Common Symptoms of Advanced Prostate Cancer

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Common Symptoms of Advanced Prostate Cancer from Patient Empowerment Network on Vimeo.

What are common symptoms of advanced prostate cancer? Expert Dr. Xin Gao discusses the various symptoms that patients may experience and treatments that may be used to manage these common issues.  

Dr. Xin Gao is a Medical Oncologist at Massachusetts General Hospital. Learn more about this expert Dr. Gao.

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Transcript:

Katherine:

What are common symptoms of advanced disease, and how are the symptoms managed? 

Dr. Gao:

So, with advanced disease, the symptoms can present in a variety of different ways. 

They’re often related to where the cancer has spread to. If there’s a tumor in the prostate gland itself or next to it, some patients might experience urinary symptoms, urinary frequency, feeling of incomplete emptying or a weak urinary flow. Or even pain or discomfort of leading with urination. That’s sort of the primary prostate tumor itself. Bone metastases can cause bone pain and commonly this involves bones in the spine or back or in the pelvis.  

There’s also a heightened risk of fractures with bone metastases and obviously that can sometimes cause pain. However, I think I should mention, many bone metastases actually don’t cause pain. It’s not uncommon that we see a bone scan or a CAT scan that the cancer is in multiple bones, but the patient actually, you know, I think fortunately, doesn’t feel any pain from that. 

Lymph node spread, I would say, rarely causes symptoms early on, but if there’s significant enlargement of these lymph nodes or in risking anatomic areas, sometimes the lymph nodes can cause discomfort or pain. Sometimes they can compress upon major veins or blood vessels or on the ureters that drain the kidneys and cause either blood clots or lower extremity swelling if it’s the major veins or cause kidney dysfunction because the ureters aren’t draining the kidneys appropriately. And then, I think in general, as with any advanced cancer, advanced prostate cancer can commonly cause fatigue and cause patients to just kind of generally feel unwell in sort of a hard to pinpoint type of way.  

I think it’s sort of the general toll that the cancer – the burden of the cancer is causing on the body and maybe taking, you know, essential nutrients or other things away from normal body organs or body cells. 

Katherine:

How are some of these symptoms managed? 

Dr. Gao:

So, pain, if people have pain, it’s typically managed with analgesics and pain medications, whether it’s Tylenol or ibuprofen. Other NSAID types of medications. Opiates and narcotic pain medications are commonly used for advanced prostate cancers as well to control and manage and treat the pain. And patients with cancers involving the bones that have become resistant to standard hormone therapy, we also commonly give medications called bisphosphonates. 

Zoledronic acid is a common one. Or a related medication called denosumab to try to reduce the risk of fractures, to strengthen the bones a bit. And these medications can also help with bone pain to some extent. And sometimes we treat other symptoms of cancer with medications that might help improve energy levels and improve the fatigue, for example.  

So, methylphenidate or methylphenidate  (Ritalin) is a common medication that is used to try to help with energy levels or reduced energy in advanced cancer patients. Sometimes steroid medications can do that as well, could be helpful. Appetite, reduced appetite with advanced cancer is not uncommon, although I think for prostate cancer, we see it to a lesser extent compared to other advanced cancers. 

There are other medications, steroids being one of them, and medications like mirtazapine or Remeron can be used to help try to simulate the appetite a little bit more. In terms of other symptoms, urinary symptoms, let’s say from the primary prostate tumor, that’s often co-managed with my colleagues in urology. There are medications that can be used to try to help with the urinary flow or stream in some situations or perhaps procedural interventions that might be able to help open up the urinary outlet a little bit more. Those things can be considered as well. 

How Does Prostate Cancer Progress? Understanding the Stages of Prostate Cancer

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How Does Prostate Cancer Progress? Understanding the Stages of Prostate Cancer from Patient Empowerment Network on Vimeo.

What do prostate cancer patients need to know about progression and recurrence? Expert Dr. Xin Gao discusses the difference between progression and recurrence and explains what occurs in the body in different stages of prostate cancer.

Dr. Xin Gao is a Medical Oncologist at Massachusetts General Hospital. Learn more about this expert Dr. Gao.

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Transcript:

Katherine:

Dr. Gao, this program is focusing on advanced prostate cancer. Would you walk us through how the disease progresses in each stage?  

Dr. Gao:

Sure. I think advanced prostate cancer can mean a lot of different things, but in general, it means a prostate cancer that has either spread out from the prostate gland itself to other areas of the body or has recurred despite either surgery or radiation-based therapy to the primary prostate tumor. 

In each of these situations, typically the focus would on medication types of treatments and we think about advanced prostate cancer as either hormone-sensitive or hormone-resistant, or the other term in the field for it would be castration-resistant, meaning that the prostate cancer is either sensitive to hormonal therapies or perhaps it’s no longer sensitive to the most common type of hormone therapy called androgen deprivation therapy. So, those are sort of the ways that the cancer can progress, and typically all these cancers start as hormone-sensitive prostate cancers and over time, they may evolve and become resistant and become what we call castration-resistant prostate cancer. 

