Faculty Bibliography

BACKGROUND:The expansion of treatment options for prostate cancer (PC) has improved disease-specific and overall survival outcomes but has also raised questions about the optimal level of treatment needed for patients based on their individual prognosis and accounting for potential toxicity, incorporating quality of life considerations. METHODS:A panel of experts met to discuss current controversies in the care of patients with PC across the disease continuum. Multidisciplinary experts review advances and persistent uncertainties in biomarker-guided assessment, imaging, and systemic therapy for prostate cancer. The discussion outlines priority gaps in evidence that must be addressed to optimize individualized patient care. RESULTS:Workshop topics included use of genomic biomarkers and artificial intelligence-guided tools to identify and manage high-risk and very-high risk localized disease, management of biochemical recurrence, identification of patients with metastatic hormone-sensitive PC who warrant treatment escalation, radiopharmaceutical therapy for metastatic castration-resistant PC including optimal sequencing of approved therapies, role of imaging in identification and management of extraprostatic disease, and lifestyle interventions to optimize survivorship. CONCLUSIONS:Many questions remain about management of PC related to biomarker-based risk stratification to guide treatment selection, use of prostate-specific membrane antigen-positron emission tomography, and balancing the risk for PC-related death with risks for treatment-related toxicity. Ongoing research efforts are needed to optimize risk-based treatment, sequence of therapies throughout the disease continuum, and survivorship care.

PURPOSE/UNASSIGNED:Underutilization of genetic testing among Hispanic males results in higher rates of variants of uncertain significance (VUS). We examined the impact of VUS on decision making and behavioral intentions. METHODS/UNASSIGNED:We conducted a nationwide survey of 807 US Hispanic males aged ≥40 in English and Spanish on perspectives about genetic testing results. Logistic regression was used to examine predictors of worry and behavior change with a hypothetical VUS result. RESULTS/UNASSIGNED:Over half of Hispanic male participants would still participate in genetic testing with a 1 in 5 chance of VUS. However, 36% were at least somewhat likely to regret testing and 49.9% would worry about cancer risk with VUS results. In addition, 56.3% were somewhat or very likely to change behavior due to a VUS, such as getting checked by the doctor more often or telling family members to get checked. Younger age and college education were associated with more worry and intended behavior change. CONCLUSION/UNASSIGNED:Although many Hispanic males are interested in genetic testing despite the higher likelihood of VUS, potential consequences include decisional regret, anxiety, and even changes in behavior. Effective counseling and support are important for minoritized groups undergoing genetic evaluation to avoid the potential to exacerbate health disparities.

BACKGROUND:Prostate cancer survivors often experience reduced health-related quality of life (QOL). Diet is related to QOL in the general population and prostate cancer survivors, with benefits observed from greater consumption of a plant-based diet post-treatment. We examined whether post-diagnostic Western and prudent dietary patterns were associated with cancer-specific QOL. METHODS:We studied 1,032 participants in the Health Professionals Follow-up Study diagnosed with non-metastatic prostate cancer (2005-2014). Diet scores were cumulatively averaged from validated food frequency questionnaires post-diagnosis. QOL was assessed with the Expanded Prostate Cancer Index Composite Short Form (EPIC-26) 2-5 years after diagnosis/treatment (2010-2016). We assessed associations between the two diet patterns and cancer-specific QOL domains (sexual function, urinary irritation/obstruction, urinary incontinence, bowel function, hormonal/vitality function), adjusting for patient, tumor, and lifestyle characteristics. RESULTS:Median age at diagnosis was 75 years; 93% had clinically localized cancer. Higher Western diet scores were associated with worse bowel function by 3 points (p-trend=0.02), below the 4-6 point threshold for clinical relevance, with suggestive trends among radiation-treated patients (p-trend=0.07). Higher prudent diet scores tended to be associated with better bowel function (p-trend=0.09). Neither diet score was associated with bowel function among patients receiving radical prostatectomy or active surveillance. There were no associations with sexual, urinary, or hormonal/vitality function. CONCLUSIONS:Among survivors of non-metastatic prostate cancer, dietary patterns were largely unrelated to cancer-specific QOL across domains and treatment subgroups. IMPACT/CONCLUSIONS:In the 2-5-year window, QOL was largely unaffected by post-diagnostic dietary patterns, warranting further research with longer follow-up to assess potential latency.

Inaccurate information about prostate cancer is widespread on online social networks in English and Spanish and spans a variety of topics from prevention and screening to treatment and survivorship. Clinicians should raise awareness that social media can be a source of misinformation about prostate cancer, preemptively address prevalent myths, and actively participate in public dissemination of evidence-based information.

