VOLUME 4; ISSUE 3 2025 UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE This publication is intended for registered healthcare professionals only.
VOLUME 4; ISSUE 3 2025 Editor Prof Shingai Mutambirwa - Urologist MBChB, MMed (Urology) Medunsa Head of Urology - Sefako Makgatho Health Sciences University Chairman - The South African Urological Association Academic committee Chairman - Medical and Scientic Advisory Board of The Prostate Cancer Foundation Editorial Board Dr. Sheynaz Bassa - Clinical and Radiation Oncologist MBChB (Univ of Natal), FC Rad (Onc) SA Head of Department: Radiation Oncology Steve Biko Academic Hospital and The University of Pretoria Dr Jireh Serfontein - Medical Sexologist MBChB (Pret.), Dip HIV Management, MMed Sexual Health (Univ. Sydney) Clinical head: My Sexual Health Pretoria Editorial and Publishing Ofce Maria Philippou Randburg 2194 Enquiries 082 3355 444 Publisher Maria Philippou Andrew Oberholzer Disclaimer All rights reserved. No editorial matter published in Urology, Urooncology and Sexology Update may be reproduced in any form or language without written permission from the publishers. While every effort is made to ensure accurate reproduction, the Prostate Cancer Foundation, the authors, publishers and their employees or agents shall not be responsible or in any way liable for any errors, omissions or inaccuracies in the publication whether arising from negligence or for any consequences arising there from. The inclusion or exclusion of any product does not mean that the Prostate Cancer Foundation, the publisher or the editorial board advocates or rejects its use either generally or in any particular eld or elds. This publication is intended for registered healthcare professionals only. If you received this publication or a link to this publication in error, please do not directly or indirectly use, print, copy, forward, or disclose any part of this publication. Please delete the copy or link to the publication and notify the publisher. UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE CONTENTS 1 UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE Supported by: Adjustment for imbalances in baseline characteristics in the MAGNITUDE phase 3 study conrms the clinical benet of niraparib in combination with abiraterone acetate plus prednisone in patients with metastatic prostate cancer. An interview with Dr. Karlheinz Jehle, president of the South African Urological Association Advanced delivery of leuprorelin acetate for the treatment of prostatic cancer Suit UP Saturday at the SA Congress of Oncology in Sandton on 13 September Thank you to our 2025 supporters! Empowering South African Men with Prostate Cancer: Join the Free PC-PEP Phase 4 Trial Suit Up Saturday at ESAU Cabozantinib versus sunitinib as initial therapy for metastatic renal cell carcinoma of intermediate or poor risk (Alliance A031203 CABOSUN randomised trial): Progression-free survival by independent review and overall survival update Canvas of Courage An oncologist's depictions of the emotional triad of fear, overwhelming uncertainty, and unrelenting hope faced by patients diagnosed with cancer and mental illness. 2 4 6 11 12 13 17 18 21
2 Adjustment for imbalances in baseline characteristics in the MAGNITUDE phase 3 study confirms the clinical benefit of niraparib in combination with abiraterone acetate plus prednisone in patients with metastatic prostate cancer. A summary of the article by Guilhem Roubaud, Gerhardt Attard, Martin Boegemann, David Olmos, Marco Trevisan, Laurent Antoni, Katie Pascoe, Camille Capone, Suzy Van Sandeng, Mahmoud Hashim, Stephen Palmeri, Kim Chi published in the European Journal of Cancer 209 (2024) 114183 Study Background and Objectives · The MAGNITUDE study aimed to assess the clinical benets of niraparib in combination with abiraterone acetate plus prednisone compared to placebo plus abiraterone acetate in patients with BRCA1/2-altered mCRPC. · Initial analyses indicated imbalances in baseline characteristics between treatment arms, which could affect the estimation of clinical benets and costeffectiveness. In particular, a higher proportion of patients at baseline in the niraparib+ abiraterone acetate plus prednisone (+AAP) arm had poor prognostic features versus abiraterone acetate plus prednisone (+AAP) which may have disadvantaged outcomes in this treatment group. · This analysis utilized inverse probability of treatment weighting (IPTW) to adjust for these imbalances and evaluate time-toevent outcomes. Methods Magnitude Study design The original MAGNITUDE STUDY was a phase 3, double-blind, placebo-controlled, Multicentre study in patients with mCRPC with (Cohort 1) and without (Cohort 2) alterations in HRR-associated genes (ATM, BRCA1, BRCA2, BRIP1, CDK12, CHEK2, FANCA, HDAC2, PALB2). The primary endpoint was radiographic progression survival (rPFS), dened as the time from randomisation to date of radiographic progression or death, whichever occurred rst, as assessed by blinded independent central review (BICR). The post hoc Analysis – The Inverse probability of treatment weighting Analysis Study In this post hoc IPTW analysis was performed on 225 patients with BRCA1/2-altered mCRPC to adjust for baseline imbalances on treatment effects. Outcomes were compared between those receiving niraparib plus abiraterone acetate plus prednisone and those receiving placebo plus abiraterone acetate plus prednisone. · Key outcomes assessed included: § overall survival (OS) § radiographic progression-free survival (rPFS) § time to symptomatic progression (TSP) § time to initiation of cytotoxic chemotherapy (TCC) § time to prostate-specic antigen (PSA) progression. · Weighted Kaplan-Meier curves and adjusted hazard ratios (HR) were generated to analyze the data. Results · Overall Survival: o Unadjusted median OS was 30.4 months for niraparib plus AAP versus 28.6 months for placebo plus AAP (HR: 0.79; p = 0.183). o After IPTW adjustment, median OS improved to 34.1 months for niraparib plus AAP and decreased to 27.4 months for placebo (HR: 0.65; p = 0.017), indicating a 35% reduction in the risk of death.
