Listen to this audio podcast to hear advanced practice providers (APPs) give an overview of the current biomarker testing landscape in patients with prostate cancer, including their thoughts on an ongoing survey exploring key barriers, communication and education unmet needs, and improving APP confidence in the application of biomarker testing.
Listen to this audio podcast covering biomarker testing in patients with prostate cancer. Learn from Sara Traverso, MMS, PA-C, and Brenda Martone, MSN, ANP-BC, AOCNP, about when to conduct germline and somatic genetic testing in patients with prostate cancer, discussing testing with patients and their caregivers, recognizing actionable biomarkers, and improving APP confidence in the application of biomarker testing results to practice.
Presenters:
Sara Traverso, MMS, PA-C
Physician Assistant
Northwestern Medicine
Robert H. Lurie Comprehensive Cancer Center
Genitourinary Oncology
Chicago, Illinois
Brenda Martone, MSN, ANP-BC, AOCNP
Nurse Practitioner
Northwestern Medicine
Chicago, Illinois
Link to full program:
https://bit.ly/3PB4ZJR
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This transcript was automatically generated from the audio recording and may contain inaccuracies, including errors or typographical mistakes.
Jerfiz Constanzo:
Hello, and welcome to this Decera Clinical Education Oncology podcast. I am your host, Jerfiz Constanzo. Today's episode features Brenda Martone, a Nurse Practitioner, and Sarah Traverso, a Physician Assistant at Northwestern Medicine Robert H. Lurie Comprehensive Cancer Center in Chicago, Illinois. Together, they will be discussing the role of advanced practice professionals APPs, regarding biomarker testing and their application in patients with prostate cancer.
This episode is part of a larger educational program entitled: The APP Guide to Actionable Biomarkers in Solid Tumors: Reducing Barriers, Promoting Confidence and Leveraging Genetic Testing for Informed Treatment Decision-Making.
For more information on Brenda and Sarah, along with the link to the complete program, including downloadable resources, clinical commentaries, and educational podcasts for lung cancer and colorectal cancer, please visit the notes for this episode.
Now, let us hear what the experts have to say regarding the role of APPs in the application of biomarker testing in patients with prostate cancer.
Sarah Traverso:
Thanks so much for having us here today. I am happy to be here with Brenda, who has been a great mentor and friend over the years, talking about this very important and relevant topic.
Oncology is really shifting and focusing a lot on targeted treatments, using biomarkers to guide treatment decisions. So I think this is a good topic to be discussing.
Brenda, I just wanted to kick it off by asking you why is biomarker testing important for prostate cancer patients?
Brenda Martone (Northwestern Medicine):
Thanks, Sarah. Happy to be here with you today also. Biomarker testing is important because there can be germline mutations, things that patients have inherited, and other somatic mutations, which are mutations that we can see in tissue. These mutations, if a patient has them, can actually be exploited with targeted therapies such as PARP inhibitors, checkpoint inhibitors. Lutetium-177 can be utilized in a PSMA-positive patient.
So, basically, the short answer is these can provide opportunities for additional treatments for patients with prostate cancer.
Biomarkers can also be prognostic in terms of possibly identifying those who have a BRCA mutation. They may have more aggressive disease. That helps providers in planning overall treatment and making good decisions.
Sarah Traverso:
Absolutely. I definitely agree. It is important, especially for prostate cancer to note that both somatic testing on the actual tumor tissue itself, as well as germline testing looking for those genetic mutations, which are somewhat prevalent in our prostate cancer patients. Both of those can be helpful not only to give them more information about their cancer, but as you said, to give us treatment guidance information for the future. So, it is important to note that. Both of those are especially important in prostate cancer patients.
And then what do you think some of the biggest barriers are for APPs and the oncology team to getting this testing done for patients in practice?
Brenda Martone:
You had sent out a survey, which I thought was extremely helpful. I am going to focus on the top four. One of the biggest barriers we are identifying which patients to test, which I am hoping throughout this podcast will help answer that question and reduce that barrier, turnaround time, in terms of waiting for the test results to come back. Sometimes depending on what the test is, it can take 10, 14 days to get those results back.