Katherine:

Okay. So, they’re not numbered as in a lot of other cancers, like stage I, stage II?  

Dr. Gao:

Meaning by stage, oh. So, there are stages. All advanced prostate cancers are by definition stage IV. All advanced cancers, in general, are stage IV but advanced prostate cancer would be stage IV. Most prostate cancers actually present as localized prostate cancer, stage I, stage II, even stage III prostate cancers and the majority of localized prostate cancers are actually, fortunately, quite curable with either surgery or radiation-based therapies.  

Unfortunately, not all are curable, and some will recur despite these curative intent treatments, and others might just be inherently more aggressive biologically, and they could even present with metastatic disease or stage IV disease having spread to other sites outside of the prostate gland, even at diagnosis. 

When prostate cancer metastasizes or spreads, it commonly spreads by lymphatic vessels or by the bloodstream and most commonly, they tend to go to either lymph nodes or bones or some combination of both. More common areas of lymph node spread are in the pelvic areas, kind of near where the prostate gland is, or deep in the abdomen in an area called the retroperitoneum. And then bones more commonly could be in sort of the back or spine bones or in the pelvic bones, but it could go to other areas less common as well. 

What Questions Should Prostate Cancer Patients Ask About Testing and Test Results?

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What Questions Should Prostate Cancer Patients Ask About Testing and Test Results? from Patient Empowerment Network on Vimeo.

What are key questions for prostate cancer patients to ask about testing and test results? Dr. David Wise explains the concept of shared decision-making and advice for taking to your doctor about test results to help access quality care.

Dr. David Wise is Director of Genitourinary Medical Oncology at the Laura and Isaac Perlmutter Cancer Center at NYU Langone Health. Learn more about Dr. Wise.

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Transcript:

Dr. David Wise:

It’s a good question. I think patients, first of all, should really understand that although the oncologist often has a lot of information and often a lot of experience, the patient is the one that really should have the power to make the decisions.  

And the patient should often remind the oncologist of that, that shared decision-making is a crucial empowerment concept that patients need to understand.   

Patients come into a treatment in an incredibly vulnerable position, and that’s for a few different factors. And I think that they need to understand that they need to express their preferences, and they need to actively take part in that decision. And I think expressing that is really important. I think oncologists should also help patients understand that, that they’re the ones in the driver’s seat, that they’re the ones that have the power to make the decision, and that the position should be arrived at in a shared decision framework.  

In terms of questions patients should ask, patients should always ask about alternative. I think oftentimes, you hear maybe just treatment option that oncologist thinks might be the best, but I think it’s important to constantly say, “Well, what are the alternative here? Is there anything else that we could think about?” Perhaps that treatment that you’re suggesting sounds really exciting, but it really may not work for me for my particular context.  

So, is there another option that the oncologist may not be thinking about because it wouldn’t be their usual recommendation. But maybe in my specific circumstance, there might be something that would work better for me. I think those are the kinds of questions, continuing to voice your preferences, what you want.   

Finding the right treatment is so critical. And arriving at it from a shared decision-making, it just continues to build that relationship, and it makes for a much better dynamic over the course of that treatment and others.  

How Do Biomarker Test Results Impact Prostate Cancer Treatment Options?

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How Do Biomarker Test Results Impact Prostate Cancer Treatment Options? from Patient Empowerment Network on Vimeo.

What can biomarker test results indicate about prostate cancer treatment options? Dr. David Wise discusses genetic mutations, treatment classes, and testing methods that are commonly examined to help determine optimal prostate cancer approaches.

Dr. David Wise is Director of Genitourinary Medical Oncology at the Laura and Isaac Perlmutter Cancer Center at NYU Langone Health. Learn more about Dr. Wise.

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Transcript:

Dr. David Wise:

So, that’s a great question. So, there are multiple gene test results that can directly influence a choice of treatment. I think that it’s important to highlight two main categories, both within the genomic testing setting. Both of these test results have their major impact in patients with metastatic prostate cancer, whether the cancer has been treated already and is resistant to current treatments, or even some situations where the cancer has not even been treated.  

For metastatic prostate cancer, I think it’s important to assess whether the cancer has evidence of a BRCA1 or 2 mutation, or whether the cancer has evidence of a genetic feature called microsatellite instability, or MSI high. Cancers that have evidence of BRCA1 or 2 have clear benefit. Patients have clear benefit from treatment that targets those genes. And that’s a class of oral medications called PARP inhibitors, several of which are already FDA-approved for hormone-resistant metastatic prostate cancer with evidence of BRCA1 or 2 mutation.  

