Al-Asaaed Sohaib, Winquist Eric
London Health Sciences Centre and Western University, London, Ontario, Canada.
Can J Urol. 2014 Apr;21(2 Supp 1):37-41.
Castration resistant prostate cancer (CRPC) is the single common pathway to prostate cancer death. For men with symptomatic metastatic disease, docetaxel chemotherapy remains a standard of care. However, blood prostatic-specific antigen (PSA) testing allows the identification of CRPC before clinical metastases or symptoms occur, providing a long diagnostic lead time in many patients. The use of secondary hormonal manipulations (SHMs) in men not candidates for immediate chemotherapy is reviewed.
PubMed was searched for randomized clinical trials, systematic reviews or clinical practice guidelines addressing SHMs in CRPC.
A recent systematic review and practice guideline was identified, and used as the evidence base for this review along with reports from randomized trials over the past year.
The goals of therapy with SHMs should be discussed with patients and their preferences considered. In men without clinical evidence of metastases, gonadal androgen suppression should be maintained and generally patients should be observed. There is no clear evidence that SHMs are of benefit in these patients. Abiraterone plus prednisone is of proven benefit in men with CRPC metastases who are without significant symptoms prior to chemotherapy. Based on emerging data, enzalutamide may be of similar benefit. Use of other SHMs should be based on patient preference and consideration of possible adverse effects; with the exception of low dose prednisone, there is little evidence of benefit supporting their use. For patients accepting these uncertainties, a trial of nonsteroidal antiandrogen may be considered as an adjunct to observation, followed by low dose corticosteroid with immediate or delayed addition of abiraterone (in men with metastases) as a reasonable next step.
去势抵抗性前列腺癌（CRPC）是前列腺癌致死的唯一常见途径。对于有症状的转移性疾病患者，多西他赛化疗仍是标准治疗方法。然而，血液前列腺特异性抗原（PSA）检测可在临床转移或症状出现之前识别CRPC，这在许多患者中提供了较长的诊断提前期。本文综述了在不适合立即进行化疗的男性中使用二线激素治疗（SHMs）的情况。
检索PubMed以查找关于CRPC中SHMs的随机临床试验、系统评价或临床实践指南。
确定了一项近期的系统评价和实践指南，并将其与过去一年随机试验的报告一起用作本综述的证据基础。
应与患者讨论SHMs治疗的目标并考虑其偏好。对于没有临床转移证据的男性，应维持性腺雄激素抑制，一般应观察患者。没有明确证据表明SHMs对这些患者有益。阿比特龙加泼尼松已被证明对化疗前无症状的CRPC转移男性有益。基于新出现的数据，恩杂鲁胺可能有类似益处。其他SHMs的使用应基于患者偏好并考虑可能的不良反应；除低剂量泼尼松外，几乎没有证据支持其使用有益。对于接受这些不确定性的患者，可考虑将非甾体抗雄激素试验作为观察的辅助手段，随后使用低剂量皮质类固醇，并根据情况立即或延迟加用阿比特龙（对于有转移的男性）作为合理的下一步。
