a big controversy when I was in. Do you follow men on active surveillance. I was wondering, maybe for the audience, level setting on where the field's at in today's thinking.

0:12:41.2 AB: I think personally there's been a big paradigm shift in how urologists treat cancer nowadays. It's become, as you mentioned, early on it was very... It was a hot topic because the knee jerk reaction for most urologists was, if you have cancer, we gotta treat you somehow. We have to take out your prostate, radiation or something, and we clearly were over-treating. That was not an issue that we don't recognize or to knew about. The differences is that I think the education has been phenomenal around this topic to the point now where all the urologists are really aware, acutely aware of the fact that we don't need to treat all prostate cancers. The hard part though, is figuring out which cancers we need to treat and which ones we don't, that's really where it becomes challenging.

0:13:29.5 AB: And there's also the things that we use to help us with that, whether it's MRI, the pathology report, but one of the things that has helped us dramatically lately is the addition of genetics at the time of doing that biopsy to really to determine for us who is the right candidate. Because that is probably the most important part of active surveillance in terms of we all have the pathways that we typically know, maybe some variation, but for the most part, we all kind of do the same thing in active surveillance. But the question is, who's the right patient? We certainly don't wanna be undertreating somebody who really needs treatment, but we don't wanna overtreat them as well. I think it's become a lot more prevalent now. And we are doing a lot more of that. And fortunately, we have a lot better tools to do it than we used to in the past. Kara, would you agree or...

0:14:17.9 KC: Yeah, absolutely, and then I'd say in addition to that, there's this next level, based on all those things, there's the next level imaging as well that exists to help stratify risk too. And so I guess one of the questions that I was thinking about when they're saying that there's more advanced patients, is it truly that there's more advanced patients or we're just picking it up better 'cause we have better imaging as well that maybe we didn't have access to. You kind of have to interpret what's really happening based on that we have better tools now than we did before.

0:14:57.2 DS: Yeah. Well said. How do you think this is gonna change? If these rates actually keep increasing though, whether there's a lead time detection bias or not, with the better tools, how do you think it's gonna start changing clinical practice, and this was brought up by a advocacy group to Sunny as well.

0:15:19.8 AB: Yeah, Kara go. Please go.

0:15:20.9 KC: No, I was just gonna say, I think definitely, it's pretty clear that there is going to be just a provider physician shortage, upcoming. It seems very clear among primaries and specialists, so I think there's going to be, how do we handle these patients, the volume, and getting them to the right people. Comparatively, the shift, once upon a time, everyone went to medical oncology and urology people didn't really deal with a lot of these things, and that's really shifted as well. That a lot of the urology physicians and APPs have taken on trying to manage these advanced states and now have felt comfortable with adding the genetic testing, with adding the oral oncolytic treatment. We know with getting to the treatments that they need, with the exception of the services that they don't provide, so I think really there's going to have to be an addition of adding the correct team members, whether that's additional APPs, additional physicians. Maybe there is adding an oncologist, the radiation... Getting those essential people into your team, or at least outsourcing within the community those appropriate team members to be able to handle this population, as well as all the additional treatments that now exist.

0:16:44.8 KC: Before, it was very unilateral. You got hormones, you maybe got chemo, that was your option. There wasn't all these other things that existed, and now there's so many different options and combinations that were not part of the treatment not so long ago.

0:17:06.8 AB: Yeah. I agree. I think that there's a good opportunity for us actually in this space because it's growing and we're seeing so much more advanced disease as Kara mentioned, with all these different options. It's important that we get people who... We have enough providers who can specialize in this or sub-specialize in it, I should say, because there is so many options, it's hard to stay abreast of everything. And there's a lot of options that we can even give in the urology office and they may not even need to send to medical oncology. So number one, having the right people in place who recognize this, understand if we have the advanced practice or excuse me, advanced prostate cancer clinics. And these clinics really help bring these patients together, we make sure we're getting uniformity of care and have the patients know all the different options that are out there, that the providers need to be aware of that. So that's one thing I think that we can do better at, is making sure that we are aware of those, but then also identifying who those patients are. We have a real opportunity now to potentially offer targeted treatment for people who have certain genetic abnormalities, knowing who they are up ahead of time, will help us provide better care earlier in the process. And I think that's another important part of this growing population that we need to be aware of.

