Men pondering prostate cancer genetic testing may find a pretest educational video preferable to genetic counseling (GC), according to a recent study published in JCO Precision Oncology.
Thousands of men are eligible for prostate cancer genetic testing to inform precision therapy, screening, and hereditary cancer risk, but a shortage of trained genetic counselors is a barrier to testing. Counseling patients with an educational video could address this issue.
“This is the first study with real-world data to publish on a pretest video in a male population in the context of prostate cancer germline testing,” said lead investigator Veda N. Giri, MD, a medical oncologist at the Sidney Kimmel Cancer Center at Thomas Jefferson University in Philadelphia, Pennsylvania, where she is director of Cancer Risk Assessment and Clinical Cancer Genetics. “Results are supportive of practice change for alternate delivery of pretest information for men to make an informed decision for genetic testing.”
The findings are from the Evaluation and Management for Prostate Oncology, Wellness, and Risk (EMPOWER) Study, which included 127 men asked to choose between pretest video-based genetic education (VBGE) or GC. Of these, 90.6% had prostate cancer and 85.7% had a family history of cancer. Study participants had a mean age of 65.5 years. The cohort was 85.8% White.
A higher proportion of patients chose VBGE over GC (71% vs 29%). The VBGE group had a higher proportion of patients who intended to share genetic testing results (96.4% vs 86.4%). Both the VBGE and GC groups had high rates of genetic testing (94.4% and 92.0%). Cancer genetics knowledge improved to a similar extent in both groups.
Factors Affecting Choice
Major reasons for choosing the video included greater convenience (62.2%), less time commitment (37.8%), and absence of waiting time to view the video (20.2%). Individuals in the GC arm received personalized counseling by telehealth or telephone. Major reasons for choosing GC included ability to ask questions to a genetics provider (62.2%) and preference or ability to do the visit from home.
The 11-minute video addressed cancer inheritance, purpose of testing, risks and benefits of testing, multigene panel options, and types of potential results. It also included implications of results for treatment, screening, and cancer management, implications of hereditary cancer risk for blood relatives, genetic discrimination laws, and possible reproductive implications. A link to the video was sent to men who chose it. The men had an opportunity to ask questions of a study investigator before proceeding with genetic testing.
Genetic testing has become important in prostate cancer because it can provide information that enables more precise therapy. For example, pathogenic variants in BRCA1 and BRCA2 may determine which men may respond to poly (ADP-ribose) polymerase (PARP) inhibitors. In 2020, the PARP inhibitors olaparib and rucaparib were approved for men with metastatic castration-resistant prostate cancer (mCRPC) who carry BRCA pathogenic variants after progression on standard therapy. Olaparib also is approved for men with pathogenic variants in several additional DNA repair genes.
“There are now 2 PARP inhibitors that are FDA-approved to treat men with metastatic, castration-resistant prostate cancer who have progressed on initial lines of therapy, and clinical activity is seen in those men who have BRCA mutations and possibly mutations in other DNA repair genes,” Dr Giri said.
With respect to study strengths, Dr Giri observed: “The sample size was robust enough to deliver meaningful results on key patient-reported outcomes, such as decisional conflict for genetic testing and satisfaction with the process. Importantly, there was no difference in uptake of genetic testing among men who chose pretest video versus genetic counseling.” Study limitations included a lack of racial or ethnic diversity.
“Urology practice is now a critical doorway into hereditary cancer information for men and their families, and genetic testing is essential to consider for men due to the impact on precision medicine, emerging impact on active surveillance, and prostate cancer screening,” Dr Giri said.
Daniel A Barocas, MD, MPH, associate professor of urology and executive vice chair for the department of urology at Vanderbilt University in Nashville, Tennessee, said genetic testing and counseling are more important than ever in the management of men diagnosed with prostate cancer. “It helps us identify potentially aggressive or lethal disease, enables patients to inform family members about harmful mutations, and, in some cases, helps determine what medications a patient will be responsive to,” Dr Barocas said.
Supported by Guidelines
Brock O’Neil, MD, an assistant professor in the division of urology at the University of Utah Hospital in Salt Lake City, said guidelines support that a growing number of men should be offered genetic testing because of increasing understanding of the important role germline genetic defects play in the development of prostate cancer. “While we are able to identify such defects in only a minority of men, the implications for treatment and screening in family members has a potentially large impact,” Dr O’Neil said. “Additionally, we are regularly learning of new potential germline mutations and the role that they play in prostate cancer, increasing the benefit of this knowledge with time.”
Awareness of the importance of genetic testing for men with prostate cancer has grown in recent years, said Todd Morgan, MD, professor of urology and chief of the division of urologic oncology at the University of Michigan Rogel Cancer Center in Ann Arbor. “There are a number of excellent guidelines on this topic, including from the [National Comprehensive Cancer Network] as well as the Philadelphia Consensus Conference, and it is critical that urologists are familiar with these guidelines since we are the primary oncology providers for so many of these patients,” Dr Morgan said.
Russo J, McDougall C, Bowler N, et al. Pretest genetic education video versus genetic counseling for men considering prostate cancer germline testing: A patient-choice study to address urgent practice needs. JCO Precis Oncol. 2021;5:1377-1386.