目的:为转移性去势抵抗性前列腺癌(CRPC)患者提供治疗建议。
方法:美国临床肿瘤和癌症护理协会安大略省召集了一个专家小组,通过对文献的系统回顾,制定基于证据的建议。
结果:当添加到雄激素剥夺时,显示生存率提高的疗法,提高生活质量(QOL),有利的利害平衡包括醋酸阿比特龙/泼尼松,恩扎鲁他胺,和镭-223((223)Ra;用于主要骨转移的男性)。多西他赛/泼尼松改善生存率和生活质量与中等毒性风险相关。对于无症状/症状轻微的男性,sipuleucel-T.与生活质量影响不明确和低毒性有关对于以前接受多西他赛的男性,提高生存率,不清楚QOL影响,和中度至高度毒性风险与卡巴他赛/泼尼松相关。多西他赛后,米托蒽醌/泼尼松的生活质量获益(无生存获益)和高毒性风险相关。贝伐单抗没有观察到益处和过度毒性,雌莫司汀,还有舒尼替尼.
结论:无限期持续雄激素剥夺(药物或手术)。醋酸阿比特龙/泼尼松,恩扎鲁他胺,或(223)应提供Ra;还应提供多西他赛/泼尼松,伴随着毒性风险的讨论。Sipuleucel-T可用于无症状/症状轻微的男性。对于经历多西他赛进展的男性,可以提供卡巴他赛,伴随着毒性风险的讨论。可能会提供米托蒽醌,伴随着有限的临床获益和毒性风险的讨论。酮康唑或抗雄激素(例如,比卡鲁胺,氟他胺,尼鲁他胺)可以提供,伴随着对有限已知临床益处的讨论。贝伐单抗,雌莫司汀,和舒尼替尼不应该提供。没有足够的证据来评估治疗的最佳序列或组合。应向所有患者提供姑息治疗。
OBJECTIVE: To provide treatment recommendations for men with metastatic castration-resistant prostate cancer (CRPC).
METHODS: The American Society of Clinical Oncology and Cancer Care Ontario convened an expert panel to develop evidence-based recommendations informed by a systematic review of the literature.
RESULTS: When added to androgen deprivation, therapies demonstrating improved survival, improved quality of life (QOL), and favorable benefit-harm balance include abiraterone acetate/prednisone, enzalutamide, and radium-223 ((223)Ra; for men with predominantly bone metastases). Improved survival and QOL with moderate toxicity risk are associated with docetaxel/prednisone. For asymptomatic/minimally symptomatic men, improved survival with unclear QOL impact and low toxicity are associated with sipuleucel-T. For men who previously received docetaxel, improved survival, unclear QOL impact, and moderate to high toxicity risk are associated with cabazitaxel/prednisone. Modest QOL benefit (without survival benefit) and high toxicity risk are associated with mitoxantrone/prednisone after docetaxel. No benefit and excess toxicity are observed with bevacizumab, estramustine, and sunitinib.
CONCLUSIONS: Continue androgen deprivation (pharmaceutical or surgical) indefinitely. Abiraterone acetate/prednisone, enzalutamide, or (223)Ra should be offered; docetaxel/prednisone should also be offered, accompanied by discussion of toxicity risk. Sipuleucel-T may be offered to asymptomatic/minimally symptomatic men. For men who have experienced progression with docetaxel, cabazitaxel may be offered, accompanied by discussion of toxicity risk. Mitoxantrone may be offered, accompanied by discussion of limited clinical benefit and toxicity risk. Ketoconazole or antiandrogens (eg, bicalutamide, flutamide, nilutamide) may be offered, accompanied by discussion of limited known clinical benefit. Bevacizumab, estramustine, and sunitinib should not be offered. There is insufficient evidence to evaluate optimal sequences or combinations of therapies. Palliative care should be offered to all patients.