6 UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE The inaugural Apex (Advancing prostate cancer excellence) meeting was held in Lisbon, Portugal between 8-9 September 2023. Hosted by Bayer, the meeting was a convergence of leading prostate cancer researchers in one room to share their knowledge and expertise. The therapeutic strategies for prostate cancer have expanded rapidly - from testosterone suppression (ADT) and mitoxantrone two decades ago, to a current pool of twelve therapies (and counting) that have demonstrated an increase life expectancy. These include systemic therapies and androgen receptor pathway inhibitors (ARPI). Prostate Specic Antigen (PSA), humorously referred to as “patient/physician specic anxiety”, remains a sensitive measure of disease activity. The appropriate means to monitor disease response in the metastatic setting is uncertain. Should this be based on biochemical progression, or should it include biochemical and clinical progression bearing in mind there is often a small window of opportunity to initiate newer therapies while the patient remains in an optimal performance status. There is often a 6-month lag between biochemical progression and radiological progression while 25% of patients will demonstrate radiological progression before PSA progression. Small cell differentiation may occur during the disease process. A high serum LDH, the presence of lytic lesions, relatively low PSA in the setting of visceral disease are factors that should raise suspicion of histological transformation. While PSMA PET or targeted imaging is often used to stage patients, one needs to be bear in mind that contrast CT scan is complimentary to identify non-PET avid disease. This is important in patients with progressive disease and those planned for later lines of therapy. However, PSMA PET remains more sensitive in detection of metastatic disease as seen in the proPSMA study (J Nucl Med 2020). MRI has an established role for biopsy guidance and staging of localised disease as was conrmed in the PROMIS study (Lancet 2017). Systemic therapy is being initiated sooner, following the proven efcacy in nonmetastatic castration resistance disease as well as recent trials demonstrating a benet in high-risk disease. Nomograms in addition to risk classication can assist with the selection of appropriate therapies. The Katan nomograms and CAPRA risk model are important tools in treatment selection. Pathology Improvements in pathological assessment have been important in identifying high risk patients that will benet from earlier, longer systemic therapies in addition to local treatment. Biochemical failure is more often evident in tumours demonstrating a large cribriform pattern and intraductal carcinoma. Somatic gene testing including ® tools such as Decipher®, Oncotype Dx® and Prolaris are important in selecting the correct patients for adjuvant radiotherapy post radical prostatectomy. Castration resistant non metastatic prostate cancer (nmCRPC) nmCRPC is diagnosed by a rising PSA without any evidence of disease. The PSA doubling time (PSADT) is predictive of the risk of distant metastases and often manifests within 18 months if left untreated. One should bear in mind that contrast CT scan and bone imaging was used to exclude metastatic disease in clinical trials. Apex Chronicles Dr Sheynaz Bassa is the Head of Radiation Oncology at The University of Pretoria and Steve Biko Academic Hospital. She studied medicine at The University of Natal Medical School and graduated Summa Cum Laude in 1998. She went onto to specialise in clinical and radiation oncology at The University of Witwatersrand and completed her studies in 2006. She is a full member of the South African Society of Radiation and Clinical Oncology and the European Society of Radiotherapy and Oncology. She is also a member of the Prostate Cancer Foundation's Medical and Scientic Advisory Board. She has numerous publications to her name and has assisted with the compilation of a number of diagnostic and treatment guidelines. Dr Sheynaz Bassa Clinical and Radiation Oncologist MBCHB Univ. of Natal. FC Rad Onc (SA) University of Witwatersrand
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