Dr. Phillip Koo:
Welcome back to Prostate Cancer Patient Voices, where we're going on to part number two of our discussion on Decipher testing. I'm Philip Koo, and we're here again today with Dr. Eric Kim, who's the chief of Urology at the University of Nevada, Reno and Renown Health. So thanks for joining us again, Eric.
Dr. Eric Kim:
Yeah, thanks for having me, Phil.
Dr. Phillip Koo:
So we're going to go through some case studies regarding Decipher reports. So let's start off with case number one, where we discuss a patient who's NCCN high or very high risk prostate cancer based on their biopsy, and then comes back with Decipher low risk. So this is the type of report that you would receive after this test is done. Eric, walk us through this report and what this says to you.
Dr. Eric Kim:
Yeah, thanks Phil. Yeah, I think these cases are the most interesting and probably the most helpful when there's a little bit of a discordance between the Decipher score and the NCCN risk group or the clinical data that we would have. And it's, again, really nice with Decipher because it's an independent genomic test. The clinician then has to put those pieces together, and it's more, I don't want to say art than science, but it is the art of medicine.
So to your point, for this patient, and we see this often, they have probably low volume, but high-risk disease. It's Gleason 8 Grade Group 4, but the PSA is low. And we're seeing this more often with MRIs and MRI targeted biopsies because our biopsies are getting so much better, if you're hitting the worst part of the tumor, it may show up as a Grade Group 4, but the actual tumor itself, if they were to have a prostatectomy, the cancer is maybe not as bad.
And so the Decipher does a great job telling us, well, actually the genomics, the mutational profile of your cancer, it's relatively non-aggressive. And so you put those two pieces together, and for us, that would tell us if the patient wanted to go the radiation route, they wouldn't need long-term hormones with it. So instead of two years of hormones, which can be a real bear, this is a patient that we know would do very well with short course hormones, and depending on maybe the size of the tumor, the way it looks on the MRI, you could even consider no hormones with such a low Decipher score.
And so here it makes a big impact on use and duration of hormone therapy, which I think any patient that's been on hormones would tell you it is, that's a dramatic difference in their quality of life.
Dr. Phillip Koo:
That's great. That's really informative how this patient, you speak to anyone, you say, "Oh, there are Gleason 8 or Gleason 9." Obviously that's very, very scary, but getting a result like this sort of changes the perspective on how aggressive their tumor might be. Is that a safe summary?
Dr. Eric Kim:
Yeah, it really gives you a broader picture. It's not perfect. We talk about personalized medicine and really trying to figure out your specific cancer and how to treat it best. We're not quite there, but this is the step in the right direction. So instead of studies of thousands of people, it's okay, well, let's call that list down to the people that are most like you and see what worked well for them.
Dr. Phillip Koo:
And I love the other point that you brought up as well, that the data used here is independent. So Gleason score is sort of separate. Then you have the Decipher score, it's looked at independently, and it sort of provides a whole new sort of perspective on how your tumor is behaving, and then it's up to the team to balance those to really come up with that personalized plan. Is that sort of a good summary as well?
Dr. Eric Kim:
Yeah, no. I think, yeah, because it's independent, just as you're saying, it adds another tool to your toolkit of trying to figure out what's really going on with the patient and having that more holistic view. Instead of just giving you another screwdriver with a longer head, it's like, "Well, here's a brand new tool you can add to your armamentarium of figuring out what to do for this patient."
And this example is a great one where this patient, I think by clinical criteria alone, may end up getting a long course of hormones, which may be deleterious to their cardiac health, obviously impacts their muscle mass, going to impact their energy levels, maybe even their mood, and actually spares them the suffering of two years of hormone therapy and maybe gets them down to three to six months, or again, depending on size of tumor and some other factors, maybe no hormones, which is a dramatic difference.
Dr. Phillip Koo:
Yeah, that's a significant improvement. So I like these tables or these graphs that they have, and it sort of shows how that tumor is scoring on a 1.0 scale. This is another graph that shows up in those reports. Can you walk us through this?
Dr. Eric Kim:
So this is on the second page of the Decipher report. And so if you ever want to see it as the patient, you can just ask your provider, say, "Hey, you ran this test." It's a two page report. It's not all that complicated. It's not going to kill a bunch of trees. They can print it out for you. And so I think this graph's very helpful just to put it in the context of, "Hey, here's everybody that falls under that same bucket of your clinical risk criteria. Okay. And then let's just look at the people that are like you. So who are the people that are most like you?" We're not at individual personalized medicine, but again, this is a step in the right direction.
And for this guy, you'd say, "You're one of the best-looking guys in the group. You're in the second percentile of high-risk prostate cancer. Yours really doesn't behave that aggressively, and so let's figure out how to modulate the treatment to effectively treat your cancer but not give you a bunch of extra stuff that's going to have side effects that's not necessary."
Dr. Phillip Koo:
That's great. And I think the patients listening can see how powerful that is with regards to a test. So thank you. So we're going to go on to another case where you have someone who has metastatic disease, low-volume disease at the time of diagnosis. They go ahead and do a Decipher test, and it comes back as a little bit higher. So this is the score on this sample patient. So walk us through what you see here.