0:18:26.0 DS: Yeah, well said. And how do you both involve patients in that shared decision-making, because obviously this is a complex field, you got imaging genetics, they're faced with cancer, they're worried about risks of their offspring, or why did I get cancer in the first place? And how am I gonna treat it and all the downstream side effects and thoughts of mortality, how do you bring in then the testing aspects, whether genetics or imaging into that to have those discussions, PSA, and talk with your patients so that they have a voice? 

0:19:05.2 AB: I think explaining to them the importance of it, really so they understand in simple terms, understanding why we're doing, what's the value behind doing the things that we're doing. It's hard 'cause whether you're talking about shared decision to determine whether or not to biopsy, whether or not to utilize the PSA and do something, we were talking about, Okay, now you're a prostate cancer, we wanna do all these other things as well, whether it's imaging or whether it's genetic testing or so forth, it is a long road and it's a lot of information, and so it requires time, so to Kara's point, we need to have the providers to be able to do it, but it should be in our hands, it should be with urologist, I think sometimes even with the early shared decision making was sort of taken out of our hands, at some of the task force recommendations were not even checking PSA. It is not the PSA, that is the issue, is what do we do with the cancer? Right. That's the issue, if we find it, should we be checking for it, and if we do, how do we treat it? 

0:20:00.5 AB: And that's really what urologist and urology PAs do best, that's our job and physician assistance and nurse practitioners do best, and so I think that that's something that we need to incorporate and make sure that they have the time to discuss all that 'cause it's a lot.

0:20:20.0 DS: Yeah.

0:20:21.5 KC: I would say with respect to at least germline testing, so I guess just to make sure everyone on the call, I guess sort of understands, we use the term genetic testing. But we're really talking about two different things, one is the germline, meaning, is there a hereditary gene, that's never gonna change, so is there something from your parents, your grandparents there, particularly for myself with that I offer all eligible patients that upon their diagnosis, their genetics will never change, they either have it in their gene or they don't. As far as the other type that I was referring to is called somatic testing, in case people aren't exactly sure what that means, and that's the production of an abnormal gene from the cancer or the tumor itself, that can be done either from the tissue or a distant metastatic site or within the serum blood. So for me personally, I don't always do that at the beginning, but I think we're trying to make a shift to have it, but I agree fully, having those tools to know, I always like to plan, well, what's the next step? If somebody's failing their treatment, what is this? And I think right now, where this exists, as far as a treatment line, they have to have failed several other treatments to be eligible for the treatments like the PARP inhibitors, for example, but if...

0:21:55.6 KC: As things change, I think you anticipate too, that there may be that opportunity to use those treatments earlier on, and so we would want to know that information to know how to direct their care as the research evolves.

0:22:10.2 DS: Yeah, and thanks, Kara, you did touch a little bit, Shelly, put in the chat a question from your expert perspectives are there unique tools or things that urologist need to be better equipped to utilize genetic testing on routine basis, and what are the barriers to the step of regular implementation? I think it segues nicely off of what you're just bringing up, I don't know if you wanna add to any of that perspective.

0:22:39.3 KC: Yes, I think maybe it's just being comfortable with having a conversation so the patient understands why you need it. I've had people say they're worried about their insurance finding out about it, or they're losing the ability to have life insurance or various things, so they don't necessarily understand some of the implications of what it can mean for further treatment. So what I initially meet with somebody and I'm telling them, I really say, "Hey, this is a three-fold reason why I would wanna get this one is just to tell us a little bit more about the cancer itself, and then just to give me some more information like, is there something in there?" I may say it may not make a difference of what we're doing for you to treat you at this moment, but it could be impactful later on, but also when this test is run, it does check for other cancer risks, which is important. I have a terrible example, so I'm just gonna say it because you'll see why it's terrible in a moment, but I think it's... People can understand it. So this is why I use it.