There are even newer clinical trials which are testing the use of those medicines at the outset of men who are initially diagnosed with metastatic prostate cancer, even naïve to treatment and testing whether we should be adding on PARP inhibitors for men with that genetic feature.  

Microsatellite instability, as well, leads to a clear FDA indication for immunotherapy with what we call checkpoint inhibitors that target and reinvigorate the body’s immune system. We know that prostate cancers with that particular genetic feature, which unfortunately is still an uncommon type of prostate cancer – but when it happens, it’s important to know about it because those immunotherapies can have truly life-changing, truly very long lasting, in the order of years, benefit to keeping that cancer to an undetectable level. Now, I would say, those are the key genomic features that directly translate to changes in treatment.  

There are other biomarkers, one we haven’t talked about which is very impactful, which is levels of PSMA expression on a PET scan. So, we talked about that in the setting of making a diagnosis, but it also is important for dictating best treatment. So, we now know, based on the results of a large Phase III trial that patients with prostate cancers that have PSMA uptake on PET imaging, which is an imaging biomarker, not a genetic biomarker, but an imaging biomarker.  

Those patients respond quite well to lutetium PSMA, which is a radioligand therapy that targets PSMA-producing prostate cancers. And so, those are examples of, I think, very impactful biomarkers that patients need to know about, so that they can ask their physicians to get tested to see if they’re candidates for those potential treatments.  

So, the genetic tests can be done either on biopsy material or on blood. And the latter has really been a major advance because we’ve been able to identify patients who are eligible without exposing them to an additional fresh biopsy. Sometimes, we need to because sometimes the blood does not have sufficient material to be able to establish the diagnosis. But still, it is often worth trying because, of course, we would try to do anything to avoid undergoing a risky procedure, and this is an example of that. In order to assess hereditary genetic risk, that can be done from a saliva sample. So, often, a cheek swab is enough, but testing for that is often pretty standard as well. So, that’s another option.  

So, in order to assess PSMA expression, which lends itself directly to the use of lutetium PSMA, that’s the straightforward PET scan. It’s now something that is readily available at the vast majority of academic centers and in the community as well. 

How Do Biomarker Test Results Impact a Prostate Cancer Patient’s Prognosis?

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How Do Biomarker Test Results Impact a Prostate Cancer Patient’s Prognosis? from Patient Empowerment Network on Vimeo.

How can a prostate cancer patient’s prognosis be impacted by biomarker test results? Dr. David Wise shares insight about biomarkers that are important in determining higher risk prostate cancer.

Dr. David Wise is Director of Genitourinary Medical Oncology at the Laura and Isaac Perlmutter Cancer Center at NYU Langone Health. Learn more about Dr. Wise.

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Transcript:

Dr. David Wise:

Great question. So, every biomarker needs to be considered independently.   

And whether it adds additional prognostic information to the other variables that we’ve already collected. And so, there are a few different biomarkers that we can discuss. I think that perhaps the most well-known, and in some sense very important one, is the one I mentioned before, which is the abnormal BRCA2 gene test results.  

So, patients who have that hereditary genetic mutation with BRCA2, we do have evidence that those cancers at diagnosis tend to have a higher Gleason score. They tend to be higher risk. Those cancers are still curable. Those cancers are still very treatable, but they tend to be less common in that low-risk category. So, we tend to be, at times, a bit more reluctant to manage patients with BRCA2 with surveillance alone, because their cancers typically need more intensive treatment.  

Prostate Cancer: What’s the Difference Between Hereditary and Biomarker Testing?

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Prostate Cancer: What’s the Difference Between Hereditary and Biomarker Testing? from Patient Empowerment Network on Vimeo.

What’s the difference between hereditary testing and biomarker testing? Dr. David Wise explains how biomarker testing and hereditary testing differ – and discusses the impact and potential risks of some mutations.

Dr. David Wise is Director of Genitourinary Medical Oncology at the Laura and Isaac Perlmutter Cancer Center at NYU Langone Health. Learn more about Dr. Wise.

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Transcript:

Dr. David Wise:

That’s a great question. So, hereditary genetic testing is a test that looks specifically to establish whether a person is born with a gene that predisposed them to develop that cancer, and therefore has two clear implications.  

If the test result is abnormal, then the patient was born with that gene. Therefore, other family members, first-degree relatives, may also have that gene, and that may predispose those other family members to the same cancer or to other cancers. For example, BRCA2 can predispose to the prostate cancer that the patient that we’re discussing has, but it can also predispose to breast or ovarian cancer or pancreas cancer. And if the patient has an abnormal BRCA2 gene, then their first-degree relatives have a 50 percent chance of having that gene and being predisposed to cancer, not necessarily having a guaranteed development of that cancer, but having a higher risk of developing that cancer.  

