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引言

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随着转移性激素敏感性前列腺癌(mHSPC)治疗进入新型内分泌治疗(NHT)联合雄激素剥夺治疗(ADT)的时代,如何为患者选择起始治疗方案,实现疗效与安全性的最佳平衡,成为临床决策的核心。长期以来,二联(NHT+ADT)与三联(NHT+ADT+多西他赛)之争悬而未决。随着多项临床研究的验证,二联方案已逐步成为mHSPC全人群起始治疗方案,而三联方案则是高瘤负荷/高风险mHSPC患者的优选方案。

然而,在众多已获批的NHT药物中,如何基于临床实践证据进行选择?近期,两项真实世界研究在大样本人群中不仅证实了阿帕他胺在前列腺特异性抗原(PSA)深度应答和总生存期(OS)上的双重优势,更以扎实的数据为mHSPC二联疗法的优越性提供了关键佐证,为临床治疗决策提供了重要参考。

在陶醉于联合一切之后的反思:mHSPC从“三联热潮”到“二联基石”的理性回归

mHSPC的治疗经历了三个关键发展阶段。最初,ADT单药治疗是标准方案,但疗效有限,患者往往在短期内进展为转移性去势抵抗性前列腺癌(mCRPC)。随着临床研究的深入,“ADT + 多西他赛”和“ADT + NHT”二联方案应运而生,多项III期临床试验证实,这类方案能显著降低疾病进展风险,延长患者生存期,逐渐成为指南推荐的核心治疗选择[1]。随后,“ADT + NHT + 多西他赛”三联方案进入视野,引发了临床对“强化治疗”的热议,部分学者认为其可能为患者带来更大获益。

然而,三联方案的推广并非一帆风顺。多项Meta分析证实,与NHT二联相比,三联疗法并未显著改善总人群OS获益,仅高瘤负荷患者可能具有OS获益[2–6]。以及多西他赛作为化疗药物,存在骨髓抑制、神经毒性等不良反应,相比NHT二联疗法,三联疗法与≥3级不良事件(AE)风险增加相关[2]。且患者用药周期长,依从性也面临挑战。真实世界数据显示,仅约43.9%的mHSPC患者能完成至少6个周期的多西他赛治疗,显著影响了三联方案的实际疗效[7]。Meta分析也表明,三联方案的生活质量劣于NHT二联方案[8]。基于此,国内外权威指南大多推荐:三联方案主要推荐用于高瘤负荷且可耐受化疗的患者,而NHT联合ADT的二联方案适用于所有mHSPC患者[1,9,10]mHSPC的治疗策略正从“强化治疗”向“精准分层”理性回归。

乱花渐欲迷人眼:哪种NHT二联方案才能为mHSPC患者赢得更多生机

在二联方案因其广泛的适用性和良好的风险效益比,被确立为大多数mHSPC患者的治疗基石后,一个临床问题随之浮现:在多种NHT药物中,如何进一步优化选择?OS是评价肿瘤治疗疗效的金标准[11]。但遗憾的是,并非所有NHT二联方案的III期临床研究都表现出显著生存获益。例如,在ARANOTE研究的最终OS分析中,OS并没有达到预设的显著性差异。

表1 NHT二联方案关键III期研究汇总*

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*注:非头对头研究,数据无法直接对比,请谨慎解读。

#ARANOTE研究中OS预设的显著性α=0.0202(单侧)

尽管缺乏直接的头对头III期临床试验,但通过间接治疗比较、药理学差异分析以及真实世界疗效研究,探索不同药物间的潜在差异,对于实现个体化精准治疗具有重要意义。在此背景下,诞生了多项探索不同NHT方案用于mHSPC真实世界研究,例如PROMPT-1、PROMPT-2、ROME、OASIS等。其中,两项分别在今年国际前列腺癌更新(IPCU)年会和美国大型泌尿科团体实践协会(LUGPA)全球前列腺癌年会中公布的针对阿帕他胺与达罗他胺的直接比较研究,因其大规模的真实世界数据和严谨的分析方法而备受关注。

真实世界证据一:PSA深度缓解,阿帕他胺引领二联方案精准降瘤

一项回顾性纵向分析旨在基于真实世界数据,比较阿帕他胺与达罗他胺(均未联用多西他赛)在雄激素受体通路抑制剂(ARPI)初治的mHSPC患者中,诱导早期深度PSA应答(定义为PSA值降至≤0.2 ng/mL,即PSA0.2应答)的能力[25]。研究链接了临床泌尿外科数据库和管理式医疗索赔数据库,共纳入714例阿帕他胺治疗患者和145例达罗他胺治疗患者。通过逆概率治疗加权平衡了包括人口统计学、临床特征等基线变量后,分析主要终点——治疗开始后6个月内达到PSA0.2应答的比例。