0:23:44.4 KC: So I have some patients that I've checked and they carry a gene that puts them more at risk for colorectal cancer, so the standard is that in general, most people get routine colonoscopies on a 10-year basis, and knowing that information, the GI specialist, usually we'll screen them on a more frequent basis, whether it be one, three, five or whatever yours, but they're not waiting 10 years if there's a perspective colon cancer, for example. And people can conceptually understand that, so I use that example, but who wants more frequent colonoscopy? So that's why it's not a great example at the same time, but anyway, so I say, but I know it screens you for other cancers, and then I tell them that it may make a difference, they're able to offer you treatment-wise, and then if they have genetic children, it could make a difference with how their children are being screened or manage their personal health, so I try to have that conversation with them, do you know, so they can understand why we would wanna do it? I think the biggest things are really just the time for it and who's filling out the paperwork and just getting those things.

0:24:50.9 KC: So I've seen various things at various offices, whether it's the medical assistant or there's a nurse or the advanced practice provider, it's not usually the doctors in our office, but it's not that it couldn't be. There's just one more time-consuming thing, so I think that's... The biggest thing is just taking the time to do it and then filling out the paperwork.

0:25:13.1 DS: So Kara, there's a comment in the... Or there's a question in the comments, or I guess it's a comment in the comments, I would love to see better screening in primary care to identify these men before they get cancer, let's catch these men and monitor them better, so they get screened and found at an earlier stage, can you comment on that? 

0:25:32.7 KC: I think that would be great. I think the biggest barrier to that, specifically around the genetic component would be just being able to be eligible if there is not like a family history or something, and just the insurance ramifications right now, but I would love to not have people come to be metastatic for sure, if they're getting some routine, shared decision, medical PSA or digital exam. So I find in general, that doesn't happen so much anymore, but I think those are the biggest things, or at least having some baseline at some point, whether... It's not every year or something like that, but just being able to have it... And it's really challenging. Primary care physicians are so bungled down with everything they're here and they're trying to condense this into this 15-minute visit, sometimes that's just one more thing on there, so having a shared decision-making is a challenging thing to then screen on top of the 20 other things you're trying to do about prostate cancer.

0:26:42.7 AB: I think it goes back to the PSA testing. As we mentioned earlier, there's a lot of confusion brought out there with the United States Preventive Task Force recommendations, and those things really, I think, are at the heart of making sure that we find these patients early, everyone understands and knows that it's not a great task. We all agree and urologist agree, everyone in that field agrees but it is what we have as an initial test, and I think it shows should be done, it should be done appropriately and judiciously, and when it's done, that's where urology practices should take over at that point and talk about, Do we need to do further testing? Do we just watch this? What do we do? And I think that's the way that we're gonna find these patients a little bit earlier and be able to offer them a better treatment option plan that's indicated.

0:27:30.3 DS: Yeah, I remember in medical school, a good way to get lectured too was suggest PSA testing for screening [laughter] for someone 20 years ago and then things swung back saying it's okay to do it again because... The thought for a long time was just do digital rectal exams only.

0:27:51.8 KC: Well, and to Kara's point, I think medical doctors are a little overwhelmed. It's a lot of stuff. And now there's all of these different pathways, the different things that they're required to do, and it's a lot and to expect to have them have this decision-making discussion after a PSA that's maybe slightly abnormal, what do we do with it? That's not really... It's not gonna be possible quite frankly, it's just too much, so they need to call on us.

0:28:19.9 KC: Yeah, I couldn't agree more. And I think we're seeing a lot of elevated PSAs that just come over to us in consultation, and it's been a total shift because like I said before, people are just more automatically move on to biopsy, but now people really wanna talk about it, they wanna get some risk stratification stuff, they wanna know more about the number before they make the decision, and I don't know if you're seeing that in your practice, but I definitely am seeing that there's been a big shift for a lot of more specialty testing and discussion around moving forward with the biopsy, rather than moving forward with a biopsy as a next step.

0:28:58.9 DS: One of the questions that came in before the call from one of the patient advocacy groups was, Do we really need shared decision-making for PSA tests when other cancer tests do not demand this? Can you talked a little bit about the shared decision-making? About getting PSAs.