3 · Radiographic Progression-Free Survival: o Unadjusted median rPFS was 19.5 months for niraparib plus AAP versus 10.9 months for placebo plus AAP (HR: 0.55; p = 0.001). o Following IPTW adjustment, median rPFS increased to 22.0 months for niraparib plus AAP and decreased to 8.4 months for placebo (HR: 0.47; p < 0.001). · Time to Symptomatic Progression and Time to Initiation of Cytotoxic Chemotherapy: o Unadjusted TSP was nonestimable for niraparib plus AAP versus 21.7 months for placebo (HR: 0.56; p = 0.0056). After IPTW adjustment, TSP was nonestimable for niraparib plus AAP and 21.3 months for placebo (HR: 0.49; p = 0.0007). o Unadjusted TCC was nonestimable for niraparib plus AAP versus 28.2 months for placebo (HR: 0.60; p = 0.0192). After IPTW adjustment, TCC was nonestimable for niraparib plus AAP and 25.0 months for placebo (HR: 0.49; p = 0.0012). Discussion · The analysis highlights the importance of adjusting for baseline imbalances in clinical trials, particularly in smaller studies where chance imbalances can occur. · IPTW adjustment provided a more accurate estimate of the clinical benet of niraparib plus AAP, reinforcing the ndings from the pre-specied multivariable analysis (MVA). · The results suggest that niraparib plus AAP offers signicant clinical advantages for patients with mCRPC and BRCA1/2 mutations, which are associated with poor prognosis. Strengths and Limitations · A key strength of the IPTW method is its ability to create balanced pseudopopulations while retaining data from most participants, enhancing the robustness of the ndings. · Limitations include the potential impact of unadjusted baseline characteristics and the lack of a pre-specied method for handling missing data, although the majority of patients had complete data. · The analysis did not explore the impact of baseline imbalances on adverse events, which is crucial for assessing overall treatment benet versus risk. Conclusions · The IPTW analysis conrmed the clinical benet of niraparib plus AAP in patients with mCRPC and BRCA1/2 alterations, showing a greater reduction in the risk of death and progression compared to unadjusted analyses. · These ndings support the use of niraparib plus AAP as a rst-line treatment option and emphasize the need for robust methodologies in future clinical trials to account for baseline imbalances. · The study's results are relevant for regulatory and cost-effectiveness assessments, providing a framework for future analyses in targeted populations.
4 An interview with Dr. Karlheinz Jehle, president of the South African Urological Association It's been just over a year since Dr. Karlheinz Jehle took over the reins as the president of SAUA. In this interview he shares some insights about his journey into urology, the role of SAUA in dealing with the challenges faced by the rising prostate cancer burden, and how AI and technology are affecting the urology profession. Dr Karlheinz Jehle was educated in Cape Town and graduated MBChB from the University of the Free State in 1998. He obtained his Membership of the Royal College of Surgeons of England in 2006. He returned to Cape Town and completed his urology specialist training at Groote Schuur Hospital in 2011, where he was awarded a master's degree from the University of Cape Town with his dissertation on ultrasound guided prostate biopsies. He was awarded the Philip Smith prize in 2012 as the best postgraduate student in Urology. He was appointed Senior Lecturer in the Division of Urology at Groote Schuur and New Somerset Hospitals until 2018 and maintains an interest in research and medical education. He has a broad interest across the subspecialties of Urology. He is a Fellow and Examiner of the College of Urologists of South Africa, and a member of the South African and European Urological Associations and the International Hypospadias Society. He is the current President of the South African Urological Association. What inspired you to become a urologist? I knew early on that I wanted a surgical career. During my early surgical training in the UK, I rotated for six months in urology. I found the team dynamic and the work environment in urology enjoyable and was drawn to the diversity within the eld, compared to a subspecialisation in general surgery. That experience, along with mentorship from colleagues like Declan Murphy, who was a registrar at the time, inspired me to pursue urology. Being a urologist in private practice must be pretty demanding on your time, so what made you volunteer for the position of President of The South African Urological Association? I put my hand up to get involved as an Exco member a few years ago, because I felt that the association needed more people to share the workload, and our group practice in Cape Town has a long tradition of involvement with the SAUA. I believe it is important to work together as doctors. Professional associations are vital in achieving this and I wanted to contribute my time towards growing our association. What is the biggest challenge facing the Urology profession in South Africa? The biggest challenge is sustainability. We face unprecedented challenges in terms of the future of private practice, the future of urology training and academic urology in South Africa, and the need to address universal access to healthcare. Similarly, internally, our association relies on a handful of people, which in the past has led to burnout and a lack of continuity in projects. I think the SAUA needs better funding, professional management, and an organisational structure that ensures our work continues beyond individual terms of ofce. I hope that during my term at the helm, I can convince my colleagues of this vision for the future.