Dr. Eric Kim:
Yeah, so again, another discordant case, which these are not always the situation, but obviously the most impactful. And now with Decipher metastatic, which is this test report you're showing us, we know that the genomics of the prostate cancer will inform you about the behavior of the cancer even when it's left the prostate.
And so for this patient, even though maybe there's only a couple metastatic sites in the bone, we know that their tumor is very aggressive. And so to me, personally, I think these are the patients that are going to benefit the most from local therapy. So a lot of doctors may think, and some patients may have this misconception that, oh, the prostate cancer, the cat's out of the bag, so do we even need to worry about the bag anymore?
For these patients, I think maybe so. You only have a few metastatic sites, but obviously your prostate cancer has a high ability to send out metastatic clones, and so then attacking the bag may help reduce further metastatic spread or metastatic disease development. Then in the validation studies, these patients are the ones that would benefit the most from intensification. So instead of just the radiation of the prostate, plus or minus radiation of the bone, plus the hormone therapy, they really would need a second agent, so chemotherapy or Abi (abiraterone acetate), Enzalutamide, any of those secondary hormonal agents to, again, really try to be definitive about the cancer that they have.
Dr. Phillip Koo:
So oftentimes patients get a little confused with regards to what staging means versus what grading means. And I know, Eric, you have a great way to explain this, so can you help explain that for our patients?
Dr. Eric Kim:
Yeah, and thanks for the lead-in, Phil. Yeah, no, I think I often tell the patients who bring that up, grade is how fast your car can go. So what's it capable of? What's it 0 to 60? And stage is how far does the car actually traveled? So you could have a Honda Accord and it's made it halfway across the country, and a lot of that comes down to delays in diagnosis. When was your PSA checked? I know that's been a controversial topic over the past decade. I think where Decipher metastatic really helps us, it helps to further clarify the grading concept.
How fast is your car? How aggressively may it behave? Now we have all this great technology for the staging concept with MRIs, with PET scans, so we have a really clear picture or a clearer picture of how far has your disease traveled. That'll only get better. Decipher is I think the next step over just PSA and the biopsy Gleason score to tell you how aggressive can your cancer behave, what's the likelihood that it's going to develop more metastatic disease over time.
Dr. Phillip Koo:
Great, thanks. So in that Decipher report for patients with metastatic disease, this table is also inserted. Can you walk us through this table?
Dr. Eric Kim:
Yeah, so there's been, I think six, maybe it's seven now, validation studies in these phase three trials looking at Decipher metastatic and how predictive it is of intensification of your therapy. And this I think is on the second page or the bottom of the first page of the readout for the Decipher metastatic test. And this would tell you for this patient specifically who's got a higher Decipher metastatic score, addition of a secondary therapy. So not just doing hormones, but adding in abiraterone, which you're seeing in the top table, or adding in chemotherapy, which is in the bottom table, is going to be highly beneficial to that patient. There's a big survival difference by adding in that additional therapy. And so if the patient is healthy enough to withstand or take on that therapy, then this would tell us we definitely should be thinking along those lines.
Dr. Phillip Koo:
That's fascinating that this test could actually tell you how well you'll respond to a certain treatment, and I think we could all agree how important and how significant that is with regards to making treatment decisions, so.
Dr. Eric Kim:
Yeah, I think especially the Docetaxel data, again, if you look at that, the second table, the bottom one, imagine if the patient was a low Decipher. So even if they had more metastatic disease with a lower Decipher, so again, think of the Honda Accord that's traveled across the country, adding chemotherapy is only going to give them a 1% benefit. And chemotherapy we know has various toxicities. I think just about every medical oncologist I've talked to would say that the side effects or risks are greater than 1%.
So then you would say, "Okay, well..." Especially if it's an older patient who has some medical comorbidities, although in general we think, "Oh, someone with a lot of metastatic disease, we need to do more." This Decipher would really guide us toward the right path to say, "Wait a minute, this patient actually doesn't need that chemotherapy. That's not going to be beneficial to them."
Dr. Phillip Koo:
So just to summarize, in scenario one, we had a patient who was high, very high risk, who then came back with a Decipher low score, which I think provides some good information to allow the de-intensification or perhaps just not as aggressive of a treatment for that patient, which obviously is very powerful.
And then in scenario two, we had a patient who had metastatic disease, but it was low volume, their Decipher score came back as higher. So that would be a patient perhaps in which adding additional treatments and being more aggressive with the therapies would potentially benefit the patient.
So I think both cases really show the importance and the impact that this test can have.
Dr. Eric Kim:
Yeah, absolutely, Phil. No, I think, and it's not uncommon, which is important for I think patients to know that you can be high risk by your Gleason score, your PSA, and about 20% of the time the Decipher is going to come back low risk.
And so it's a not uncommon scenario that there's that discrepancy, and when there is the discrepancy, that's when it adds the most value to you, the patient, but also hopefully the clinician and the treatment team to tailor the therapy to try to personalize the care as much as possible for you.