0:29:16.2 AB: I think that in terms of even just getting PSAs, the decision-making that needs to happen is perhaps on older patients, patients who have family history, that's where that discussion needs to be done, because I think it should be relatively routine, I agree, and your average patient, your 50-year-old, your 70-year-old, and it should be part of their normal workup, but in someone who's younger but has a family history, that's where they need to understand in terms of catching them early, this is an important part of their work, of their medical work up. And someone's who is over the age of 70 who's had a normal PSA all wrong, do we still need to follow that? Probably not if their PSAs have been one and they're 70 years old, no need to check that again, but that's where I think that discussion needs to happen. Sure to that though, I don't disagree, I think it should be pretty uniform in the 50 to 70-year-old age group, this is what the AA recommends, this is what we should be doing.

0:30:12.0 DS: Yeah. Let's switch gears a little bit. Genetics show, we'll dive a lot deeper into genetics, so there's essentially three main buckets for generics, I think we touched on all of them to some extent, but probably good to define them out a little bit more, and there is overlap between them that makes things more fun but we already talked about hereditary risk, so that's one, we talked about... Then if you get cancer, there's tools now to help understand, Is this something that I can watch it wait, Is this something that's aggressive? So gene expression profiling being the large gene test there, and then also in the case of advanced metastatic disease, Hey, what kind of mutations are in this tumor that can lead to some sort of testing, targeted therapy like Kara brought up. PARP inhibitors would be a good example of that. Just curious how each of you use these tools in your practice, specifically because it's complex and there's different areas where you use different tools, and sometimes even in urology, maybe pass off to the medical oncologist before doing the genetic test on tumor.

0:31:39.6 DS: I think everybody practice a little bit differently, so yeah, we just love your perspectives on how you see the field evolving as these tests are relatively new, these are really... In the last 10, 20 years, we didn't have these tools.

0:31:54.6 AB: I think we solved the importance of the genetic profiling of prostate cancer tissue very early on, so if someone has prostate cancer, we get profiling of all of those patients, we get test that... We get our preliminary stats, which runs and looks at cell cycle progression genes to determine basically is this what we think we're seeing from a pathologic standpoint, 'cause we know that this genetic testing can outperform purely looking at genetic, excuse me, purely looking at pathology, which is very important because we used to base all of our decisions on how aggressive or treatment's gonna be, or are we gonna watch them and do surveillance purely based on path, and we know now that that's really not the end all be all of decision making. So we get this on all of our patients, and we do that right through our pathology office, they know that if a prostate cancer is positive, they're gonna send it out, we use that for all levels, and so the reason that we think that's important, it helps us to determine whether or not it's active surrounds, whether or not if it's they will move into the active treatment, do we do single treatment, if we're talking about prostate radiation, do we just get the radiation, do we add hormones or.

0:33:11.8 AB: If it's even surgery, we're trying to look now at what type of surgery do we do, do we do something more aggressive, if they are a continuum of being in a multi-modal therapy is this somebody who's gonna probably need radiation. It's a discussion with the patient and you say, "Hey, listen, we are gonna do a prostatectomy. There's a good chance you're gonna need radiation afterwards," or do we also do something interoperatively, do we do more of an extended lymph node dissection. There's no data on that that necessarily says it's better, but my point though, is that in that discussion with the patient, you let them know, "Hey, this is something a little bit more severe than maybe what someone else your age and your pathology and your PSA will typically present with." And I think that's important to have for the patient, sets expectations. So that's an area that we use it for, I think that's important. Kara, your thoughts on that? 

0:34:00.5 KC: Yeah, so that happens on a physician level at the time of biopsy as well, and I think, yeah, that it's been very important for determining how the treatment pathway, like you mentioned, whether it looks more like a surgery, just a radiation... With ADT radiation, trimodal like I think a lot of treatment decisions are being made on that information, I'd say that one thing that I would like to see us a little bit better with, that we're trying to work on as a practice ourselves, is that with respect to patients who are metastatic at their diagnosis, sending that for a somatic tissue test may make sense in that setting too. The thing is if the tissue is too old, so I believe it has to be at least 10 years or less than 10 years for accuracy of an abnormal gene. So I think we're trying to get better at having that be more of a reflexive thing, so we even know while the tissue is still viable and fresh, if that is something that we can then use later, probably will be more, again, impactful as the therapies may exist more early on than where they currently do in the treatment algorithms.