5 The latest Globocan statistics on prostate cancer, show that South Africa has one of the highest mortality rates from prostate cancer. In addition, actuarial forecasts commissioned by Cancer Alliance in 2021 show that prostate cancer will be the most common cancer in South Africa by 2030. The South African public sector appears to be hopelessly ill-prepared to deal with the coming prostate cancer Tsunami. What role can the SAUA play in addressing these challenges? The SAUA has an important role to play. Urologists are at the forefront of the ght against prostate cancer. Education is important. Awareness is equally important from a public health perspective. I don't think it's just the public sector that's unprepared, the private sector is also struggling with the rising cost of treatments. I believe we need to recognise the high risk in men of African descent and promote earlier, risk-based screening. The SAUA is involved in obtaining data more relevant to our local population and is instrumental in collaboration with international prostate cancer researchers. We're working to shift diagnosis to earlier stages of the disease, which will hopefully allow for earlier and more cost-effective treatments for those who need it. Technological innovations are changing the face of urology at a rapid pace. Robotic surgery has been a game changer as have the new medications for treating biochemical recurrence and advanced prostate cancer. Are we reaching a stage where urologists, like many other disciplines, will start to super specialise in order to be able to provide their patients with optimal care? Super-specialisation is denitely the future, but in South Africa, we don't have the volume or funding to support it everywhere. We need better training, accreditation, and collaboration between public and private sectors. Mentorship and national registries are also essential to ensure quality and safety as we move forward. We know that robotic prostatectomy outcomes are best when done by high volume surgeons at high volume centres. Should patients have access to this information to assist them with choosing a surgeon? I support transparency, but publishing individual surgeon numbers in South Africa could have unintended negative consequences for the majority of practitioners because the nature of state and private practice in South Africa means our patient volumes are generally lower, compared to rst world cancer treatment centres. I think national surgical registries and patient education initiatives are better ways to empower patients to make informed choices. Given that most urologists who graduate have had limited exposure to robotic surgery, does SAUA have any plans to set up fellowships for graduating urologists who want to become robotic surgeons? We have successfully set up the Robotic Surgery Interest Group within the SAUA. They have been working on establishing standardised training pathways for robotic surgery, involving international opinion leaders, industry, academic units and local experts. I rmly believe local fellowships are the future for specialised training, and it is our duty to pool our collective resources within the country to train our surgeons to the highest possible level. This can only be achieved if we think outside the box and pursue innovative solutions to our training challenges. Private public partnerships are certainly achievable in the immediate future. AI is likely to have a profound and multifaceted impact on medicine, enhancing diagnostics, enabling personalised treatment, and speeding up drug development. What is SAUA doing to prepare for the impact of AI on urology? We're exploring ways to give our members better access to medical AI tools, like AI-driven note-keeping and diagnostic support. AI is already improving patient information, improving diagnostic accuracy, for example in prostate MRI reporting, enabling urologists to more easily target abnormal areas with biopsies. The SAUA is negotiating broader access to these technologies for our members. Tell us about your interests and hobbies, and how you manage to balance work, family and recreation. I enjoy mountain biking and riding my motorbike, and I try to spend as much time as I can with my family. Honestly, I nd achieving work-life balance is tough, and I don't always manage it as well as I'd like.
6 Advanced delivery of leuprorelin acetate for the treatment of prostatic cancer A summary from the article by Axel S Merseburger & Marie Christine Roesch published in Expert Review of Anticancer Therapy 2022, Vol. 22, No. 7, 703 – 715. 1. Introduction Prostate cancer (PCa) is the most common cancer in Europe, with an increasing incidence projected from 2020 to 2030. Androgendeprivation therapy (ADT) is the cornerstone treatment for advanced and metastatic prostate cancer PCa, aiming to reduce serum testosterone levels to castration levels (<20 ng/dL) and thus inhibiting the growth of tumour cells. Luteinizing hormone-releasing hormone (LHRH) agonists and antagonists are widely used due to their effectiveness and tolerability. Due to its favourable tolerability, leuprorelin acetate (LA) is well established as one of the leading luteinizing hormone-releasing hormone (LHRH) analogues. A second-generation LA depot formulation has been developed to ensure a controlled and sustained release of leuprorelin between injections and to reduce testosterone levels more efciently compared to conventional LHRH agonists. 2. Leuprorelin Acetate for the Treatment of PCa: Biological and Clinical Rationale Leuprorelin acetate, a synthetic analog of gonadotropin-releasing hormone (GnRH), has been used for over 30 years to treat PCa. It effectively lowers testosterone levels, delays tumour progression, and alleviates symptoms like bone pain. Its tolerability and exibility of administration make it one of the leading LHRH analogs worldwide. 3. Advanced Delivery of Leuprorelin Acetate 3.1. LA Gel Depot Pharmacokinetics The LA gel depot formulation uses the Atrigel® delivery system to provide sustained testosterone suppression over 6 months (45 mg formulation) and is also available in 1- and 3month formulations (7.5 mg and 22.5 mg formulations). After injection, leuprorelin acetate levels rise initially and then stabilize at a constant level, ensuring no accumulation over long-term treatment. Editors note: the 1 month formulation is not currently available in South Africa 3.2. Therapeutic Activity of the LA Gel Depot The latest evidence suggests that a proper threshold for testosterone levels should be <20 ng/dL as the mean testosterone level achieved by surgical castration is 15 ng/dL. The LA gel depot achieves testosterone suppression below 20 ng/dL in most patients, with minimal testosterone breakthroughs. Clinical trials demonstrated its efcacy in reducing testosterone and PSA levels, with consistent results across all formulations. 3.2.1. Pivotal Trials Three pivotal trials conrmed the LA gel depot's ability to suppress testosterone levels to ≤20 ng/dL in 88–97% of patients, depending on the formulation. Minimal testosterone breakthroughs (<1%) were reported, and PSA levels decreased signicantly. This sustained and persistent testosterone suppression is of clinical relevance as testosterone ares are often associated with morbidity.