So, it has implications for family member testing or what we call cascade testing, but it also has potential implications depending on the gene. And we’re looking for, even if it’s a hereditary gene, it can still have implications for how to best treat or monitor that patient’s cancer. And so, that’s the hereditary genetic testing. Now, biomarker testing is a broader umbrella term, and it just refers to any information or test result that we collect that gives us information about how that patient is going to respond to treatment, which means a predictive result. So, it tells us potentially which treatment might work better or worse or what we call a general prognostic information.  

So, information about that patient’s…the important things to what that person is worried about: How long they’re going to live, how well they’re going to respond to treatment, how aggressive their cancer is going to be. So, that’s biomarker testing. Now, what I think is particularly confusing – and maybe I’ll shed light on this – is: Well, what’s the difference between somatic genetic testing and hereditary genetic testing?  

So, somatic genetic testing is actually testing that is focused purely on what genes were mutated in the prostate that promoted the development of that cancer. Abnormal test results on that test are not directly related to hereditary risk. Just because a patient’s cancer has mutated gene X does not mean that their family member has a predisposition to develop to having that gene. They’re completely unrelated. So, really, patients should have both types of genetic testing.  

But there are specific criteria for which patient qualifies for which type of test, and that’s a detailed conversation that needs to happen between the physician and the patient. 

Essential Testing Following a Prostate Cancer Diagnosis

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Essential Testing Following a Prostate Cancer Diagnosis from Patient Empowerment Network on Vimeo.

What essential tests do prostate cancer patients need following a diagnosis? Dr. David Wise shares an overview of imaging, scans, and targeted testing to help guide an optimal care and treatment plan for each patient.

Dr. David Wise is Director of Genitourinary Medical Oncology at the Laura and Isaac Perlmutter Cancer Center at NYU Langone Health. Learn more about Dr. Wise.

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Transcript:

Dr. David Wise:

Sure. So, that’s a great question. The testing for prostate cancer really has advanced over the last decade. So, it’s very much standard, of course, for patients to have a biopsy to confirm evidence of prostate cancer. That biopsy will assess for the Gleason score, which gives us information about how abnormal those cells look under the microscope.  

It remains the most important feature for understanding the risk of the cancer and how intensive the treatment needs to be to treat that cancer. Of course, the PSA at the time of diagnosis is also useful for that assessment of risk. And the MRI is the third key feature that we look at, the MRI of the prostate, that is, which is often done before biopsy and often guides the biopsy for the urologists to make sure that they’re sampling the most concerning nodule within the prostate. And that MRI gives us information about the extent of the cancer, whether there had been any spread of the cancer, and the overall size of the prostate cancer mass. Now, over the past few years, there’s been some changes.  

So, patients with high risk or very high risk but nonmetastatic prostate cancer are often also imaged with something called PET scan, which is specific for prostate cancer looking at the levels of a protein called PSMA. And there are several brand names that will provide that imaging test through this PET imaging scan. That also gives us an even more accurate sense of the extent of the cancer, whether it has spread or not.  

And I think what’s really important is also thinking about the genetics of the cancer. And so, for patients with high-risk early-stage prostate cancer or metastatic prostate cancer and for patients with a significant family history or with an Ashkenazi Jewish ancestry, we recommend hereditary genetic testing.  

And that needs to be distinguished from testing of the tumor itself or testing of the DNA derived from the tumor, which is called somatic testing. And it is not a hereditary test, but it’s a test that actually gives us information about the genes that are mutated and promoted at the development of that cancer. And that somatic testing is important, but it’s really critical for men who have advanced prostate cancer, metastatic hormone-resistant prostate cancer, where we already have FDA-approved treatments that are tailored to the results of those gene test results.  

So, those are really the standard tests that we think about. There are some emerging tests I think that some oncologists will recommend, and some won’t. The most prominent of those is the Decipher genomic score. So, that’s a test that also uses RNA or a type of genetic information from the cancer that can be used to assess the risk.  

And in my experience, that gives sometimes complementary information and adds further, I would say, or sheds further light on the tests that we already have. And particularly for men with otherwise intermediate risk prostate cancer, sometimes, the Decipher test can give us some more clarity, but I don’t think it’s absolutely critical at this time to order that test. I think we usually get the information that we need from the test that we have. 

Could Genetic Mutations Impact Your Prostate Cancer Treatment Options?

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Could Genetic Mutations Impact Your Prostate Cancer Treatment Options? from Patient Empowerment Network on Vimeo.

Can prostate cancer treatment options be impacted by a patient’s genetic mutations? Expert Dr. Tomasz Beer defines precision oncology and explains how DNA repair and mutations can affect treatment options.

Dr. Tomasz Beer is Deputy Director at OHSU Knight Cancer Institute. Learn more here: https://www.ohsu.edu/people/tomasz-m-beer-md-facp.

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Transcript:

Katherine:

Are there genetic mutations that affect the choices for prostate cancer treatment?

