Katherine S. Virgo, Emory University, Atlanta, GA; Ethan Basch, University of North Carolina, Chapel Hill, NC; D. Andrew Loblaw, Sunnybrook Health Sciences Centre, Toronto; Eric Winquist, London Health Sciences Centre, London, Ontario, Canada; Thomas K. Oliver and R. Bryan Rumble, American Society of Clinical Oncology, Alexandria, VA; Michael A. Carducci, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD; Luke Nordquist, Urology Cancer Center and GU Research Network, Omaha, NE; Mary-Ellen Taplin, Dana-Farber Cancer Institute, Boston, MA; and Eric A. Singer, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ.
J Clin Oncol. 2017 Jun 10;35(17):1952-1964. doi: 10.1200/JCO.2017.72.8030. Epub 2017 Apr 25.
Purpose ASCO provisional clinical opinions (PCOs) offer direction to the ASCO membership after publication or presentation of potential practice-changing data. This PCO addresses second-line hormonal therapy for chemotherapy-naïve men with castration-resistant prostate cancer (CRPC) who range from being asymptomatic with only biochemical evidence of CRPC to having documented metastases but minimal symptoms. Clinical Context The treatment goal for CRPC is palliation. Despite resistance to initial androgen deprivation therapy, most men respond to second-line hormonal therapies. However, guidelines have neither addressed second-line hormonal therapy for nonmetastatic CRPC nor provided specific guidance with regard to the chemotherapy-naïve population. Recent Data Six phase III randomized controlled trials and expert consensus opinion inform this PCO. Provisional Clinical Opinion For men with CRPC, a castrate state should be maintained indefinitely. Second-line hormonal therapy (eg, antiandrogens, CYP17 inhibitors) may be considered in patients with nonmetastatic CRPC at high risk for metastatic disease (rapid prostate-specific antigen doubling time or velocity) but otherwise is not suggested. In patients with radiographic evidence of metastases and minimal symptoms, enzalutamide or abiraterone plus prednisone should be offered after discussion with patients about potential harms, benefits, costs, and patient preferences. Radium-223 and sipuleucel-T also are options. No evidence provides guidance about the optimal order of hormonal therapies for CRPC beyond second-line treatment. Prostate-specific antigen testing every 4 to 6 months is reasonable for men without metastases. Routine radiographic restaging generally is not suggested but can be considered for patients at risk for metastases or who exhibit symptoms or other evidence of progression. Additional information is available at www.asco.org/genitourinary-cancer-guidelines and www.asco.org/guidelineswiki .
目的
ASCO 临时临床意见 (PCO) 在潜在的改变实践的数据发表或呈现后为 ASCO 成员提供指导。本 PCO 针对化疗初治的去势抵抗性前列腺癌 (CRPC) 男性的二线激素治疗，这些患者从仅有生化证据的 CRPC 无症状到有记录的转移但症状最小。
临床背景
CRPC 的治疗目标是缓解症状。尽管对初始雄激素剥夺治疗有耐药性，但大多数男性对二线激素治疗有反应。然而，指南既没有解决非转移性 CRPC 的二线激素治疗问题，也没有为化疗初治人群提供具体指导。
最新数据
六项 III 期随机对照试验和专家共识意见为该 PCO 提供了信息。
临时临床意见
对于 CRPC 患者，应无限期维持去势状态。对于非转移性 CRPC 且有发生转移性疾病高风险（前列腺特异性抗原快速倍增时间或速度）的患者，可考虑二线激素治疗（如抗雄激素、CYP17 抑制剂），但不建议用于其他患者。对于有放射学转移证据且症状轻微的患者，在与患者讨论潜在危害、益处、成本和患者偏好后，可提供恩杂鲁胺或阿比特龙加泼尼松治疗。镭-223 和 sipuleucel-T 也是选择。没有证据提供关于 CRPC 二线治疗以外的最佳激素治疗顺序的指导。对于无转移的患者，每 4 至 6 个月进行前列腺特异性抗原检测是合理的。一般不建议常规进行放射学重新分期，但对于有转移风险或出现症状或其他进展证据的患者，可以考虑进行。更多信息可在 www.asco.org/genitourinary-cancer-guidelines 和 www.asco.org/guidelineswiki 上获得。