0:35:26.4 AB: And I think offering it to the patients, as you mentioned, it's so important we follow NCCN guidelines, that's kind of what we're asked to do and we do that, and so lining that up with the right patients, people who are metastatic, they need that testing. It is what it is, we should be getting it right away, but also more aggressive patients or patients who maybe don't have aggressive disease but have family history, so that history taking the pathologic diagnosis really kinda leads us to who should be getting that somatic testing, which is so very important in directing future care as Kara mentioned.

0:36:03.4 DS: Yeah. What kind of barriers do you see in your practices to doing this testing? Are there times you're like, Oh, I wish I could do a test but I just can't, for whatever reason.

0:36:15.3 AB: I think in general, not too much, we sometimes worry about coverage and things like that, fortunately I think Medicare is aligned with NCCN guidelines now, so we are okay from a Medicare standpoint for that, but more so I think thinking about it from a practice standpoint is ensuring that we have uniformity across the practice is being done everywhere.

0:36:38.3 DS: That can sometimes be an issue. And so we've set up, I think pathways are... I'm a huge believer in that. I've mentioned this a couple of times already, even just today, I'm a huge believer in that for any practice that's successful... I know the practice in Maryland does a great job with that. For sure. And we've tried to do the same here. And this is one area where what you're talking about, urology, but I think specifically, and for today's discussion in prostate cancer, making sure that patients are following this pathway, so we're getting a good history or we really evaluating the path, and are we doing... Are we following NCCN guidelines across the group, and that's something that we constantly go back to.

0:37:19.0 KC: So one challenge I've seen is that sometimes like I agree completely that Medicare is fully on board but some of the commercial payers put this intermediate step where instead of just ordering it they have to have speak to a genetic counselor before the insurance will authorize the testing to be done. And so there's there's a lot of steps that are involved like the patient. And while the companies... I know you guys have made it very easy by the way, the genetic counselor will just call them. But then the patient has to answer the phone and nobody wants to answer a number they don't know. So there's all these things that then happen that if it's not just an automatic thing by the insurance side that kind of stand in the way of moving forward with the test actually being done.

0:38:10.8 DS: Yeah. And how do you feel that the field is embracing all of this? I mean urologists as a whole it seems like there's different practice patterns emerging. Some are embracing genetic testing. Some are not necessarily, some are even getting a little bit more into chemotherapy. Some are than others.

0:38:34.1 AB: Yeah. I think TJ, I think really it's a it's a big issue with education. I really think that's what it just comes down to. I think when when urologists really understand and know it the education's out there but are they sticking to it? Are they getting the the message across that it's important? I don't disagree. I don't think that there's uniformity in care. I think we can do a better job of that as urologists as a whole. And I think things like this hopefully help that people really understand these are guidelines these are things that we should be doing. We see this in different pockets in different areas of urology as well. But this is I think a big one.

0:39:12.2 DS: Yeah. And it's not unique to urologists either. I mean I think we see this across medicine. You have early adopters adopters that wait for guidelines and then sometimes folks that tend to lag on these kind of things. I was gonna ask too I mean how important do you think it is having one like local solution? Kara you brought up the paperwork and things, how important is it to you in your workflow just to have one easy place to get all this type of testing? 

0:39:47.3 KC: Oh I mean I think the the easier it is the more adaptable everyone will be to it. So whatever that process is I met another group and honestly they hired a young lady and her job was just to do the genetic aspect. Like it was a full-time job and a practice. So believe it or not I mean things like this can exist as a as a full-time opportunity within practices. So whether you're pulling somebody who's being in other directions but I think it's just really figuring out the the proper workflow and what works for your particular organization...