Dr. Beer:                     

Increasingly so. So, this is an exciting era in terms of those kinds of approaches. You may have heard the term “precision oncology” or “personalized oncology.” The ideas behind precision oncology is that each individual patient’s tumor is analyzed in detail for their biologic differences, and for the most part, those are mutations; although, it can be other. And that treatments may be available that work particularly well for patients whose cancers have a particular mutation. And so, today, there are a couple of categories of treatments that are FDA-approved and that can be used in prostate cancer treatment if the right mutations are present.

And one of those is a class of drugs called PARP inhibitors and those are indicated in patients with advanced prostate cancer who received some of our most commonly used routine treatments and who harbor mutations in a series of genes that are responsible for DNA repair. BRCA-2 or BRCA-2 is the most common of those, and that may be a gene that is familiar to people because it’s also a significant gene in terms of conferring risk of breast and ovarian cancer.

So, that’s the same gene we’ve been thinking about for breast cancer is also important in prostate cancer. There are other DNA repair genes as well that may sensitize a cancer to PARP inhibitors. Another area is something called microsatellite instability, which is a measure of how mutation prone a cancer is.

And cancers that acquire a large number of mutations are more likely to respond to immune therapies. And one might ask why that is, and it’s an interesting question. We believe it’s because, as a large number of mutations accumulate, we see more and more abnormal proteins that are made from those mutated genes, and those abnormal proteins, some of them are different enough from our native proteins, to cause the immune system to recognize them. And when we have an immune system that actually recognizes our cancer as foreign, we’re often able to amplify that immune signal and turn it into a potent anticancer weapon.

So, those are the two categories of mutations that we use in the clinic today, DNA repair and this microsatellite instability, but others are coming as we develop more targeted, specific agents designed for people with specific cancers who have specific mutations.

Katherine:                  

Dr. Beer, why should prostate cancer patients ask their doctor about genetic testing?

Dr. Beer:                     

Well, there are a couple main reasons for that. One is, of course, to examine their cancer and determine if they’re eligible for one of these targeted therapies. If we find those mutations, those patients have an extra treatment available to them. They can still be treated with all the hormonal therapies, chemotherapy, radiation-based treatments, but in addition to those, they have an additional targeted option. And so, that’s a real advantage for those patients who harbor those mutations. So, that’s really reason number one reason, number two is to potentially protect their families.

So, if a germline mutation is identified, that mutation can be passed on to kids. It may also be in other family members, brothers and sisters, and potentially be passed onto their kids. Important to understand that these mutations, as I alluded to earlier, are not just prostate cancer mutations. They can be passed through the mother. They can predispose folks to bre  ast cancer. So, a germline mutation may be something the family would benefit from knowing about. It’s a complicated area, learning about inherited cancer mutation in the family, could be very stressful and frightening.

So, I wouldn’t say this lightly. I think it needs to be done within the context of genetic counseling and good advice about how to communicate things like that and what to do with them. We want to be able to help people reduce their risk of cancer without taking an emotional toll on multiple members of the family.

So, it’s important, and it’s also important to do it thoughtfully and carefully.  

 

                  

 

What Do Prostate Cancer Patients Need to Know About Genetic Testing?

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What Do Prostate Cancer Patients Need to Know About Genetic Testing? from Patient Empowerment Network on Vimeo.

 What should men with prostate cancer know about genetic testing? Expert Dr. Tomasz Beer explains inherited mutations versus cancer-specific mutations and discusses the roles they can play in the development of prostate cancer.

Dr. Tomasz Beer is Deputy Director at OHSU Knight Cancer Institute. Learn more here: https://www.ohsu.edu/people/tomasz-m-beer-md-facp.

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Transcript:

Katherine:

Excellent. Let’s talk a bit about genetic testing and the role it plays in prostate cancer. I’d like to start by defining a few terms that are often confusing for patients. First of all, what is a somatic mutation?

Dr. Beer:                     

Well, so let’s first start with what is a mutation. So, we all have DNA that is the code of life in every cell in our body in the nucleus of the cell, and that is where all of the encoding for all the genes that then identify the proteins that make up our cells in our body exist. A mutation is a change in the sequence of that gene of that DNA, a missing letter, or a letter that’s been replaced by another letter, that can lead to a faulty protein being made. Sometimes, a mutation can cause a protein to be activated inappropriately.

Otherwise, we can see situations where the protein is silenced and inactive when it’s needed. So, those are mutations. Now, somatic mutations occur in a cancer. The person does not carry those mutations in their genome. They’re not passed along to their children or inherited from their parents. They happen in the cancer itself, and that’s the nature of cancer. Many cancers have a propensity to accumulate mutations, and so, a somatic mutation represents a cancer-specific mutation.

Katherine:                  

What then is the difference between somatic and a germline mutation?