If you are waiting for a patient to get treatment started, that could be a barrier. That is also another thing that we are going to cover shortly about when and who to test so that we have that information ahead of time. Limited access to resources or guidelines, not being aware of, again, who to test or when to test or what tests to order.
Cost and reimbursement issues. We do know that genetic testing used to cost thousands of dollars, but based on technology and being able to sequence things, it has really been reduced in price. Again, patients may have a concern about that. Most commercial insurances and Medicare will cover germline testing for appropriate patients.
Also, patients and caregivers and providers may not be aware that there are patient assistance programs that are offered by many of these labs, and they can help reduce the cost down to perhaps just a couple of hundred dollars. Again, we have to be mindful that maybe in certain patients the cost could be prohibitive. Those are some of the biggest barriers, and again, which tests to order.
Sarah Traverso:
Absolutely. Even in my own practice, I have spent some time in academic medicine here, obviously, but as well as in the community before that, and I definitely think we experience some of those barriers ourselves. I am hoping through this our conversation today that will help providers in the field to learn how to overcome some of those barriers that they have been experiencing.
Brenda Martone:
When should patients be offered somatic and germline testing?
Sarah Traverso:
If a patient maybe started their treatment at an outside facility, and now they are coming to join your team, and you notice that they meet the recommendations for getting testing done, I usually will bring that up and discuss it with them, let them know why we would recommend this testing.
This testing is helpful to one to learn more about the cancer itself, to learn about their risk or their family's risk for cancer, if that is something they are interested in. It is important to note not every patient wants that information, but I do think it is important to mention to them, too, that that information can also guide treatment decisions in the future. Both the germline and somatic testing. So it is a discussion of why we should be doing it.
The results from might not impact the immediate treatment decisions upfront. A lot of these biomarkers that we look for and test for impact later lines of treatment, not necessarily first-line. That is important. A lot of times patients will want to know why should we do this now. It is really helpful to be getting it upfront.
Brenda, you had mentioned that sometimes they are not getting it early enough and turnaround time of these results might be a barrier if patients are starting to deteriorate and we are needing to change treatment fast, you do not always have the time to wait several weeks for results of biomarker testing. I always like to tell patients having it upfront, so we have the information in our back pocket when we need it will be better than scrambling if things are changing rapidly and having to wait for those results.
Sarah Traverso:
The NCCN guidelines are a great reference in terms of who should be offered somatic and germline testing. They recommend germline testing for all patients with metastatic prostate cancer, node-positive or regional, very high-risk or high-risk localized prostate cancer.
I also think it is important to be asking about family history in these patients. Definitely, if the patient has a family history of breast, ovarian, prostate, or pancreatic cancer, that should be tipping you off to be talking about germline testing.
And then for somatic testing, the NCCN guidelines recommend this for all patients with metastatic disease. So definitely just for our more advanced prostate cancer patients, as well as higher risk, we should be talking about that.
It is important too that, to note that germline testing only needs to be done once. That is looking at the patient's own DNA and genes, but somatic testing could be repeated at times of progression. That is important for patients and providers to know as well. What do you think, Brenda?
Brenda Martone:
I agree, and it is also important that we spend some time talking about somatic testing, there can be HRR recombination repair pathway mutations that we can see in tissue such as ATM or CHEK2, or CDK12 that can open the door to get a PARP inhibitor. Again, a lot of PARP inhibitors now are being used in combination with the second-generation AR inhibitor.
Obviously, a germline mutation does have that effect. If a patient has a germline mutation, how does that affect families and genetic testing, and those things need to also be incorporated into conversations with patients.
Then, with somatic testing, too, I mentioned some of those homologous recombination repair pathway mutations, but also looking for MSI-high, so microsatellite instability high on tissue or tumor mutation burden high. That would open the door for actually getting a checkpoint inhibitor in the metastatic CRPC setting.
Sarah Traverso:
With that in particular, it is not super common. I do not know about you. I definitely have a lot of patients seeing commercials on TV for immunotherapy drugs, and are often asking me if they are a candidate for that. That is something we do not see as frequently in prostate cancer. I have had a couple patients have MSI-high, and they have been able to get immunotherapy for, I think our record is 4 years for a patient even.