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8 3.2.2. Post-Marketing Clinical Trials and Analyses Post-marketing studies conrmed the LA gel depot's effectiveness in routine clinical practice, showing consistent testosterone suppression and PSA reduction across diverse patient populations, including those switching from other therapies. 3.2.2.1 Effectiveness and safety of the 6-month LA gel depot formulation for the treatment of advanced PCa in routine clinical practice This prospective observational study included a total of 1,273 PCa patients that were involved and observed for 1 year. The study conrmed the effectiveness and safety of the 6-month LA gel depot formulation in routine urological practice. 3.2.2.2. Effectiveness and tolerability of 1- and 3-month LA gel depot formulations for treating advanced PCa in routine clinical practice This prospective observational study, conducted in Belgium (MANTA study), evaluated the effectiveness and tolerability of the 1- and 3-month LA gel depot formulations in 243 prostate cancer (PCa) patients over a minimum period of 3 months. Results showed a 94% reduction in median testosterone levels (from 360 ng/dL to 20 ng/dL) and a 95% reduction in median PSA levels (from 12 ng/mL to 0.6 ng/mL). 3.2.2.3. Effectiveness of LA gel depot to achieve low nadir testosterone in PCa patients This study assessed the ability of the LA gel depot to achieve low nadir testosterone levels, which are associated with delayed disease progression and improved survival. Data from pivotal trials showed that the LA gel depot consistently reduced testosterone levels to ≤20 ng/dL within 4 weeks and ≤10 ng/dL by 5 weeks. The suppression was maintained consistently across all formulations, with 100% of patients achieving testosterone ≤50 ng/dL, 94–99% achieving ≤20 ng/dL, and 66–85% achieving ≤10 ng/dL. These results highlight the depot's effectiveness in maintaining low testosterone levels critical for improved clinical outcomes. 3.2.2.4. Evaluation of the LA Gel Depot in Achieving and Maintaining Castrate Testosterone Levels This analysis evaluated the ability of the LA gel depot to reduce and maintain testosterone levels ≤20 ng/dL in 348 advanced prostate cancer (PCa) patients across three formulations (1-month, 3-month, and 6-month). Results showed that testosterone suppression was achieved within 6 weeks in 90–96% of patients, with 90–97% maintaining suppression throughout the study. Mean testosterone levels at the end of therapy were ≤20 ng/dL for all formulations: 6 ng/dL (1-month), 10 ng/dL (3-month), and 13 ng/dL (6-month). The study conrmed the depot's effectiveness in achieving consistent and durable testosterone suppression. 3.2.2.5. Evaluation of the Pharmacokinetics of the LA Gel Depot and the Impact of Age and Body Weight on Testosterone Reduction This analysis assessed the pharmacokinetics (PK) and pharmacodynamics (PD) of the LA gel depot in advanced prostate cancer (PCa) patients, focusing on the inuence of age and body weight. Results showed that leuprorelin acetate levels were consistently maintained between 0.05 and 1 ng/mL from week 6 to week 24 across all formulations (1-, 3-, and 6month). Age and body weight did not affect testosterone suppression, which was achieved and maintained in all subgroups, including patients with higher body weights (>120 kg) and younger ages (<60 years). The study conrmed the depot's consistent and long-lasting drug delivery and effectiveness, regardless of patient demographics. 3.2.2.6. Comparison of Subcutaneous and Intramuscular Leuprorelin Acetate Formulations This study compared the pharmacokinetics (PK) and pharmacodynamics (PD) of the 1month LA gel depot (subcutaneous) with the 7.5 mg intramuscular leuprorelin acetate (IMLA).
