Prostate Cancer Diagnosis

Phillip Koo, MD [00:00:00] Think about patients who just get diagnosed. I think you’re inundated with so much information and you’re trying to figure out what decision you need to make which is best for you and your family. And it’s really tricky because you’re getting so much information thrown at you all at once. Hopefully today’s webinar will bring a lot of these topics into a certain focus that will help everyone make the best decisions for them. You know in this hour we can’t cover everything but hopefully we empower you with some tools to go and ask the right questions that will lead to you know better decision making so Jim let’s start off with you. You know, everyone gets, you know hopefully everyone’s getting their screening PSAs if their PSAs are abnormal usually, they’re sent to a urologist. Walk us through what you are thinking once you get that referral and you see that patient for first time.

Jim Hu, MD, MPH [00:00:53] Absolutely, Phil. So, one thing is typically we’re not getting just one single PSA, but we’re seeing a trend. Like for example, was it done the year before or someone’s had it done last couple of months. And so, one thing to remember is that PSA normal varies by age, the older a man is, the higher the normal range for PSA. But certainly, given in the last 10 years, I’d say there’s just a highest level of evidence that someone coming in with an elevated PSA should get a prostate MRI because it just gives us so much good information in terms of the suspicion for prostate cancer that the radiologists are going to interpret. And also, it gives us the prostate volume because as we talked about, the prostate gets larger as men get older, and it’s good to index that against the prostate volume to a metric called the PSA density.

Phillip Koo, MD [00:01:42] Great. So, you know, there are different types of PSA tests out there. Do they matter? What sort of big level, high level? What are the differences? Does it matter?

Jim Hu, MD, MPH [00:01:52] Absolutely. The typical PSA is going to be your total PSA, but there’s also the percent-free PSA and that’s usually obtained when someone’s PSA is greater than four or let’s say the four to 10 level. You’re in the gray area and it’s just another test to determine, well, is it possibly cancer that’s causing that rise or is it benign prosthetic hyperplasia, the growth as we get older, right? And so. So, the lower the percent-free PSA, like less than 15%, that may trigger a greater concern that it’s the prostate cancer that is behind the rising PSA. There’s also now a 4K score, which is looking at different isoforms of PSA and the nice thing about that test is that it gives you a percent chance that a man may have clinically significant prostate cancer. So, you can decide what the next step may be based on that percent chance.

Phillip Koo, MD [00:02:47] All right, great. So, what is localized prostate cancer and what are the tests that you would order to sort of help confirm that or put patients into that category?

Jim Hu, MD, MPH [00:03:00] Absolutely. So localized prostate cancer, say a person has gotten a prostate biopsy, we look at the grade. Typically, again, I think in most practices or practices that these patients should go to, there’s been an MRI. So, the MRI will also give you a sense already if the prostate cancer is diagnosed, whether or not the cancer is confined to the prostate has spread, for example, outside the capsule into the seminal vesicles. So that gives you a localized staging definition, you know, if the grade comes back, let’s say, higher than a grade group 3 or what’s formerly known as a Gleason 4 plus
3, then the guidelines indicate that we should get a PSMA PET-CT scan, that is to look head to toe and see if the cancer has spread outside of the prostate.

Phillip Koo, MD [00:03:46] All right, great. And then after you sort of get it diagnosed, the patient receives a diagnosis of prostate cancer, what’s your approach to getting germline genetic testing, so genetic testing that you inherited from your parents, and then genomic testing on the prostate cancer sample?

Jim Hu, MD, MPH [00:04:04] Absolutely. So, you know, germline testing, for example, there’s going to be more and more patients that are very sophisticated and for example know that they have several relatives that have prostate cancer or let’s say they themselves or their family members were diagnosed at an early age. There may be a family history of breast and ovarian cancers or let say BRCA, which we now know is very common. And so in those scenarios, it’s always a good idea, I think, to do germline testing because it just helps inform that individual as well as disclosing to the family members, and the practical takeaway is, let’s say you’re BRCA positive or some of the 30 genes that are tested, for example, germline mutations, then the practical knowledge is start screening for prostate cancer at an earlier age. Let’s say 40, instead of the guidelines saying 55. Your point about genomic testing, that’s different. That’s looking at the tissue that’s been removed and sending it out for a third-party test. In which it basically determines a molecular fingerprint. It’s looking at different really RNA pathways and that molecular fingerprint is then compared to a library of thousands of men. For example, an example of a genomic test is the Decipher score. And so, we know that in looking at the grade or the appearance of cancer under the microscope, there could be some subjectivity from pathologist to pathologist. So, the Decipher score is just a nice way to get. A more standardized molecular fingerprint that can be compared to a library of individuals that have been treated years ago for which we know the long-term outcomes. I usually get that a lot of times to reinforce the decision to do active surveillance, but I know Dr. Vapiwala may use it for other reasons as I’m sure we’ll get to later.