0:40:20.9 AB: Yeah, I would agree. As I mentioned workflow is so important that if you... The whole idea behind workflow is making it easy. So if you are getting a test from a certain area and and it's it the pathway is set up there you have a portal where you can get the information and then as the patient progresses or as patients come in with different types of stages of disease you may wanna order different types of testing. Having it all in one location is what makes that pathway run and makes it smooth. As as Kara said that could be a full-time job. And we're all struggling with FTEs as it is now so we need to make it as simple as possible.

0:40:57.5 DS: Yeah, that was part of the reason we just launched what's called UroSuite which includes germline and Prolaris testing for gene expression profiling then the tumor testing as well for decisions. We are hearing a lot of that feedback that yes can we make it easy for providers to order these things? We already launched the tumor test last year in our oncology business unit. So I always thought that yes let's make it easy for the urology team as well.

0:41:26.9 AB: Yeah, I mean in our office we have a portal set up. We can literally click on the types of tests that we want from UroSuite make it all happen and go, I mean that that's hugely beneficial.

0:41:38.4 DS: Yeah.

0:41:38.5 KC: Yeah. The portal slows me down just a little bit because I'm not like a good typer like the... But on on the local level like we've had our representatives just have the applications filled out with all of our information, our office locations basically all of the administrative part. So literally we're just putting in the patient information and even the test is checked. So I think the more automatic you make something the easier it is for everyone to wanna try to take it on.

0:42:10.7 DS: Yeah. Let's just pause there for questions. This was a really good discussion. Covered a lot of ground. Any any questions out there in our audience for our two special guests? 

0:42:34.9 Rosalyn: Hi, can you hear me? 

0:42:37.8 DS: Yes.

0:42:39.5 Rosalyn: Hi, it's Rosalyn. I really I really appreciate what y'all are doing and so far with us using the Myriad testing it is, there's so much about it that I like just I don't really have any questions but I just wanted to commend the company for always taking that extra step and staying on top of all the new technology and science that's out there. Because you know as well as I know there's lots of competitors and I don't... I just, I enjoy the product that y'all have and and the forms and the reports are are easy for us to analyze and understand. And I just wanted to thank y'all for it.

0:43:39.6 DS: Oh thanks Rosalyn. Nice nice feedback.

0:43:44.3 AB: So I agree I think that's a really important point. We get this testing and we have certain things, you guys have a great diagram, those on the call who haven't seen this maybe haven't ordered it. You you would see this on there where they have the prostate cancer's stratified by the different risk groups and then they show kind of where you should... Where the typical patient should be but then the continuum of where they could potentially be in that group and where they put a little a little figure of where your patient is in that continuum. And that's a really easy way I think for patients to understand where they stand against their peers. The other person just like me who has my type of prostate cancer might be more aggressive or less aggressive than them and that's just an easy quick view. You can just show them and say this is where genetically this is where you're showing. And that's the whole point of the test is not everybody's the same. And we shouldn't be treating them as such because someone has Gleason 7 cancer. Okay. There's a lot of lot of variation there. And so we use genetics to help 'em and and those types of things that you guys provide I think are hugely beneficial.

0:44:51.4 DS: Yeah, thank you.

0:44:52.8 KC: Yeah I was gonna say similarly on like the mutation side of things too the report is very easy. It gives a big plus sign you can't miss it. And by history I mean I'm not a genetic person, I've learned a lot over ordering many tests but spelling it out and then having the accessibility to the genetic team like Rob who's on the call I mean I call him, I email him I'm like what does this mean? And the patient's having the ability to also be able to connect with a genetic counselor themselves too instead of seeing an outside party. I think it's been very patient friendly as well as provider friendly.

0:45:35.0 DS: Yeah. No that's great. I appreciate it. So what what do you think, for both of you, I mean what do you think is the the future of all this? I mean where would you like to see what's on your wishlist? Where where do you think we're headed? 