9 The LA gel depot showed a longer duration of drug delivery and testosterone suppression compared to IM-LA. While IM-LA had a higher initial release and shorter Tmax (time to peak concentration), testosterone levels began to rise by day 42 in IM-LA patients, whereas the LA gel depot maintained suppression for over 50 days in most patients. The LA gel depot demonstrated more consistent and prolonged testosterone suppression, making it a more effective option for advanced prostate cancer treatment. 3.2.2.7. Evaluation of Late Dosing on Testosterone Suppression with LA Gel Depot and Microsphere Formulations This study analysed the impact of late dosing on testosterone suppression in prostate cancer patients treated with LA gel depot and LA microsphere (LA-MS) formulations. Late dosing was dened using two criteria: a "28-day month" and an "extended month." Results showed that late injections were common for both formulations, but the LA-MS treatment had higher rates of testosterone breakthroughs compared to the LA gel depot. For late injections, LA-MS was 1.5 times more likely to result in testosterone levels above 50 ng/dL or 20 ng/dL. The LA gel depot demonstrated better testosterone suppression consistency, even with delayed dosing, highlighting its effectiveness and reliability in maintaining therapeutic outcomes. 3.2.2.8. Evaluation of Intermittent vs Continuous Androgen Deprivation Therapy (ADT) The ICELAND study compared intermittent androgen deprivation (IAD) and continuous androgen deprivation (CAD) in patients with non-metastatic relapsing or locally advanced prostate cancer. Both regimens showed similar efcacy, tolerability, and quality of life outcomes. A post-hoc analysis further examined the correlation between testosterone levels during the rst year of CAD and survival outcomes. Patients were stratied into three groups based on testosterone levels: minimum (≤20 ng/dL), median (>20 to ≤50 ng/dL), and maximum (>50 ng/dL). All groups demonstrated comparable causespecic survival rates and time to PSA progression, indicating that CAD effectively lowers testosterone levels and maintains clinical benets regardless of the subgroup. 3.3. Safety of LA Gel Depot The LA gel depot is well-tolerated, with mild to moderate adverse events such as hot ushes and injection site reactions. It is contraindicated in patients with spinal metastases, spinal cord injury, and hypersensitivity to leuprorelin. 4. Expert Opinion The attributes for a perfect ADT are a sustained release of the drug between two injections, a sufcient and rapid suppression of the serum testosterone level and the reduction of testosterone breakthroughs. The leuprorelin acetate gel depot provides an advanced delivery method for advanced PCa due to its sustained testosterone suppression, minimal breakthroughs, and favourable safety prole. The 6-month formulation is associated with half the risk for patients to lose therapeutic effect due to delayed injection and thus provides improved patient compliance and quality of life by reducing injection frequency. It is a reliable backbone therapy for systemic treatment in metastatic hormone-sensitive and castration-resistant PCa. 5. Conclusion ADT remains the backbone therapy of advanced PCa. Among different options, longacting LHRH agonists represent the gold standard and the most used worldwide form of ADT. The leuprolide LA gel depot represents a second-generation LA formulation developed to ensure a controlled and sustained release of leuprorelin between injections and to reach lower castrate testosterone levels compared to other LHRH agonists.
10 The leuprolide LA gel depot represents an advanced delivery method for ADT, offering long-term efcacy, tolerability, and convenience. The collected data suggests that give its consistent testosterone suppression and improved patient outcomes it may be recommended as the ADT of choice for advanced Pca. Acknowledgments Editorial and graphical assistance were provided by Polistudium SRL, Milan, Italy, with funding support from Recordati S.p.A. Declaration of Interest The authors disclosed nancial relationships with various pharmaceutical companies, including Recordati S.p.A., but declared no other conicts of interest. Peer reviewers reported no relevant nancial or other relationships. Editor's note: This article was created using several editorial tools, including generative AI models, as part of the process. Human review and editing of this content were performed prior to publication.
11 Suit UP Saturday at the SA Congress of Oncology in Sandton on 13 September Radiation oncologist Dr Prinitha Pillay Winner of the best dressed man – Dr Chuma Njovu Winner of the best dressed woman prize, Elsie Llale Medical Oncologists Dr Devon Moodley and Dr Ronwyn Van Eeden PCF's CEO Andrew Oberholzer with PCF's Chairman Dr Lance Coetzee Winner of the wackiest dressed prize – pharmacist Marthie Hendriksz Thanks to Bionike and Dischem for the Suit Up Saturday prizes
12 Thank you to our 2025 supporters!
13 By Dr. Rob Rutledge, Radiation Oncologist, and Dr. Gabriela Ilie, Endowed Scientist in Prostate Cancer Quality of Life Research, Dalhousie University. A transformative opportunity is now available for men in South Africa diagnosed with prostate cancer: participation in a free, evidence-based Phase 4 trial of the Prostate Cancer Patient Empowerment Program (PCPEP.org/za). What is PC-PEP? PC-PEP is a comprehensive, home-based, daily 6-month program designed to support men at any stage of prostate cancer care—from active surveillance to post-treatment recovery. It is suitable for patients scheduled (or not) for prostatectomy (RP), radiation therapy (RT) with or without hormone therapy (HT or ARAT), or active surveillance (AS). Delivered via 182 daily emails and short 5-minute videos, PC-PEP guides participants through: • Daily exercise routines: Aerobic and home-based strength training by video • Pelvic oor training: Three 10-minute video sessions daily • Stress reduction: Daily 10-minute relaxation techniques • Dietary advice and cooking videos • Healthy lifestyle coaching: sleep hygiene, and relationship support. • Optional peer support: Weekly buddy calls and monthly group videoconferences A 10-minute overview video is available on the program's website: www.PCPEP.org Is PC-PEP Effective? In a randomized controlled trial of 128 men undergoing RP or RT ± HT, PC-PEP demonstrated statistically and clinically signicant improvements in mental health (K10 scores) at 6 and 12 months compared to standard care. The results are published in European Urology. Additional analyses show benets in urinary symptoms, quality of life, and reduced healthcare visits. Feedback from both patients and clinicians has been overwhelmingly positive. Empowering South African Men with Prostate Cancer: Join the Free PC-PEP Phase 4 Trial
