Dragomir A, Rocha J, Vanhuyse M, Cury F L, Kassouf W, Hu J, Aprikian A G
Urology, Department of Surgery, McGill University.
Research Institute of the McGill University Health Centre.
Curr Oncol. 2017 Aug;24(4):240-248. doi: 10.3747/co.24.3598. Epub 2017 Aug 31.
Since just after the year 2000 in Quebec, the management of metastatic castration-resistant prostate cancer (mcrpc) has evolved considerably, with the inclusion of docetaxel-based chemotherapy, bone-targeted therapies (zoledronic acid and denosumab), and more recently, abiraterone, enzalutamide, and cabazitaxel for docetaxel-refractory patients. In the present study, we aimed to analyze contemporary mcrpc management patterns and therapy utilization trends in Quebec.
The study cohort consisted of patients dying of prostate cancer (pca) between January 2001 and December 2013, selected from Quebec public health care insurance databases. Patient selection was based on death from a pca-related cause or therapy used according to the Canadian Urological Association guidelines on mcrpc management. Treatments included chemotherapy (mitoxantrone before 2005 and docetaxel after 2005), abiraterone, bone-targeted therapy (zoledronic acid or denosumab, or both), and palliative radiation therapy (rt). During the study period, neither enzalutamide nor cabazitaxel was publicly reimbursed in Quebec, and as a result, no capture of their use was possible for this study. Multivariate logistic regression was used to identify factors associated with the probability of receiving chemotherapy, bone-targeted therapies, and palliative rt before death from pca.
Overall, the database search identified 3106 patients who died of pca between January 2001 and December 2013. Median age of death was 78 years. Of those 3106 patients, just 2568 (83%) received mcrpc-specific treatments: chemotherapy, abiraterone, palliative rt, or bone-targeted therapy; the other 17% of the patients were managed solely with maximum androgen blockade (androgen deprivation therapy plus anti-androgens) despite a record of pca-related death. Logistic regression analyses indicate that patients dying after 2005 were more likely to have received chemotherapy [odds ratio (or): 1.51; 95% ci: 1.22 to 1.85] and bone-targeted therapy (or: 1.97; 95% ci: 1.64 to 2.37). Age was a significant predictor for the use of chemotherapy, bone-targeted therapy, and palliative rt (ors in the range 0.96-0.98, < 0.05).
Patient age seems to be a strong determinant in the of selection mcrpc therapy, affecting the probability of the use of chemotherapy, bone-targeted therapy, or palliative rt. Although chemotherapy is still used only in a small percentage of patients, the introduction of new therapies-such as bone-targeted therapy, docetaxel, and abiraterone-affected treatment selection over time. The availability of enzalutamide since February 2014 will likely produce additional changes in mcrpc management.
自2000年后不久起，魁北克转移性去势抵抗性前列腺癌（mcrpc）的管理有了显著进展，纳入了以多西他赛为基础的化疗、骨靶向治疗（唑来膦酸和地诺单抗），以及最近用于多西他赛难治性患者的阿比特龙、恩杂鲁胺和卡巴他赛。在本研究中，我们旨在分析魁北克当代mcrpc的管理模式和治疗使用趋势。
研究队列由2001年1月至2013年12月间死于前列腺癌（pca）的患者组成，选自魁北克公共医疗保险数据库。患者选择基于因pca相关原因死亡或根据加拿大泌尿外科协会mcrpc管理指南使用的治疗方法。治疗包括化疗（2005年前为米托蒽醌，2005年后为多西他赛）、阿比特龙、骨靶向治疗（唑来膦酸或地诺单抗，或两者），以及姑息性放射治疗（rt）。在研究期间，恩杂鲁胺和卡巴他赛在魁北克均未获得公共报销，因此本研究无法获取其使用情况。多因素逻辑回归用于确定与在因pca死亡前接受化疗、骨靶向治疗和姑息性rt可能性相关的因素。
总体而言，数据库搜索确定了2001年1月至2013年12月间3106例死于pca的患者。死亡中位年龄为78岁。在这3106例患者中，仅2568例（83%）接受了mcrpc特异性治疗：化疗、阿比特龙、姑息性rt或骨靶向治疗；另外17%的患者尽管有pca相关死亡记录，但仅接受了最大雄激素阻断治疗（雄激素剥夺治疗加抗雄激素药物）。逻辑回归分析表明，2005年后死亡的患者更有可能接受化疗[比值比（or）：1.51；95%置信区间（ci）：1.22至1.85]和骨靶向治疗（or：1.97；95%ci：1.64至2.37）。年龄是化疗、骨靶向治疗和姑息性rt使用的重要预测因素（ors范围为0.96 - 0.98，<0.05）。
患者年龄似乎是mcrpc治疗选择的一个重要决定因素，影响化疗、骨靶向治疗或姑息性rt的使用概率。尽管仍只有一小部分患者使用化疗，但随着时间推移，新疗法如骨靶向治疗、多西他赛和阿比特龙的引入影响了治疗选择。自2014年2月起恩杂鲁胺的可及性可能会使mcrpc管理产生更多变化。
