Pretest Video Education Versus Genetic Counseling for Patients With Prostate Cancer: ProGen, A Multisite Randomized Controlled Trial.

PURPOSE: Germline genetic testing (GT) is recommended for men with prostate cancer (PC), but testing through traditional models is limited. The ProGen study examined a novel model aimed at providing access to GT while promoting education and informed consent. METHODS: Men with potentially lethal PC (metastatic, localized with a Gleason score of ≥8, persistent prostate-specific antigen after local therapy), diagnosis age ≤55 years, previous malignancy, and family history suggestive of a pathogenic variant (PV) and/or at oncologist's discretion were randomly assigned 3:1 to video education (VE) or in-person genetic counseling (GC). Participants had 67 genes analyzed (Ambry), with results disclosed via telephone by a genetic counselor. Outcomes included GT consent, GT completion, PV prevalence, and survey measures of satisfaction, psychological impact, genetics knowledge, and family communication. Two-sided Fisher's exact tests were used for between-arm comparisons. RESULTS: Over a 2-year period, 662 participants at three sites were randomly assigned and pretest VE (n = 498) or GC (n = 164) was completed by 604 participants (VE, 93.1%; GC, 88.8%), of whom 596 participants (VE, 98.9%; GC, 97.9%) consented to GT and 591 participants completed GT (VE, 99.3%; GC, 98.6%). These differences were not statistically significant although subtle differences in satisfaction and psychological impact were. Notably, 84 PVs were identified in 78 participants (13.2%), with BRCA1/2 PV comprising 32% of participants with a positive result (BRCA2 n = 21, BRCA1 n = 4). CONCLUSION: Both VE and traditional GC yielded high GT uptake without significant differences in outcome measures of completion, GT uptake, genetics knowledge, and family communication. The increased demand for GT with limited genetics resources supports consideration of pretest VE for patients with PC.

Unsuccessful high dose IL-2 therapy followed immediately by near continuous low dose temozolomide can result in rapid durable complete and near-complete remissions in metastatic melanoma.

Metastatic melanoma remains a disease with a very poor prognosis. High dose Interleukin-2 (HD IL-2) and temozolomide (TMZ) are both approved treatments for this malignancy but response rates remain poor. HD IL-2 is the only approved therapy that has been shown to induce durable complete responses albeit in a very small percentage of patients. The combination of TMZ followed by HD IL-2 as biochemotherapy has been studied previously but did not improve responses over what had been observed for HD IL-2 alone. In our clinical practice, we noted surprising rapid and dramatic responses to TMZ when given as therapy at 75 mg/m2 for 21 days per one month cycles in 6/9 (67%) sequentially treated patients who had just completed a full course of HD IL-2 and either had failed to respond (11%) or frankly progressed (89%). The TMZ therapy began on average within 6 weeks of stopping the IL-2. All responding patients had complete or near complete responses (CR and nearCR) to TMZ. The responses became evident rapidly, typically within 1 or 2 cycles of TMZ. Three patients remain alive and completely disease free, two are off of all therapy to date. Two patients recurred after initial CR and nearCR. One patient died from an acute myocardial infarction while in a CR. One patient had prolonged stable disease and 2 patients progressed. These were much better responses than what is typically observed for single agent TMZ; indeed, durable CR to TMZ that persists off therapy is an unrecognized phenomenon to our knowledge. TMZ is an oral atypical alkylating agent that in addition to having cytotoxic activity against melanoma has also been shown to decrease the T regulatory population of lymphocytes (T-regs). We hypothesize that the TMZ may be synergistic with HD IL-2 in a sequence-specific fashion by allowing the immune activation induced by the HD IL-2 to proceed without negative feedback applied by the T-reg population of cells whose major function is to inhibit an exuberant immune response. This postulated mechanism would result in the sequence-specific activity noted in our patients. Of interest, 3/6 responding patients and 1/3 stable/ non-responding patients also exhibited persistent polyarthralgias that began on TMZ suggesting the induction of autoimmunity which may be related to anti-melanoma effects. The durable CRs that persist after the cessation of treatment suggest that this sequence-specific combination should be studied further, ideally in a prospective trial of repeated courses of HD IL-2 followed strategically by continuous TMZ.