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15 Phase 4 Trial Expansion – Now Open in South Africa The PC-PEP Phase 4 trial is expanding internationally, including to South Africa, and is open to any man with a prostate cancer diagnosis—from active surveillance to metastatic disease—with an expected survival of more than two years and medically safe to exercise. This trial features: • Comprehensive quality-of-life assessments at baseline, 6, 12, and 24 months. • Opportunities for co-authorship in pooled data publications. • Zero cost to participants. • Simple enrollment: Takes just 15 seconds in clinic to direct patients to www.PCPEP.org, and our study team will take care of enrollment from there. Join the Movement PC-PEP is more than a program—it's a Community of Empowerment. By participating, men gain tools to take charge of their health, connect with peers, raise awareness of prostate cancer and screening, and contribute to groundbreaking research that is shaping the future of prostate cancer care. “Having experienced the practical and comprehensive PEP program, I am in no doubt that for any man facing prostate cancer, PEP should be an essential and integral part of their health and wellness regime” -Iain Johnston, Patient Affairs Chairman, PCFSA Dr. Gabriela Ilie, PC-PEP Principal Investigator; Dr. Conray Moolman, Robotic Urological Surgeon, Cape Town; Dr. Rob Rutledge, PC-PEP Clinical Lead; and Mr. Cody MacDonald, PC-PEP Project Manager. Dr. Lance Coetzee, Robotic Urological Surgeon, Pretoria and Dr. Gabriela Ilie, PC-PEP Principal Investigator
16 Dr. Rob Rutledge, PC-PEP Clinical Lead and Dr. Gabriela Ilie, PC-PEP Principal Investigator with Urology Nurses from across South Africa Dr. Rob Rutledge, PC-PEP Clinical Lead, Dr. Gabriela Ilie and Cody MacDonald, PC-PEP Project Manager on a recent trip to South Africa where they presented at the ESAU congress in Pretoria.
17 Suit Up Saturday at ESAU Winner of the best dressed lady prize, Prof Lisa Kaestner from Cape Town with PCF CEO Andrew Oberholzer Winner of the best dressed man prize, Dr Smit Van Zyl from Polokwane with PCF CEO Andrew Oberholzer Congress chair for ESAU 2025, Dr Nico Lourens with PCF CEO, Andrew Oberholzer Dr James Ury from Midrand Winner of the best dressed urology department, Dr Jeff John and his team from the urology department at Frere hospital
18 A summary from the article by Toni K. Choueiri, Colin Hessel, Susan Halabi, Ben Sanford, M. Dror Michaelson, Olwen Hahn, Meghara Walsh, Thomas Olencki, Joel Picus, Eric J. Small, Shaker Dakhil, Darren R. Feldman, Milan Mangeshkar, Christian Scheffold, Daniel George, Michael J. Morris. Published in European Journal of Cancer 94 (2018) 115-125 Introduction Advanced renal cell carcinoma (RCC) remains incurable despite various treatment options. The International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) criteria classify patients into prognostic groups based on risk factors, with intermediate and poor-risk patients (70-80% of advanced RCC cases) having shorter survival durations and a greater need for effective therapies. VEGFRtargeted therapies, such as sunitinib and pazopanib, are the current standard rst-line treatments, but progression typically occurs within 8-11 months for mixed-risk populations and less than 6 months for intermediate and poor-risk patients. Targeting additional oncogenic pathways like MET and AXL, which are associated with tumour progression and resistance to VEGF inhibition, may offer therapeutic benets. Cabozantinib, an oral inhibitor of MET, AXL, and VEGFR2, has shown promise in treating advanced RCC after prior antiangiogenic therapy. The CABOSUN trial was designed to compare cabozantinib and sunitinib as initial therapies for metastatic RCC in intermediate or poor-risk patients. Methods The CABOSUN trial was a randomized, phase 2 study conducted at 77 centres in the U.S. to compare cabozantinib and sunitinib as initial therapies for advanced renal cell carcinoma (RCC) in intermediate or poor-risk patients. Eligible participants were 18 years or older, had advanced RCC with a clear-cell component, measurable disease, and no prior systemic treatment. Patients were stratied by IMDC risk group and presence of bone metastases and randomized 1:1 to receive cabozantinib (60 mg daily) or sunitinib (50 mg daily, 4 weeks on/2 weeks off). Treatment continued until disease progression, intolerance, or withdrawal of consent. Tumour response and progression were assessed using RECIST criteria, with radiographic images reviewed by both investigators and a blinded independent radiology review committee (IRC). Outcomes The primary end-point was progression-free survival (PFS). Secondary end-points were objective response rate (ORR), overall survival (OS), and safety. C abozantinib versus sunitinib as initial therapy for metastatic renal cell carcinoma of intermediate or poor risk (Alliance A031203 CABOSUN randomised trial): Progression-free survival by independent review and overall survival update
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20 Results The CABOSUN trial enrolled 157 patients who were randomised 1:1 to receive cabozantinib (n=78) or sunitinib (n=79). Patient characteristics: • 81% of patients were intermediate risk • 19% of patients were poor risk according to IMDC criteria • 25% of patients had not had prior nephrectomy • 36% had bone metastases • 73% had two or more metastatic sites • Tumour MET status was determined for 83% of patients • 39% of all randomised patients were MET positive • 44% were MET negative • Key ndings PROGRESSION-FREE SURVIVAL (PFS): Median PFS per independent radiology review committee (IRC) was 8.6 months for cabozantinib vs. 5.3 months for sunitinib (HR 0.48, p=0.0008). Subgroup analyses showed consistent benets for cabozantinib, with MET-positive patients showing the greatest improvement. OBJECTIVE RESPONSE RATE (ORR): ORR per IRC was 20% for cabozantinib vs. 9% for sunitinib. TUMOUR REDUCTION: Tumour reduction was observed in 80% of cabozantinib patients vs. 50% of sunitinib patients. OVERALL SURVIVAL (OS): Median OS was 26.6 months for cabozantinib vs. 21.2 months for sunitinib (HR 0.80). SAFETY: Grade 3 or 4 adverse events occurred in 68% of cabozantinib patients and 65% of sunitinib patients. Common adverse events included diarrhoea, hypertension, and fatigue for cabozantinib, and fatigue, decreased platelet count, and diarrhoea for sunitinib. Conclusion In this phase 2 study, cabozantinib treatment resulted in clinically meaningful and statistically signicant prolongation of PFS per IRC when compared with sunitinib as initial targeted therapy in patients with advanced RCC. The independent assessment conrms the investigator-assessed results for PFS and supports the use of cabozantinib as initial therapy for patients with advanced RCC of intermediate or poor risk.