It is important to be checking for that. Even if it is not common, it definitely opens the door for more potential treatment options for these patients that they might not normally know about or typically have.
Brenda Martone:
That again highlights the importance of actually looking at this, because these therapies are associated with overall survival benefit. We know patients and family members and everything they want to spend as much time as possible together. Also, in terms of what biomarkers to look for. I know that can be really confusing and intimidating.
I actually came across a really good resource. The Prostate Cancer Foundation has a patient handbook about somatic and germline testing. And yes, it is geared towards patients, but it really does a good job of explaining everything and goes through which tumor markers might be associated with which therapy options. I strongly encourage the audience to visit the Prostate Cancer Foundation, look for that resource, and it is something that can be utilized in your practice.
Sarah Traverso: Yes, that is great. Especially with PARP inhibitors, we mentioned with BRCA1 and BRCA2, and there is a variety of different HRR mutations. I think this space is getting a little bit more saturated with PARP inhibitor options, and in combination with those second-generation AR inhibitors, which is great for our patients, but definitely can make it a little bit confusing in terms of what options they might be eligible for if they have any of these mutations.
Again, the more resources providers have, the better, because we have the important task a lot of times of having to discuss these results with patients. A lot of times physicians will initiate a lot of this testing at the first visit for patients, and then the APPs are seeing them back at the next visit or two for side effect check or go over some of these results.
It is important to know which markers are relevant. If you have a report in front of you, and let us say a patient has ATM or CHEK2 mutation as well as a high tumor mutational burden, how do you talk through that with a patient? Let us say the CHEK2 is on germline and the TMB was on somatic testing, how do you talk through that and explain that to patients?
Brenda Martone:
Well, patients can carry multiple mutations. The germline mutation, depending on what it is, those are inherited genes. And then with the tumor testing, those are mutations that can occur because of the prostate cancer cells and their aggressiveness. Depending on which mutation they would have, you would target the one that would be more aggressive. Also, some of the PARP inhibitors, like olaparib or niraparib as well as um talazoparib, some of their indications also would guide which PARP inhibitor you would recommend based on what mutation they have. So I think all of this in plays into what we can do streamline and do precision therapy for these patients.
Sarah Traverso:
Absolutely. It is important, too, patients will wonder if something does pop up on the somatic testing. This is a good talking point, too, especially if you are ordering some of this testing for patients, and maybe you are just doing somatic testing at first, for whatever reason, is making sure they are aware that that could actually lead us to find some germline mutations as well. Obviously, that has a little bit more implication if we find something that might be meaningful and impact their family members or their children. That is important to make sure patients are aware before going through with any of this testing, just making sure they have good informed consent.
Then this leads me to if they do have something on germline testing, the importance of talking to them about establishing with a genetic counselor. Is that something you are typically doing for patients with germline mutations as well?
Brenda Martone:
Yes, absolutely, because their expertise is needed to put out that family tree and discuss screening options and things like that. So yes, if there is a germline mutation, definitely referring to a genetic counselor.
Sarah Traverso:
That is certainly a helpful resource there.
PSMA status is not necessarily something that is looked at in somatic or germline testing that is more evaluated with these PSMA-directed PET scans. But I wanted to ask you, Brenda, how do you approach that to patients when talking about the reason to get a PSMA PET scan? What is PSMA-positive? What treatments is that going to guide for them in the future?
Brenda Martone:
When talking to patients or explaining why we are getting the scan, we know that the majority of patients with prostate cancer, especially in the metastatic CRPC setting express a protein called PSMA. So the PSMA scan is actually looking for that protein and it will light up on the scan indicating that it is positive, and if patients have PSMA-positive scan, that opens the door for them to receive targeted therapy called lutetium-177
Sarah Traverso:
I like to tell patients similar to what you said, it is a protein that can be expressed on the prostate cancer cells and we have this liquid radiation treatment that goes and binds and targets that and it is a good option for patients. And that lutetium-177, it is still in the castrate-resistant prostate cancer space, but they have been evaluating it to be used a little bit earlier.
