Angelo A. Baccala Jr., MD: We’ve taken the conversation to the more localized patient with prostate cancer, really looking at the benefits for these patients. It’s huge, and we understand that, but it’s hard for the patients to understand it at that time. They think, “I have localized cancer, and I know what those options are,” and you may have discussed it with them. But explaining that to the patients is important. What do you tell the patients in terms of the benefits of genetic testing at initial diagnosis if they have localized prostate cancer?
Jason M. Hafron, MD: It actually is an easy conversation because most patients are receptive to genetic testing. They’ve heard about genetic testing, it resonates well, and they’re always concerned about their family members and if they could carry this on to their sons or even daughters with BRCA1 and BRCA2 testing. Patients are very open to it. But it’s similar to a standard consent—state why we’re doing it, what the risks are, what the benefits are—and you clearly have to say that this could affect your offspring because the results of this testing may affect them and may affect your risk for other diseases. Generally, it’s a quick discussion, and I don’t get a lot of pushback. Another key that you have to discuss is there’s a lot of legal protection with the genetic results. Insurances and payers can’t hold that against you, and sometimes people will question that. Thankfully, the breast cancer surgeons have cleared a path for us where there are good protections, where this genetic information can’t be held against you.
But I really think that as urologists, we have to get to the level of how breast cancer is managed. Of women who are diagnosed with breast cancer, the majority are getting BRCA1 and BRCA2 testing. It’s well understood throughout the lay press, and they almost expect it. If you look at the incidence of BRCA1 and BRCA2 in prostate, that story is not told, but it has a higher incidence. There’s more BRCA1 and BRCA2 positivity than there is in breast cancer. It’s almost as if we should change the name from BRCA1 and BRCA2 to PRCA1 and PRCA2. But getting back to your initial question, as urologists, we’re very comfortable consenting patients. We understand the consent process, and it’s similar to how you would consent a patient for a surgical procedure.
Angelo A. Baccala Jr., MD: I get a lot of questions from patients: “What are we going to do with this specific test? We’re testing BRCA1 and BRCA2, but are there other genes?” Certainly there are. That’s why partnership with a genetic counselor is important. If they’re positive for that, they can run panels for different things. They ask about some other genes, like ATM, HOXB13, and CHEK2 and so forth, in addition to BRCA1 and BRCA2. These are some of the other genetic mutations that we may be looking for, but we’re FDA approved for the BRCA1 and BRCA2, and starting with that really helps in our role to get the ball rolling for them. It’s probably the most common for them.
As you said, I explain to them that it is important for them to know for their own knowledge, but this may change their candidacy for something like a clinical trial or a treatment with a PARP inhibitor or something like that in the future; that if this becomes more aggressive and we treat it and then they recur, we’d have those opportunities for them. Having that information in hand is important.