21 Dr Prinitha Pillay MBBCh, MSc, MMed, FC Rad Onc Dr Pillay has worked in the medical eld for just over 25 years. After graduating with a BSc Hons. in Molecular Biology in 1996 at University of Witwatersrand and as a doctor in 2003, she joined Doctors Without Borders (MSF), and over the next 10 years worked in many different settings from Lesotho, Sudan, India, Sierra Leone and Libya. She served as President of MSF in South Africa and on the board internationally; and was featured in the top 10 Women in Health by the Mail and Guardian in 2011. Upon returning to South Africa, she worked as a technical specialist on HIV/TB with the University of Witwatersrand, and for the Rural Health Advocacy Project advocating for better access for those living in rural areas. She served as an independent panelist on the South African Human Right Commission that investigated access to emergency services as a basic human right. During this time, she completed a Master's in Infectious Diseases and Global Policy from the London School of Hygiene & Tropical Medicine. She then attained a Fellowship in Oncology and a Masters in Medicine in 2019. This month we are proud to showcase the remarkable artwork of Dr Prinitha Pillay, an oncologist in private practice in Johannesburg and a valued member of the Gauteng Uro-Oncology Multidisciplinary Team. Beyond her medical expertise, Dr. Pillay is a talented artist whose work deeply resonates with the cancer community. This opportunity to showcase her work is a tting highlight for the last issue of the magazine for the year. Dr. Pillay's art series is a profound expression of both personal and professional catharsis. She describes it as a way to “touch the intangible pain of my patients and myself.” Her pieces reect the solitary struggles faced by those battling cancer and other diseases, including mental health challenges. Through her art, Dr. Pillay captures not only the pain but also the enduring spirit and hope that shine through adversity. This powerful connection to the cancer experience makes her work a meaningful addition to our magazine's efforts to inspire and uplift our readers. Canvas of Courage An oncologist's depictions of the emotional triad of fear, overwhelming uncertainty, and unrelenting hope faced by patients diagnosed with cancer and mental illness. Title: “Locked in Love” This painting is a vivid, emotional tribute to my late father, who lived with dementia and locked-in syndrome during the nal two years of his life. Created through an intuitive process of layering vibrant colours, his essence emerged organically on the canvas, hunched over, a gure woven from complex, interwoven hues that reect the depth of his spirit. The heavy dark grey crowning the composition symbolizes the weight of those challenging nal years, transitioning into chaotic greys that lighten as they descend, revealing the Mini-Mental State Examination, a test used for assessing cognitive impairment. This test was a source of pride for my father, who relished outsmarting his geriatrician with his sharp wit, a rare spark of triumph in his constrained world. As both a daughter and an oncologist, I grapple with the duality of love and professional responsibility, a tension that permeates the work. The painting holds my deepest regret: never asking him how to ease his suffering if locked-in syndrome claimed him. Amid the sorrow, a cluster of colourful sticks in the corner shines as a beacon of hope, representing the caregivers—whose wicked humour and unconditional love brought joy to his days in ways I couldn't. Their presence was a saving grace, a reminder of light amid the grief. This piece captures my father—my everything—his resilience, complexity, and the enduring love we shared. It is a testament to his life, his struggles, and the caregivers who became family. I miss him deeply, and this painting carries that longing into the world.