BACKGROUND:Hispanic/Latinx males and those who are non-English proficient are significantly less likely to receive germline genetic evaluation for prostate cancer. Undertesting can impact downstream outcomes, including reduced access to approved targeted therapies, barriers to precision medicine trials, and hereditary cancer assessment for patients and family members. The goal of our study was to explore the knowledge and perceptions of genetic testing among U.S. Hispanic males, with the ultimate goal to identify potentially actionable targets to increase guideline-concordant genetic evaluation. METHODS:We conducted a nationwide online survey including U.S. Hispanic males aged ≥ 40 in English and Spanish using the 9-item Knowledge of Hereditary Prostate Cancer Scale and adapted questions about desire for more information from the Behavioral Beliefs about BRCA Genetic Counseling scale. RESULTS:Among 807 participants, the mean score for genetic knowledge was 5.8 out of 9, with gaps in understanding of incomplete penetrance of genes and maternal genetic inheritance. Medical mistrust and lower health literacy were associated with significantly lower knowledge of prostate cancer genetics. Overall, attitudes toward genetic counseling were favorable, with the majority of participants endorsing that it would help with decision-making, is concordant with cultural beliefs, and that they were interested in more information. Concerns about genetic evaluation included cost and impact for insurance. CONCLUSIONS:Despite generally favorable attitudes toward genetic evaluation among Hispanic males, there are important knowledge gaps, including the importance of both maternal and paternal family history, as well as logistical concerns. Addressing these gaps through culturally targeted outreach may help to promote equitable uptake of germline genetic evaluation.

BACKGROUND:Germline genetic testing is recommended for patients with prostate cancer, both localized and advanced, based on disease and family history criteria, with results that may inform targeted therapy. However, real-world utilization of germline genetic testing and potential disparities in access remain inadequately characterized. We analyzed germline genetic testing utilization in a national cohort of Medicare beneficiaries with prostate cancer, examining geographic variation and factors associated with testing. METHODS:Using nationwide Medicare claims (2019-2023), we identified patients with newly diagnosed prostate cancer and germline genetic testing claims. Patient-level geographic patterns of testing rates were evaluated using Rural-Urban Continuum Codes (metropolitan, urban, rural) and hospital referral regions. Using multivariable logistic regression, we assessed associations between residence type and germline genetic testing receipt, adjusted for sociodemographic covariates. The SEER database was used to estimate the proportion of patients meeting clinicopathologic criteria for testing. RESULTS:Among 749,202 men with prostate cancer, 17,821 (2.38%) underwent germline genetic testing. Based on SEER data, 36.5% of patients would have met clinicopathologic criteria for testing. Across 306 hospital referral regions, testing rates ranged from 0.29% to 14.1%. Urban residents were less likely to undergo germline genetic testing than metropolitan residents (odds ratio [OR], 0.85; 95% CI, 0.75-0.95). Increasing age (≥81 years: OR, 0.54; 95% CI, 0.50-0.58) and Asian ethnicity (OR, 0.69; 95% CI, 0.58-0.82) were associated with a lower odds of germline genetic testing. CONCLUSIONS:This study reveals substantial underutilization of germline genetic testing among Medicare beneficiaries with prostate cancer. Despite evidence supporting its use and benefits, <3% of patients underwent testing, even though more than one-third met established criteria. These findings underscore the need to improve regional access to testing and increase awareness among patients and physicians, particularly for older and Asian populations.

Prostate-specific membrane antigen (PSMA) PET is a powerful tool for prostate cancer staging and restaging, providing higher sensitivity and specificity than conventional imaging. The recognition of interpretive pitfalls led to the development of various scoring systems and frameworks, which in turn created challenges for consistent interpretation. The Prostate Cancer Molecular Imaging Standardized Evaluation (PROMISE) version 2 classification integrates the five-point PRIMARY score for assessing local disease, the molecular imaging TNM stage for disease extent, and the PSMA expression score to assess eligibility for PSMA-targeted radioligand therapy. The PSMA Reporting and Data System (PSMA-RADS) classifies PSMA PET/CT findings on the basis of the likelihood of presence of prostate cancer. For assessing therapy response, PSMA PET Progression (PPP) criteria focus on new lesions and clinical or biochemical progression, whereas Response Evaluation Criteria in PSMA PET/CT (RECIP 1.0) assess new lesions and changes in total PSMA-positive total tumor volume. The European Association of Nuclear Medicine (EANM) E-PSMA guideline and EANM-Society of Nuclear Medicine and Molecular Imaging procedure guidelines provide standardized reporting recommendations, incorporating elements from existing systems such as PROMISE, PSMA-RADS, and PPP. Nevertheless, such systems can be essential for optimizing prostate cancer management and facilitating communication among imaging professionals, clinicians, and patients. This article outlines these systems and discusses potential strengths and weaknesses.