The following content originally aired on 29th May 2025, 'Beyond the Slide' via The Oncology Podcast
BRCA testing in advanced prostate cancer is all the rage in the oncology world. With PARP inhibitors and molecular tumour testing on the horizon, understanding tissue and specimen collection has never been more important. A recent podcast between leading experts in the field - Professor Fiona Maclean, anatomical pathologist, and Associate Professor Matthew Roberts, urologist - focused on discussing the challenges and considerations around BRCA testing and tissue stewardship in prostate cancer.
Tissue Stewardship
Professor Fiona Maclean says pathologists are always looking for more tissue to do tests, but they have to balance the need for samples with the limitations of the specimens.
“We need to be sensible about how we use the tissue we have” said Maclean.
In molecular testing each test requires careful planning and an understanding of the specimen quality, as getting the tissue right the first time is key. Pathologists often work with old samples which can complicate molecular testing results. Hence the familiar debate around whether “tissue is the issue”; especially in prostate cancer where the right specimen can make all the difference to genetic testing.
Getting Quality Specimens
Assoc. Prof. Matthew Roberts says molecular testing has changed the way urologists approach biopsies.
“We now do primary tumour biopsies in metastatic patients which we wouldn’t have previously” he said.
Historically, metastatic prostate cancer patients were treated with androgen deprivation therapy (ADT) without considering molecular testing upfront. With genetic testing becoming more common - especially for BRCA mutations - testing is now a priority, even at primary diagnosis.
Optimal Specimen Selection
Experts agree that the choice of specimen is key to getting accurate results. For example, radical prostatectomy specimens are better for testing than core biopsy samples, as the latter may have fewer cells and be contaminated. Bone specimens (which are commonly used in prostate cancer as it tends to metastasise to bone) pose particular challenges, as DNA denatures during decalcification process.
Identifying the “index tumour” or the primary site of malignancy to ensure the most relevant tissue is used for genetic testing cannot be understated. Prof. Maclean also stressed the need for pathologists to document optimal blocks to make future testing more efficient.
Multidisciplinary Collaboration
The need for multidisciplinary collaboration between oncologists, urologists, pathologists and radiologists is topical. Both Maclean and Roberts agree that testing and treatment should be approached from a multidisciplinary perspective. Coordinating efforts between specialties helps ensure patients get timely and accurate results. Imaging (PET scans and MRIs) can be key in identifying the best biopsy sites, especially in metastatic disease where the index tumour may not be detectable.
The Future
What does the future hold for BRCA testing in prostate cancer? Both speakers said current testing is valuable but there is room for improvement. As testing becomes more affordable and accessible there is potential to test all patients with high grade disease and intervene earlier and have more personalised treatment pathways.
Liquid biopsy (which is already used in some cancers) was discussed as a potential future solution for prostate cancer. However, there are also limitations to this, such as the need for sufficient tumour DNA in the blood for this to work. So whilst it has potential, this is by no means a silver bullet solution.
Conclusion
Tissue stewardship and the challenges of BRCA testing in advanced prostate cancer remain important topics for healthcare clinicians in pathology. As new therapies and testing emerge, collaboration between disciplines and specimen handling will be key to advancing cancer care.
Click here to listen to the original podcast on the Oncology Network