22 Title: “Musing in the maelstrom” This painting portrays a complex, clothed gure caught in a moment of deep contemplation, his face resting thoughtfully on his hand. As an oncologist, I witness the emotional triad of fear, overwhelming uncertainty, and unrelenting hope in my patients—a universal human experience that this character embodies. His expression, neither overtly sad nor joyful, captures the intricate balance of these emotions, reecting the nuanced reality of existence. The background, woven with complex greys, speaks to the layered and often tumultuous feelings that dene our inner worlds and which are dramatically heightened when dealing with cancer. Beneath the gure, a deep black suggests the ever-present threat of being overwhelmed, as if teetering on the edge of drowning in life's challenges. Yet, shimmering metallics interwoven throughout the composition evoke the vibrant, unpredictable avours of life—moments of brilliance and vitality that persist despite adversity. This artwork is a meditation on the human condition, capturing the weight of introspection and the resilient spark of hope that endures. It stands as a tribute to the emotional complexity we all navigate, rendered in a palette that mirrors both struggle and beauty. Title: “Triptych of the Depths: A Journey Through Depression” This series of three paintings offers a poignant exploration of depression, capturing its weight, isolation, and eventual glimmers of renewal represented by the bent over person resembling a ower. The rst painting, shrouded in the darkest blacks and deep greys, embodies the suffocating void of depression at its most relentless. The canvas is consumed by an almost tangible darkness, reecting the overwhelming absence of light and hope that denes the condition's deepest moments. There are no gures, no distractions—just the stark, unyielding presence of consuming despair. The third painting shifts to a single, more vibrant gure, awash in colour that signify the lifting of depression's heavy weight. The return of colour to the canvas mirrors the reawakening of life's vibrancy, a tentative step toward healing. Yet, the gure remains alone, a nod to the eternal struggle of solitude that lingers even in moments of recovery, a reminder of the delicate balance between light and shadow, between depression and vitality. This triptych is a raw, visual narrative of depression's journey—from its darkest depths to the quiet hope of renewal, while acknowledging the enduring solitude that characterize depression and its human experience. The second painting centres on a solitary, depressed bent over gure, positioned in a plain, unmarked expanse that symbolizes the emotional abyss of depression, where nothing is felt. Surrounding this void is a cacophony of chaotic black marks representing the noise of life—its demands, expectations, and relentless energy—contrasting sharply with the gure's inner emptiness. On the edges, the outlines of a psychiatrist and a loved one peer in, their presence a reminder of support that feels distant yet persistent, unable to fully penetrate the isolating core of the illness.
23 Title: “Splinters of Light: Echoes of Endurance” This abstract painting emerges as a spontaneous expression of the emotional landscape I navigate. The canvas is predominantly a soft, off-white, serving as a quiet foundation that mirrors the blank slate of uncertainty faced by those with illness. Against this backdrop, vibrant splashes of colour—pink, yellow, purple, and green—burst forth in irregular, organic shapes, symbolizing eeting moments of hope, vitality, and the unpredictable nature of life amid adversity. The colours appear scattered yet deliberate, each blotch a testament to the strength that persists even in the face of suffering. The pink streak hints at a tender, fragile optimism, while the yellow orb radiates a quiet strength. The larger green form, with its subtle gradients and splattered edges, suggest the complexity of emotions—joy, struggle, and renewal—entwined in the human experience. Title: “Bone Deep Blue: The Weight of Fatigue” This abstract painting channels the visceral experience of fatigue—that bone-deep exhaustion often felt by those battling illness and those on hormonal blockade treatments. The canvas is dominated by a sweeping expanse of blue, ranging from deep, sombre to eeting, lighter hues, embodying the overwhelming weight of weariness that permeates both body and soul. Interspersed with vibrant bursts of colour—ery red, vivid yellow, and sharp greens—these ashes represent the persistent pulse of life, resilience, and eeting moments of energy that icker against the tide of fatigue. In the bottom corner, a translucent blue glaze is poured over- its heavy, almost liquid texture evoking the inescapable, sinking sensation of exhaustion that anchors one to the ground. As a medical doctor, I paint because I can palpate the pain of my patients, and this piece serves as a therapeutic exploration of the fatigue that denes so much of their journey—a silent, pervasive force that is both deeply personal and universally understood. This abstract work is a testament to the tension between life's vibrancy and the bone-deep weariness that can consume it, offering a visual meditation on endurance and the human spirit. Title: “Echoes of Why: The Solitude of Cancer” This series of paintings captures the profound aloneness and the haunting question— “Why me?”—that reverberates through the hearts of those aficted with cancer. As an oncologist, I have witnessed this existential plea countless times, and these works channel that raw, universal experience into visual form. This series is a heartfelt reection of the isolating, questioning journey of those touched by cancer, capturing both the depth of their solitude and the universal cry for meaning in the face of suffering and being faced with mortality. The rst painting presents a solitary gure, shrouded in muted, sombre tones of black, sitting against in an empty room. The gure's posture—head bowed, shoulders curved inward—embodies the weight of isolation that cancer often brings. The sparse, almost barren canvas reects the stark loneliness of grappling with a diagnosis, where the question “Why me?” echoes unanswered in the void. The second painting intensies this inquiry, with the gure now surrounded by swirling, chaotic streaks of shades of blues and reds, symbolizing the turmoil of fear, uncertainty, unanswered questions and the involuntary isolation that such stark and existential questions inevitably carry. The phrase “Why me?” is subtly woven into the composition through fragmented, abstract shape of a person, as if the question itself is breaking apart under its own weight. The gure remains alone, yet the vibrant chaos around them suggests the overwhelming noise of medical interventions, societal expectations, and inner turmoil that accompany the disease. The nal painting shifts toward a colour-full palette, with hues of green and orange breaking through the gloom, hinting at moments of eeting hope. The gure still has its hand next to its face, their silhouette sharper by scratched out material, as if hardened by the journey. The question “Why me?” persists, etched into the delicate interplay of light and shadow, acknowledging that even in moments of clarity or survival, the solitude and existential weight of cancer endure. Visit Dr Pillay's instagram to view more. https://www.instagram.com/prinithapillay?igsh=Y3RnajBxMG1icXZk&utm_source=qr
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