Dr. Beer:                     

Yeah. So, germline is an inherited mutation. That is a mutation that is in the genetic code that that individual is born with, almost always inherited from their parents.

And I say almost always because in rare circumstances, a new mutation emerges in the fetus and becomes a germline mutation, but almost always this is a mutation that’s inherited.

And an important thing to understand about those is that because it’s in the germline, in the parent DNA, that mutation is present in every cell in the body of that human being, including the eggs and sperm, and that’s how it’s then transmitted to the next generation. Those germline mutations, they predispose people to cancer, can turn out to be deleterious and can lead to the development of cancer, typically when an additional mutation develops, and the two together team up to begin the process of cancer development.

Why Should You Ask Your Doctor About Prostate Cancer Genetic Testing?

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Why Should You Ask Your Doctor About Prostate Cancer Genetic Testing? from Patient Empowerment Network on Vimeo.

Why is it genetic testing important when it comes to prostate cancer care? Learn how test results could reveal more about YOUR prostate cancer and may indicate that one treatment may be more effective than another.

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Transcript:

Why should you ask your doctor about genetic testing?

The test results may predict how your prostate cancer will behave and could indicate that one type of treatment may be more effective than another type.

Genetic testing identifies specific gene mutations, proteins, chromosomal abnormalities, and/or other molecular changes that are unique to YOU and YOUR prostate cancer.

There are two main types of genetic tests used in prostate cancer:

  • Germline or hereditary genetic testing, which is conducted via blood or saliva and identifies inherited gene mutations in the body. Germline mutations are present from birth and can be shared among family members and passed on to subsequent generations. Results can identify whether you could be at risk for another type of cancer or if your family members may need genetic counseling and testing to guide their own cancer risk.
  • The second is somatic or tumor genetic testing, which is performed through testing tumor tissue or by testing cancer cells/DNA extracted from blood to identify gene mutations that are unique to the cancer itself. It is also commonly referred to as genomic testing, biomarker testing, or molecular profiling. Somatic mutations are NOT inherited and are NOT passed on to subsequent generations or shared among family members.
  • Depending on your history, your doctor may order one–or both–of these types of tests.

So why do the test results matter?

Both germline and somatic mutation testing can identify the presence of certain genetic mutations that may help to guide your treatment plan, and germline testing specifically can inform cancer risk for you and, potentially, family members.

  • In some cases, mutations can indicate that a newer approach, such as targeted therapy or immunotherapy, may work better for you.
  • Results of these tests may also help you to find a clinical trial that may be appropriate for your particular cancer.
  • And, genetic testing results could also show that your cancer has a mutation or marker that may prevent a certain therapy from being effective, sparing you from getting a treatment that won’t work well for you.

How can make sure you have had essential biomarker testing?

  • First, always speak up and ask questions. Remember, you have a voice in YOUR prostate cancer care.
  • Ask your doctor if you have had or will receive genetic testing, including germline and somatic testing, and how the results may impact your care and treatment plan.
  • Ask whether your family members should meet with a genetic counselor or undergo testing to help gauge their risk of developing prostate cancer.
  • And, finally, bring a friend or a loved one to your appointments to help you process and recall information.

To learn more about your prostate cancer and to access tools for self-advocacy, visit powerfulpatients.org/prostatecancer. 

Understanding Prostate Cancer Staging and Progression

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Understanding Prostate Cancer Staging and Progression from Patient Empowerment Network on Vimeo.

What are the stages of prostate cancer? Expert Dr. Maha Hussain provides an overview of prostate cancer stages and progression – and explains scans that detect disease to aid in optimal care.

Dr. Maha Hussain is the Deputy Director of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Learn more about this expert here.

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Transcript:

Katherine:

Dr. Hussain, we’re going to spend most of this conversation talking about advanced prostate cancer. But before we move on, would you give us a brief overview of the stages of prostate cancer?

Dr. Hussain:

Absolutely. So, with any cancer, we count sort of like four stages. But I would say in prostate cancer the biggest thing is when the cancer is newly diagnosed, which could be confined to the prostate or locally advanced, meaning the cancer has gotten outside the capsule of the prostate but still within that pelvic region.

There is the group of patients who have pelvic lymph nodes at time of diagnosis. And of course, that is the patients who have systemic disease, which would be technically stage four. Now, the systemic disease implies any abnormality that is found on scans that is beyond the public region. So, that could be lymph nodes in the back of the belly. That could be thoracic lymph nodes. That could be neck nodes. That could be lung lesions, of course, or bone, or liver.

Now, the most common area where the cancer goes to is really – when we talk about metastatic disease – is the bone. And then lymph is another area where the cancer goes to. Prostate cancer that is confined to the prostate is curable in the vast majority of patients. There is a category of men who undergo surgery or radiation, and then their PSA begins to go up afterwards.