0:45:53.9 AB: I think in general I think all cancer care is gonna be headed towards precision medicine we're gonna have selective tests to be able to do certain things and be able to affect care in a way that we can selectively work out what's the best treatment option for you. And really that's what we're already doing. We're on with it now and I think it's just gonna get better and better. Especially for our more advanced folks in the somatic testing space. When we start seeing certain genetic alterations and we have treatments that specifically target those genetic alterations we're gonna get the best bang for our cure for our treatment. And that's what we're looking for. Unfortunately a lot of patients in the past have been treated as standard and nobody is, right. Everyone is selective. And the more we can find out ways to to make that work the better.

0:46:49.6 DS: Yeah. Agreed. Any other thoughts there Kara? 

0:46:52.8 KC: I was gonna pretty much say say the same thing. Yeah I think it's just gonna be very directed individualized patient care once we narrow in on a little bit better than we already are.

0:47:05.4 DS: Yeah. Yeah. And hopefully we can be able to start doing some better risk assessment for the 30 and 40 somethings [laughter] men that sometimes we're not the best going in to the doctor. So we'll have to get creative as a medical community on how to access those individuals and make sure we're doing appropriate risk stratification because it is a hard group sometimes to reach. Good.

0:47:30.5 Speaker 5: I do have a question in the private chat. It says I should have asked this earlier instead of waiting until the end but I understand that germline testing is hereditary and somatic is the tumor but won't they show the same thing? Is it necessary to get both? 

0:47:49.3 KC: That's a great question. So the answer is no they won't. They they don't necessarily correlate and I forget the exact number you guys will have to, is it 10% that they will not... Well, they're two different things basically but I was just I'm trying to remember that the percentage of the time you will detect a somatic versus a germline and and vice versa.

0:48:14.1 S5: Yeah. So the literature shows up to about 17% of the time we'll find a germline mutation in a prostate cancer patient. And then looking at some of the clinical trials for PARP inhibitors it was about 28% chance of finding a mutation in the tumor itself.

0:48:31.7 KC: Thanks. See this is why like it's so important [laughter] to have a person on the line. But so the answer is no they they don't show the same thing. And that's reall why it's good. I mean I always find it's sort of a double-edged sword when I find somebody who has a positive mutation, on one aspect I'm like, Yes, I have another treatment for them but I think that their cancers tend to be more aggressive overall which is sometimes when we're checking this upfront I think there's decisions that are being made on if you're in that do I treat or not treat thought process and they do have something people are moving forward with treatment because they tend to be more aggressive. So that part isn't great, they may have a a worse more aggressive cancer. So why you're sort of saying it's... It's two-sided. I think as a clinician you're you're happy you have something but you also don't want them to have it.

0:49:25.3 AB: Yeah. I think it's important for everyone who's asking the questions to understand that there are mutations which put you at risk of getting cancer and those are the germline mutations that we know and and will potentially get you there and and unfortunately let you have cancer. But cancer being what it is cancer mutates it changes all the time. And that's the idea behind it. That's why they survive. And a lot of times we'll throw things out to try to kill 'em and they survive and find a way to still live because they continue to mutate. That's what makes the suckers so horrible. So as they mutate and they start changing they may pick up more additional mutations. And that's why in the somatic testing space where we start testing metastases and things like that we may find a different set of genes that are now mutated and changed. And now it's another, completely, another target for us. That's why both are working.

0:50:15.7 DS: Yeah we didn't even talk about liquid biopsy which is kind of the next phase of all this too. So looking at tumor mutations just from looking at what's floating around in the blood and particularly metastatic patients. So that's something we're working towards bringing up at the moment that'll add another layer to all this because then that's always a confusing test of patience too because then you're looking for tumor mutations in someone's blood [laughter] So they they get confused what that test is for a lot of times.

0:50:48.8 AB: That's exciting stuff for sure.

0:50:49.2 DS: Yeah. Yeah. The field's moving very rapidly. Any other questions for our special guests? Here's looks like one just came in.

0:51:02.8 S5: Do you find patients who are resistant to these types of new and extra tests for these types of patients? How do you talk to them and what do you make sure to cover? 

0:51:13.3 DS: Good question.