结果显示,截至索引日期后6个月,71.0%开始接受阿帕他胺治疗的mHSPC患者达到PSA0.2应答的可能性,比开始接受达罗他胺治疗的患者(55.2%)高出44%[25]。而在III期研究中,TITAN亚洲人群事后分析显示,使用阿帕他胺治疗,73.9%mHSPC患者可在中位1.9个月内实现PSA≤0.2ng/mL,即阿帕他胺联合ADT治疗能使患者快速达到PSA深度缓解[26]。在ARANOTE研究中,达罗他胺联合ADT组有62.6%的患者达到PSA<0.2ng/mL[22]*。

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图1 阿帕他胺对比达罗他胺治疗mHSPC真实世界研究的PSA 0.2应答

该真实世界研究存在潜在的局限性,如可能存在测量偏倚和其他混杂因素,以及PSA检测可能未完全覆盖所有诊疗场景。尽管如此,研究结论仍认为,即使未联合使用多西他赛进行强化治疗,阿帕他胺仍然是实现早期深度PSA应答的有效选择。鉴于早期PSA应答与生存结局相关,这些发现可能具有重要的长期临床意义,并有助于为治疗策略提供信息。

真实世界证据二:OS双重验证,阿帕他胺二联方案实现长期生存获益

对于mHSPC患者而言,延长生存期、提高生存质量是最终治疗目标。第二项真实世界研究聚焦于OS这一核心终点,再次在大样本人群中验证了阿帕他胺二联方案的优越性。

一项基于真实世界数据的回顾性纵向分析,旨在比较阿帕他胺与达罗他胺在未联用多西他赛的情况下,治疗ARPI初治的mHSPC患者的OS[27]。研究采用意向性治疗分析方法,并运用逆概率治疗加权对潜在的混杂因素进行平衡,包括年龄、种族、地理区域、转移类型、合并症评分等多个基线特征。研究共纳入1460例接受阿帕他胺治疗和287例接受达罗他胺治疗的患者。

结果显示,截至24个月,阿帕他胺组患者的死亡风险较达罗他胺组显著降低51%(加权HR = 0.49,95% CI 0.30–0.83,P = 0.007),两组的2年OS率分别为92.1%和85.8%[27]。阿帕他胺的真实世界研究结果(92.1%)与III期TITAN研究中阿帕他胺联合ADT组的2年OS率(82.4%)基本一致,且亚洲人群的疗效和安全性与总体人群表现一致[28]*。

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图 2 阿帕他胺对比达罗他胺治疗mHSPC真实世界研究的OS

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图 3 TITAN研究的OS

该真实世界研究同时指出若干局限性,包括可能存在错误分类偏倚、未观测的混杂因素、随访时间不足及死亡事件记录不全等。

这两项真实世界研究是两种二联方案的比较,而且排除了多西他赛对研究结果的干扰。在此情况下,阿帕他胺+ADT方案在短期PSA深度缓解与远期OS率两项mHSPC重要预后指标中均表现出更多获益[25,27]。这也体现了通过真实世界研究探索不同NHT二联方案用于mHSPC治疗的重要性。因为目前治疗性指南推荐意见的制订主要依据传统随机对照研究(RCT)及其整合结果,基于传统RCT得出的临床研究证据仅给出了干预措施在理想状态下的内部真实性结果,但临床诊疗环境复杂多变,并非所有临床问题均可通过传统RCT得以解决[29]。正如在mHSPC中,治疗策略日益更新,通过大型RCT研究来实时对比各方案的优劣并不现实,而真实世界研究就可以弥合临床实践指南与临床决策之间的距离。例如真实世界多中心研究显示:阿帕他胺起始治疗 mHSPC 可更快、更深降 PSA——6个月PSA90率及达成时间分别优于恩扎卢胺(62.5% vs. 58.5%;3.7 月 vs. 5.1月)与阿比特龙(63.9% vs. 41.7%;3.6月 vs. 10.3月)[30,31]。

表2 不同NHT方案用于mHSPC真实世界研究汇总*

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*注:非头对头研究,数据无法直接对比,请谨慎解读。

总结

在目前探索不同NHT方案用于mHSPC真实世界研究中,大部分研究显示阿帕他胺二联方案在短期PSA缓解与远期OS方面相对获益更多[25,27,30,31,33–36,38–40]*。本次IPCU和LUGPA公布的这两项真实世界研究以大样本量、严格的设计和长期随访,直接证实了阿帕他胺联合ADT方案在真实临床实践中与更高的早期深度PSA应答率及更低的24个月死亡风险相关,填补了临床证据空白,为指导NHT二联方案在mHSPC临床实践中的应用提供参考[25,27]。

*注:非头对头研究,数据无法直接对比,请谨慎解读。

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