And this is what we call biochemical relapse. And this is a situation where we know that, in all likelihood obviously, especially of the patients who have had their prostate out, that the cancer has spread. With the current imagine, a good chunk of times, we do not find anything because we’re able to pick up PSA that goes from undetectable to 0.2 to 0.3, but there’s not enough cancer to show up on the scans. We’re hoping, obviously, the better scans, the PET Axumin scan, the PSMA scans are going to help us to identify sites of metastases.

But this is a group of men where if there is no cancer visible and the only thing we’re dealing with is PSA that’s going up, if they’ve had surgery, then

there’s room for what we call salvage therapy with radiation and hormonal treatment. The case is a bit different if there’s only just the prostate – if radiation was given previously. And of course, we talked about metastatic disease.

Katherine:

Once someone has been diagnosed, what tests are used to help understand the aggressiveness of their disease and their overall prognosis?

Dr. Hussain:

Well, I think there is different basic things, as in, what was the extent of the cancer? How did it look under the microscope? And what is the PSA levels? So, these are the general things. There are different sort of genomic panels that the urologist will use to kind of decipher and other things to kind of help with figuring out aggressiveness and things like that. What I would say is this, is a patient who is diagnosed and has a cancer, and at a minimum has what we consider a Gleason 7 prostate cancer – so, that’s the scoring system that is done with the original Gleason score, or the new patterns where it’s talking about intermediate risk to high risk – to me, this is a cancer that needs to be treated.

And again, that’s all to do with if a person has other comorbidities, they have some other terminal condition that’s a separate story. But talking generically, that would be when we would recommend. And these are the patients that are generally not seen by the medical oncologist. They’re seen by the urologist, and then they can refer them to radiation oncology also for consultation.

Is the COVID Vaccine Safe and Effective for Prostate Cancer Patients?

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Is the COVID Vaccine Safe and Effective for Prostate Cancer Patients? from Patient Empowerment Network on Vimeo.

 What do prostate cancer patients need to know about COVID-19 vaccines? Expert Dr. Maha Hussain discusses COVID-19 vaccine safety and effectiveness — and what she’s seen with COVID-19 vaccination with her patients.

Dr. Maha Hussain is the Deputy Director of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Learn more about this expert here.

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Transcript:

Katherine:

Is the COVID vaccination safe and effective for prostate cancer patients?

Dr. Hussain:

The answer is yes and yes. So, I have to say, by default, I deal mostly with older men. Age brings in other comorbidities. And certainly, while I see all kinds of shades of gray in terms of the disease extent, going all the way from newly diagnosed all the way to end-stage disease, the bulk of the patients I end up seeing tend to have more systemic disease and have other issues going on. And I have to say, surprisingly, less than a handful of my patients had the infection.

Only one required hospitalization with supportive measure, but not even needed incubation; however, he needed a lot of CPAP and other respiratory support. I’m not aware of any of my patients or my colleague’s patients who deal with prostate cancer that have died from COVID. So, I would say that’s the good news and that we have not seen a big hit in the population that I deal with.

I also know that I would say 99.9 percent of my patients have opted to be vaccinated, and they have tolerated the vaccine just fine. There’s only one case, which I actually even saw just this week, who had been vaccinated but have a very, very severe end-stage disease with significantly compromised bone morrow, who got infected but hospitalized for a few days and is recovering.

And so, I would say just by the pool of patients I see, my answers are yes and yes.

Katherine:

Very good. Thank you.

Dr. Hussain:

And I would encourage all the audience to go get vaccinated. I myself am vaccinated. And I’ve advised all my family members to be vaccinated, just to clarify that too.

What Is a Prostate Cancer Genetic Mutation?

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What Is a Prostate Cancer Genetic Mutation? from Patient Empowerment Network on Vimeo.

 What is a prostate cancer genetic mutation? Dr. Himisha Beltran defines genetic mutations, where they may occur, and how identification of mutations can assist in prostate cancer detection and care.

Dr. Himisha Beltran is Director of Translational Research in the Department of Medical Oncology at Dana-Farber Cancer Institute. Learn more about Dr. Beltran, here.

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Transcript:

Dr. Beltran:

So, genetic mutation refers to changes in the DNA sequence of an individual or their cancer. And so, we know that normal individuals have variations in their inherited or normal DNA that drive diversity. And some of these changes actually in your inherited DNA can predispose to future development of cancer. So, those are important to identify as those are mutations that may help us guide early detection and screening strategies for people at high risk for cancer.

There are also genetic mutations in cancers themselves. And each cancer type is characterized by different patterns of mutations that can sometimes help us in the clinic figure out, where did a cancer come from? Did it come from the prostate, or did it come from somewhere else? Some of these mutations in the cancer can also be targeted with drugs. And there are drug approaches that are developed that specifically target an individual’s mutation in their cancer. And every individual, even within prostate cancer, may be different. And so, this is something that we’re commonly testing for in the cancer itself by doing DNA sequencing to look for letter changes in the DNA.

