“The closer you look at something, the more complex it seems to be.” So said Vinton Cerf, one of the “fathers of the internet,” in a 2008 interview for Esquire magazine.

This is certainly true for prostate cancer. Compared to how we are now able to analyze prostate cancer, the view of this disease 50 years ago was relatively simple. For example, it was not yet known how many different cell lines there are, or how prostate cancer cells behave differently at different stages.

Back then, prostate biopsy usually consisted of only 6 needle samples, three on each side. Plus, it was widely believed that even if only one of the six needles was positive for cancer, microscopic cells must be lurking throughout the gland (multifocal). Thus, each patient newly diagnosed with localized disease was given a choice of three simple strategies: radical prostatectomy, radiation, or watchful waiting.

Increasing knowledge

These notions are a thing of the past. That’s because advances in science and technology allow us to look more closely at prostate cancer cells. We now know far more complex things like

• family history of prostate cancer increases the risk for developing prostate cancer
• Why a family history of breast cancer also increases the risk for prostate cancer
• There are at least 15 distinct prostate cancer cell lines, though there are over 100 variations
• A single tumor may have different cell lines within it
• How prostate cancer cells can hide from the immune system
• How prostate cancer cells hijack the body’s resources to fuel their growth and survival.

Thus, like fingerprints, no two cases of prostate cancer are identical. The old 3-strategy menu was based on a one-size-fits-all approach. Today, we can tailor treatment strategies by taking a deeper dive into each risk level.

For localized prostate cancer, risk level is divided into four levels: low risk (Gleason 3+3 or Grade Group 1), favorable intermediate risk (Gleason 3+4 or Grade Group 2), unfavorable intermediate risk (Gleason 4+3 or Grade Group 3), high risk (Gleason 3 or above, or Grade Groups 4 and 5).

New tests take a deeper dive

New Guidelines from the American Urological Association recommend when and how to utilize new types of tests for even more details on the risk level of a patient’s localized prostate cancer. Such analysis helps with treatment planning by defining specific risk factors at the molecular level.

According to the Guidelines, basic risk information is obtained from the clinical stage, PSA, Grade Group (Gleason score) and tumor volume. However, when added risk stratification will influence treatment decisions, clinicians may use tissue-based genomic biomarkers.

The Prostate Cancer Foundation describes these deeper-dive tests in clear terms:

Somatic testing looks for specific changes in the DNA and proteins of your tumor cells that can drive tumor growth and treatment response. This test uses tumor tissue from a prostate biopsy or surgery. If tumor tissue is unavailable, a blood sample can be tested for circulating tumor DNA (ctDNA). Somatic testing is sometimes called genomic testing, tumor testing, or biomarker testing. These terms all mean the same thing.

Germline genetic testing looks at your healthy cells for gene alterations you inherited from your parents. The test is done on a saliva or blood sample. Germline genetic testing is sometimes called hereditary testing or inherited cancer risk gene testing. These terms all mean the same thing.

While somatic (genomic) testing can identify dangerous mutations carried by the tumor cells, germline testing is based on heredity, i.e. family history of cancer. Somatic testing is more relevant for treatment planning because it clarifies the nature of the cancer itself, whereas germline testing is not routinely recommended because it points to inherited risk but does not reveal specific characteristics of the patient’s cancer.

Experts disagree on whether genomic testing should routinely be done in all cases. Increasingly, more doctors are ordering such a test to increase confidence in customizing treatment, including Active Surveillance. The National Comprehensive Cancer Network (NCCN) states, “Depending on your situation, results from these tests may identify the right treatment for you and avoid under-treatment or over-treatment.”

Based on the combination of standard diagnostic clinical factors and multiparametric MRI (mpMRI), Sperling Prostate Center makes genomic testing available in order to clarify risk level if there is any ambiguity or doubt. Since focal treatment is not right for every patient, Dr. Sperling and his team use every appropriate resource to be highly confident when tailoring a treatment strategy for each patient.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.