Again, I find that this is one that patients ask about a lot. There is a lot of publicity and commercials for these types of treatments out there now, and it is important to be talking about why maybe this is not applicable for where they are at in their treatment yet, but again, might be helpful for us in the future.
Then similarly, going back to getting some of this testing done early rather than waiting till things are rapidly progressing, and then we have to wait several weeks for a scan or for testing. I think that is a helpful point to make for patients. This will be useful information for us to get now so that we can jump right to alternative treatment options in the future, if and when we need that.
Brenda Martone:
Sarah, we have talked about the importance of testing, who to test, implications, when we get that testing result. But there might be inequities. How would you mitigate some of these inequities regarding biomarker testing for prostate cancer patients?
Sarah Traverso:
It is important to refer back to those guidelines that really all patients with metastatic disease should be getting or being offered germline testing and somatic testing. That would be regardless of age, race, different social determinants of health. That is the biggest thing to remember is regardless of other factors, all metastatic patients should be getting it.
Then for patients that maybe have a lower health literacy or maybe they do have concerns about cost, keeping that in mind when approaching that conversation talking through it with them about options we might have to mitigate some of those barriers that might be in place are important to be including in your conversation when talking to them about the importance and why we should be getting it.
Ultimately, just remembering the most important is if they are metastatic, we should be having that conversation and we should be having it early, and then remembering some of those resources we have to mitigate things like cost and remembering some of the things we have said here, too, about how to describe what the importance is of this testing to patients, so that they can fully understand why we want to be doing it.
Brenda Martone:
I totally agree. With providers, APPs, etc., just feeling comfortable with the conversation and getting that information is very important and can open many doors. In terms of biomarkers and all the things we have been talking about, are there any recent updates to novel agents that our listeners might be interested in hearing about?
Sarah Traverso:
A lot of studies are being done looking at, like we mentioned, lutetium-177 earlier in the metastatic treatment space, as well as looking at PARP inhibitor use earlier in the metastatic prostate cancer space, both alone and in combination with those AR inhibitors.
One that I did want to mention is HER2 testing with the addition of low HER2-targeting drugs like trastuzumab deruxtecan, it is something to be considering for your metastatic prostate cancer patients that maybe have received multiple lines of therapy.
Brenda Martone:
I am really glad you mentioned that. Again, being aware of these things is super important, and opening doors, if they have been treated through multiple lines of therapy, that we always explore all options available and leave no stone unturned when we are looking for treatment choices.
Sarah Traverso:
Absolutely. Again, that hammers back our point of getting this early for patients. If someone is not doing well and you have to wait several weeks for that staining, that might be a window of time that you need to take advantage of. Again, doing all this testing early when you do not necessarily need it for immediate treatment planning is really important to help maximize patient outcomes. That is an important point to be discussing with patients as well when you are discussing the importances.
This is not going to change anything in the immediate future necessarily, but it will be helpful for us to have so we can act on it quickly, if we need to in the future.
Sarah Traverso:
To just circle back to using other health team members or resources, again, we mentioned referring patients over to a genetic counselor if they do have mutations on the germline testing. I definitely think it is okay to be honest with patients, if they have a marker that you do not necessarily know what the implications are going to be for them or their family. Especially if it is one that is not necessarily a biomarker-driven one that we have talked about here, because certainly these genetic panels are extensive, and they might pick up on other things not applicable to just their prostate cancer treatment. It is okay to tell patients you need to lean on a genetic counselor to give you more detailed information. That is what they have been trained for. That is what they have extensive knowledge in. It can be really helpful to just say, “I do not have all the answers on this, but I am going to get you connected with somebody that does.”
Jerfiz Constanzo:
Thank you, Brenda and Sarah, and thanks to you, the listeners, for joining us. As a reminder, to view the full program, the APP Guide to Actionable Biomarkers in Solid Tumors: Reducing Barriers, Promoting Confidence, and Leveraging Genetic Testing for Informed Treatment Decision-Making, and to access online content associated with this discussion, please click the link in the show notes. Thanks for listening.