What Is a Prostate Cancer Biomarker?

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What Is a Prostate Cancer Biomarker? from Patient Empowerment Network on Vimeo.

What is a prostate cancer biomarker exactly? Dr. Himisha Beltran defines biomarkers and breaks down three types of biomarkers that help guide optimal care for prostate cancer patients.

Dr. Himisha Beltran is Director of Translational Research in the Department of Medical Oncology at Dana-Farber Cancer Institute. Learn more about Dr. Beltran, here.

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Transcript:

Dr. Beltran:

So, the word, ‘biomarker’ is a term that we often use that refers to a set of information or a test that provides insights into a particular diseased state. And in prostate cancer, there are several different types of biomarkers that we use. There are diagnostic, prognostic, and predictive biomarkers. And each of them provide different sets of information. A diagnostic biomarker is a test that improves the diagnosis of prostate cancer, and one that we are very familiar with is PSA test. This is a test that’s commonly done that may lead a suspicion of cancer. That leads to an additional work-up for prostate cancer. And there are other tests, urine, blood, and tissue-based, that can improve the detection of prostate cancer as well as specific types of prostate cancer.

Then there are prognostic biomarkers. A prognostic biomarker is a biomarker that provides insight into how indolent or aggressive a cancer is. And this can inform treatment decisions for newly diagnosed patients in trying to consider whether you should do active surveillance or get local therapy. In the more advanced disease setting, a prognostic biomarker can help us think about treatment intensification strategies for patients that are predicted to not respond as well to traditional approaches. And these are often molecular tests.

And then there are predictive biomarkers, which in opinion, are quite informative in trying to make a prediction as to how likely will respond to a specific treatment. And this is a really emerging field. And in an advanced prostate cancer, one example of a predictive biomarker is a mutation in a gene called BRCA2, which can identify patients more likely to respond to a PARP inhibitor versus those that do not. That’s just one example of how we may be able to use molecular features of a cancer to provide insights into what therapy that patient might benefit from most.

There are no perfect biomarkers. All of these types of biomarkers are just tools that we use to help guide treatment decisions at different stages of prostate cancer.

Prostate Cancer Treatment Decisions: How Do Genetic Test Results Impact Your Options?

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Prostate Cancer Treatment Decisions: How Do Genetic Test Results Impact Your Options? from Patient Empowerment Network on Vimeo.

How do genetic test results impact prostate cancer treatment options? Dr. Nima Sharifi explains BRCA mutations, germline genes, and somatic mutations—and discusses when treatment with PARP inhibitors may be appropriate.

Dr. Nima Sharifi is Director of the Genitourinary (GU) Malignancies Research Center at the Cleveland Clinic. Learn more here.

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Transcript:

Dr. Sharifi:        

There are several types of mutations that occur in prostate cancer. We know about a lot of them. We’re beginning to understand the function of many of them, and the role of just a few of them has become a bit clearer in treatment of prostate cancer. So, the one that I think has the clearest implications is something called BRCA mutations.

So, you can get mutations in genes that regulate DNA damage. This can occur in either inherited genes, or these are mutations that can occur in the cancer itself. And this will allow for tumors to become the developed – actually, greater DNA damage. The implications of using this information, genetic testing for these BRCA mutations, are actually several. One is that it may – if it comes in through the germline, then it tells us something about the hereditary or familial component of it.

So, that has implications not only for the patient but also potentially family members. And then the second set of implications has to do with treatment, and specifically treatment that in more advanced cases where there are now two FDA-approved agents that are used specifically for patients who have mutations in these genes.

And we’re still learning a lot about what these genes mean, or mutations of these genes mean for patients in their clinical course. And we’re learning much more information about other mutations which may occur in prostate cancer as well.

So, we should draw a distinction between two different types of genes. One is germline. Germline has to do with the DNA or the genes that you inherit from your parents. And the second category is somatic mutations, or somatic genetics. And this, specifically, has to do with mutations that occur in the cancer cell itself, but that are not inherited from one’s parents.

It’s a very active area of research. So, again, for the vast majority of mutations that we recognize in prostate cancer, we don’t use that to make clinical decisions. There are a few, such as the DNA damage repair genes or BRCA genes – which tell us something about the potential for a more aggressive disease course or a more aggressive disease – and also the potential appropriateness of using agents called PARP inhibitors, which seem to specifically work in patients who have mutations in the BRCA family of genes.

So, in terms of the treatment options, the major genetic tests that allow us to figure out whether systemic or drug treatment option is appropriate or not, is in DNA damage repair genes such as BRCA.

So, for example, in the case of metastatic disease that’s resistant to hormonal therapy and has already been treated with other therapies, if there is a mutation in BRCA or one of the closely related gene members, then use of a drug called a PARP inhibitor may be appropriate, and that could benefit patients.