Gene classifier tests for prostate cancer may influence treatment decisions despite lack of evidence for long-term outcomes

Embargoed for release until 5:00 p.m. ET on Monday 20 January 2025   

@Annalsofim         
Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.         
----------------------------      

1. Gene classifier tests for prostate cancer may influence treatment decisions despite lack of evidence for long-term outcomes

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-00700  

Editorial: https://www.acpjournals.org/doi/10.7326/ANNALS-24-03630

URL goes live when the embargo lifts          

A systematic review found that while genomic classifier (GC) tests may influence risk classifications or treatment decisions for patients with localized prostate cancer (PCa), there is a need for better data on their cost-effectiveness, clinical utility, and their impact on racial and ethnic groups, particularly Black men. The study is published in Annals of Internal Medicine. 

Prostate cancer is the most common cancer among men, with cases ranging from barely noticeable to highly aggressive ones requiring serious treatment. Determining who needs which type of treatment remains a significant challenge. Traditionally, clinicians rely on tools like the NCCN guidelines, which assess tumor stage, PSA levels, and Gleason grades. However, these tools are not perfect and can sometimes lead to overtreatment or undertreatment. Tests like Decipher by Veracyte, Prolaris by Myriad Genetics, and Oncotype DX Genomic Prostate Score (GPS) by MDx offer a genetic snapshot of tumor aggressiveness, potentially catching things that clinical tools might miss. Despite the potential of these tests, their use in clinical practice is inconsistent due to conflicting guidelines.

Researchers from the Department of Veterans Affairs reviewed 19 studies to assess the impact of these tissue-based genomic tests on risk stratification and treatment decisions for localized prostate cancer. The researchers analyzed test type, quality, population characteristics, risk reclassification and recommended and/or received treatment intensity and found that in low risk of bias observational studies, most patients with low or very low baseline risk did not see an increase in risk classification after GC testing. This pattern differed across GC test types, however, with GPS-based studies finding 0% - 11.9% of patients were reclassified to a higher risk category versus Decipher-based studies finding 12.8% to 17.1% reclassified to a higher risk category. In a randomized trial, reclassification to higher risk was more prevalent than in the observational studies examined. Observational studies indicated that GC testing often led to more patients opting for conservative management options like active surveillance.

The researchers note that the differences in results from observational and randomized trials emphasize the need for well-designed trials evaluating the impact of GC tests in management of PCa to inform patient-clinician decision-making. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Amir Alishahi Tabriz, MD, PhD, MPH, please email Kim Polacek at Kim.Polacek@Moffitt.org.

---------------------------- 

2. VA and DoD publish updated stroke rehabilitation clinical guidelines with focus on interdisciplinary approach  

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-02205 

Editorial: https://www.acpjournals.org/doi/10.7326/ANNALS-24-03568 

URL goes live when the embargo lifts         

The U.S. Department of Veterans Affairs (VA) and U.S Department of Defense (DoD) updated their 2019 clinical practice guideline (CPG) for the management of stroke rehabilitation to provide primary care providers with recommendations for the management of adult stroke patients. A summary of these guidelines relevant to internal medicine physicians and rehabilitation professionals is published in Annals of Internal Medicine.

Researchers developed 12 questions using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) framework focusing on rehabilitation methods in the following areas: motor; cognitive, speech, or language; dysphagia; spasticity; mental or behavioral health; sensory rehabilitation; neglect; technology-assisted tools; settings and models of care; and caregiver support. To glean insights for these questions, they conducted a systematic review of studies published between July 2018 and May 2023. The key areas examined in the 2024 guideline are: transitions to community, motor therapy, dysphagia, aphasia, cognition, mental health, telehealth, and noninvasive brain stimulation. 

To ease transitions to community for stroke patients, physicians can consider case management and psychosocial interventions. For motor therapy, evidence supports the implementation of task-specific practice, mirror therapy, rhythmic auditory stimulation, electrical stimulation and botulinum toxin for spasticity management. Chin tuck against resistance and respiratory muscle strength training can help manage issues relating to dysphagia, aphasia and cognition. To treat mental health conditions after a stroke, clinicians can consider selective serotonin reuptake inhibitors (SSRIs), psychotherapy and/or mindfulness-based therapies. Clinicians should also consider an interdisciplinary team-based approach to stroke rehabilitation and use these guidelines as a supplement to the Guidelines for Adult Stroke Rehabilitation and Recovery from the American Heart Association and American Stroke Association. The full Management of Stroke Rehabilitation (2024) – VA/DoD Clinical Practice Guidelines can be accessed at https://www.healthquality.va.gov/guidelines/Rehab/stroke.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Blessen C. Eapen, MD, please email blessen.eapen2@va.gov.

---------------------------- 

Also new in this issue:

Germline UBA1 Variant With Somatic Amplification in a Woman With Inflammatory Diseases and Myelodysplastic Syndrome

Maria Creignou, MD, PhD et al.

Case Report

Abstract: https://www.acpjournals.org/doi/10.7326/L4-0125