Fournier G, Valéri A
Service d'Urologie, Centre Hospitalier Universitaire de Brest, Hôpital de la Cavale Blanche.
Presse Med. 1998 Dec 5;27(38):1996-2002.
Despite progress in early diagnosis, mainly due to prostate specific antigen (PSA) assay, metastasic cancer of the prostate remains an important health problem; more than 40,000 men died from prostate cancer in 1996 in the USA. More than 50 years after the hormone sensitivity of prostate cancer, antiandrogen therapy remains the cornerstone of treatment protocols. Although this is only a palliative therapy, it does delay disease progression for several years before the tumor inevitably escapes from hormone control. STAGE D1 DISEASE: In patients with microscopic nodal metastases (stage D1) it is classical to propose early or delayed hormone therapy which gives a 5-year survival rate in the 77-85% range. Certain teams also associate radical treatment (radical prostatectomy or pelvic prostate radiotherapy) with the hormone therapy, basically with the aim of better local control despite the lack of proven gain in survival rate. STAGE D2 DISEASE: Medical or surgical castration is the gold standard when the disease reaches stage D2. Specific treatments for urinary, neurological or bone complications may also be associated. Median survival is approximately 3 years. ASYMPTOMATIC PATIENTS: There remains a certain controversy about the best time to initiate treatment. Some advocate treatment immediately upon diagnosis while others propose delaying treatment until the onset of symptoms. There is a trend towards early treatment, but the beneficial effect in terms of survival and quality of life has not been proven. STAGE D3 DISEASE: When the tumor escapes hormone control (stage D3) mean survival is less than one year. Castration should be maintained and antiandrogens, which may have been given initially in combination with castration to achieve total androgen blockade, should be withdrawn (antiandrogen withdrawal syndrome) before assessing the need for second intention hormonal or other treatment. Such second intention regimens usually have a temporary and symptomatic effect. Their indication depends on side effects which may have a deleterious effect on quality of life. Symptomatic treatment plays a predominant role at this stage, combining analgesics, external or metabolic radiotherapy for bone pain, transurethral excision and/or urinary tract derivations for neurological or urological complications, and psychological care which requires the combined efforts of the radiotherapist, oncologist, urologist, and general practitioner.
尽管在早期诊断方面取得了进展，这主要归功于前列腺特异性抗原（PSA）检测，但前列腺转移性癌仍然是一个重要的健康问题；1996年在美国有超过40000名男性死于前列腺癌。在发现前列腺癌对激素敏感50多年后，抗雄激素治疗仍然是治疗方案的基石。尽管这只是一种姑息疗法，但它确实能在肿瘤不可避免地摆脱激素控制之前将疾病进展延缓数年。D1期疾病：对于有微小淋巴结转移的患者（D1期），通常建议进行早期或延迟激素治疗，其5年生存率在77%至85%之间。某些团队还将根治性治疗（根治性前列腺切除术或盆腔前列腺放疗）与激素治疗相结合，主要目的是更好地进行局部控制，尽管在生存率方面缺乏已证实的获益。D2期疾病：当疾病发展到D2期时，药物或手术去势是金标准。也可能会联合针对泌尿系统、神经或骨骼并发症的特定治疗。中位生存期约为3年。无症状患者：关于开始治疗的最佳时机仍存在一定争议。一些人主张在诊断后立即治疗，而另一些人则建议推迟治疗直到出现症状。目前有早期治疗的趋势，但在生存率和生活质量方面的有益效果尚未得到证实。D3期疾病：当肿瘤摆脱激素控制时（D3期），平均生存期不到一年。应维持去势治疗，并且在评估是否需要二线激素或其他治疗之前，应停用最初可能与去势联合使用以实现完全雄激素阻断的抗雄激素药物（抗雄激素撤药综合征）。此类二线治疗方案通常只有暂时的对症效果。其适应证取决于可能对生活质量产生有害影响的副作用。对症治疗在这个阶段起主要作用，包括联合使用镇痛药、针对骨痛的体外或代谢放疗、针对神经或泌尿系统并发症的经尿道切除术和/或尿路改道，以及需要放射治疗师、肿瘤学家、泌尿科医生和全科医生共同努力的心理护理。
