12 UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE With the launch of the rst PARP inhibitor in South Africa there is a lot of discussion about genetics and the shift to precision medicine. Is this the domain of the medical oncologists or do urologists have a role to play here? I think it basically involves everybody. The most important thing is to get the information about the genetic makeup for the patient and that needs to probably be done much earlier in the disease as it can even affect decision making for patients with localised disease. So even before deciding whether a patient is a candidate for active surveillance or a radical prostatectomy or brachytherapy. Research has shown that patients with localised prostate cancer undergoing active surveillance in the United States with germline BRCA1/BRCA2 or ATM mutations were 1.96 times more likely to be upgraded on re-biopsy specimens than prostate cancer patients without pathogenic variants. Patients with a BRCA2 mutation who were on active surveillance (AS) were 2.74 times more likely to have an upgraded Gleason score. This just demonstrates how early genetic testing can inuence treatment decisions. Patients with BRCA1/BRCA2 or ATM are not suitable candidates for AS even if other clinical and pathological features are ne. There is currently no standardisation of the genomic reports from pathology laboratories, and they can be very difcult to interpret, particularly when it comes to BRCA 1 mutations and their relevance for treatment with PARP inhibitors. Do you have any recommendations? There are a lot of challenges. One of them is that there is a shortage of genetic counsellors, so I think everyone, be it medical oncologists, clinical oncologists, urologists and other specialties that are involved with prostate cancer need to actually have a reasonable understanding about genomics and the mutations involved in prostate cancer. I think the bigger issue is going to be about cost, because there are lots of commercial labs that offer different tests, and they all report slightly different information. The tests report on a number of variances and there are some that are clinically signicant and some that are unlikely to be involved. If you do, for example, next generation sequencing, which is basically looking at every gene in the body It can be very expensive, but for the purposes of prescribing PARP inhibitors, we're really just looking at the homologous recombination repair genes (HRR) and the most important ones are BRCA 2 and to a lesser extent BRCA 1. Although having said that, there are some other mutations like ATM and PALB2 which can have an impact. ESMO is currently in the process of drawing up standardised reporting guidelines for pathology labs which will hopefully improve the situation. In the meantime, it's a good idea to make friends with your local pathologist. Talking castrate resistant prostate cancer and PARP inhibitors with Prof Shingai Mutambirwa 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 Shingai Mutambiwa is a urologist who is mostly in academic practise. He graduated from Godfrey Huggins School of Medicine in Harare, Zimbabwe and went on to study urology at Medunsa where he obtained a M Med (Urology) in 1996. He is involved in many projects and has a passion for men's health and the development of urology throughout Africa.
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