0:51:13.3 KC: A hundred percent. Yes. So I think so I mean when I tell them about the test and I explain it and I just say I usually say like, Is that something you would wanna know or is that something you'd be interested in? I'd say the majority of people yes they they are interested in the information but I have other people who say, Well. What am I gonna do with it? I don't wanna know. Like they just they really don't wanna know. Like I already have cancer so like I don't wanna have anything worse. I don't want you to find something. So absolutely. I think the other ramification is people are always worried about what is this test gonna cost? Hands down they say, Does my insurance cover this or not? The one thing that I think is great about Myriad itself is before they'll run a test if there is a cost to the patient they will contact them and let them know, Hey there's gonna be this cost there's the ability to apply for financial aid but they won't necessarily charge the patient for a test that is not covered. Which I think is great because people are very very economically conscious these days.

0:52:19.0 AB: I would agree. I think that the cost is probably the biggest barrier to a lot of people wanting to do it and that's one of their biggest concerns. Usually, I think when we think about genetic testing sometimes we talk about just testing people because they maybe they have a family history. This is different We're testing people who have cancer and a lot of times once they have cancer they come in, you say, Hey, listen we found this now we want to get this testing on you. That, I think that, that window of people that group of people who are resistant really narrows quite a bit because you're dealing with the different patient population. They have cancer now they're worried, Okay. Well, what does this mean for other generations? My kids? What does it mean? For me in terms of how you're gonna treat me and things like this. And so they tend to be more accepting of it. But certainly there's there's always resistance as Kara said and people are... Everyone, there's never gonna be 100%. And so being able to explain to them the test why it's important really understanding the why behind the test is important. And I think that's what we do best. That's that's our job.

0:53:17.0 KC: I think it depends too...

0:53:20.9 DS: Yeah well said.

0:53:21.3 KC: Like what stage you catch them in too. Like if I'm... If somebody's just newly diagnosed and it... Is it... Not to say it won't make a difference right now but it maybe won't make a difference. I say like, Let's table it right now but I would probably encourage you to get this again. Or to revisit this as your disease is advancing. So nothing is ever closing the door. And people, a lot of cancer I think is a gradual acceptance and hearing and revisiting and revisiting again a lot of the treatments and them hearing it multiple times and kind of wrapping their head around it. Some people, Yeah, I'll do this, I'll do whatever. But sometimes there's a lot of discussion around moving on to those and and why it's important. So if they don't do it and they're not an early adopter certainly if they're failing in their treatment, I really say this is the time we really need to do this. I really need this answer.

0:54:12.4 DS: Now, any other questions? The bad news here is that prostate cancer incidence seems to be going up a bit but the good news is as you've heard that we have new and emerging tools that are making it easier and better to treat prostate cancer. So this was a a very timely pod or webinar I should say. And it'll be up on the podcast soon. But with that I wanna share, I'm gonna re-share my screen. So one, thank you so much Kara co-assistant Dr. Bacala and Rob for helping just make this really fantastic educational webinar. This was huge. We'll we'll have it posted in a few weeks and please share with your friends. Again coming back to next week or not next week in two weeks we'll have, we'll be talking about disparities in cancer genetic testing across populations.

0:55:10.4 DS: So that'll be real good with Gail Tomlinson. And then we're gonna follow up soon again with accreditation in March. Also I forgot to say at the beginning we do have a new signup if a lot of people have expressed, Hey, I'd love to just, can I just put in my email and then I can get all these coming to my Outlook calendar or whatever calendar. Yes. So please hit this little signup link and it'll give more of an evergreen access to these. And then while we're putting new ones up we can be sure to include you on the the email that goes out so that you're not having to constantly go back to this website. Unless there's other questions I think I think we're good. I mean we're at time. I'd like to be very respectful. But again can't thank you enough to our special guests today. Covered a lot of ground. Hopefully everyone took away that this is a very rapidly emerging field and that genetics is really becoming standard care across all aspects of medicine. Thank you very much.

0:56:15.2 AB: Thank you guys.

0:56:15.8 KC: Thank you.

0:56:16.8 S5: Thank you so much.

0:56:20.1 AB: Okay. Bye-bye.

0:56:20.8 DS: Have a great rest of your day. Thanks everyone for listening.

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