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The current National Comprehensive Cancer Network guidelines recommend that men with metastatic, high- or very high-risk organ-confined prostate cancer undergo germline genetic testing. The guidelines also recommend that men with metastatic disease undergo somatic genetic testing and in particular, testing for BRCA1/2, PALB2, CHEK2, MSH2, and MSH6.

In a recent review in the , Dr. Sarah Fenton and colleagues outline the contemporary evidence supporting these recommendations as well as potential pitfalls and discuss the equitable application of these tools so that all prostate cancer patients can benefit.

The last decade has witnessed the widespread adoption of germline genetic testing, tumor genomics, and other biomarkers. However, challenges and barriers have been identified with their adoption in clinical practice. These include access to genetic counselors, incorporating genetic testing into clinical workflow, and financial and insurance implications, as well as challenges in the interpretation of results.

Most of the literature assessing hereditary risk is based on cohorts of primarily white men, which potentially limits the interpretation of the prevalence of these mutations in other groups.

Molecular imaging has also been widely adopted, with the introduction of ligands that can image prostate-specific membrane antigen (PSMA) with positron emission tomography (PET), for initial staging of newly diagnosed disease and also for the detection of biochemically recurrent disease. This has led to the emergence of theranostics in advanced prostate cancer in which a drug with an imaging isotope can be then swapped for a therapy isotope.

Currently, the FDA has approved [177Lu]PSMA-617 (Pluvicto) in men with metastatic castration-resistant disease and [68Ga]PSMA-11 PET CT scan positive disease.

Finally, while there has been widespread adoption of genetic testing and molecular imaging, not all these tools are developed and validated in diverse populations in which they are ultimately applied in practice. The transportability of these technologies across populations is poor if the original molecular methods were developed in a narrower discovery cohort, which is usually white.

These technologies offer hope to patients but are not often accessible to all populations on an equitable basis, particularly outside of tertiary referral centers or traditionally underserved populations, who may not have adequate insurance coverage or the financial means to access these emerging treatments.

While the solutions to these challenges appear simple, they will be difficult to achieve in the longer term. It is critical, however, that steps are taken to address these disparities.

Peter E. Lonergan, MD, FRCS (Urol.) is a consultant urologist at the Department of Urology at St. James's Hospital and Clinical Senior Lecturer at the School of Medicine of Trinity College Dublin in Ireland.

Read the review here and an interview about it here.