编者按：“2025浦江前列腺癌学术大会暨中国临床肿瘤学会前列腺癌专委会（CSCO-PC）年会、中国抗癌协会男性生殖系统肿瘤专委会（CACA-GO）前列腺癌会议、中国前列腺癌研究协作组（CPCC）年会”于6月27—28日在沪举行。本次大会以“全球智慧·中国实践·精准突围”为主题，吸引国内外众多专家学者，共享前列腺癌前沿进展和实践经验。来自香港综合肿瘤中心（IOC）的邝维基（Philip Kwong）教授带来了题为“Metastatic Hormone-Sensitive Prostate Cancer:New Strategies，New Horizons”的精彩报告，并在接受《肿瘤瞭望-泌尿时讯》的采访中分享了更多mHSPC诊疗领域的研究进展和实践经验。

 

邝维基（Philip Kwong）教授：目前我们主要有四种雄激素受体通路抑制剂（ARPI）可以与ADT联合用于mHSPC，包括阿比特龙、恩扎卢胺、阿帕他胺和最新的达罗他胺。虽然我们没有头对头的试验数据，但从实际经验和以往的研究来看，这四种药物的疗效和生存益处相似，副作用也大同小异。在选择时，我们可以逐个分析这些药物。

 

阿比特龙是目前上市最久的药物，我们对其更熟悉，但它需要和激素类药物一起使用，对于有糖尿病的患者，我们可能会谨慎使用类固醇。不过，阿比特龙现在有了仿制药，价格相对较低，如果经济压力大，可以考虑使用。恩扎卢胺的中枢神经副作用是我们的主要担忧，但在mHSPC患者中，这些副作用的发生率和严重程度较低。阿帕他胺和恩扎卢胺类似，中枢神经副作用小，较为常见的不良事件是皮肤反应。达罗他胺是一种更新的药物，中枢神经系统渗透性更低，对于已经患有中枢神经系统疾病或正在服用其他药物的老年患者来说，可能是一个更好的选择。总的来说，这4种药物都可以用于几乎所有的患者，主要取决于患者的个体情况和经济问题。

 

Oncology Frontier:Currently，ADT+ARPI has become the new standard for mHSPC.Faced with a variety of ARPIs，how do you think we should make individualized choices for different mHSPC patients?

 

Dr.Philip Kwong:Now we have four ARPIs that can be used together with ADT in mHSPC，including abiraterone，enzalutamide，apalutamide，and the latest darolutamide.Although we don’t have head-to-head trial data，based on real-world experience and previous studies，the efficacy and survival benefit of these four drugs are similar，and the toxicity is more or less the same.When choosing，we can analyze these drugs one by one.

 

Abiraterone is the oldest drug available，and we are more familiar with it，but it has to be used together with steroids.For patients with diabetes，we might be more cautious about using steroids.However，there are now generic versions of abiraterone，which are cheaper，so it could be a good option for patients with financial concerns.Enzalutamide is always a concern due to its CNS side effects，but in the mHSPC setting，these side effects are less frequent and less severe.Apalutamide is similar to enzalutamide but with fewer CNS side effects，and the more common adverse events are skin disorders.Darolutamide is a newer drug with less CNS penetration，which may make it a better choice for patients with pre-existing CNS disease or those taking multiple medications.Overall，all four drugs can be used in almost every patient，and the choice really depends on individual patient characteristics and financial considerations.

 

邝维基（Philip Kwong）教授：这些研究结果表明，我们必须谨慎选择患者，不能对所有患者采用同一种疗法。对于高危患者或高瘤荷疾病患者，病情非常严重，已经发生多处转移，我们需要通过全身治疗（如ADT联合ARPI或化疗）来积极治疗。对于这些患者，针对原发前列腺癌的增强放疗可能对整体情况影响不大。但对于低瘤荷疾病患者，特别是病灶非常小的患者，全身治疗已经能很好地控制病情，对原发肿瘤的增强放疗治疗很可能提高生存率。当前，结合PSMA PET-CT技术，我们发现越来越多的患者出现寡转移的情况。对于这些患者，我们不仅会对原发肿瘤进行放疗，还会考虑对寡转移病灶进行精准放疗，这肯定能提高总生存期和疾病控制率。因此，我们必须慎重选择患者，避免过度治疗。

 

Oncology Frontier:The ITT population in the H group of the STAMPEDE trial did not benefit from the combined radiotherapy regimen，but there was a survival benefit in the low-volume subgroup.Faced with different results，how do you view the value of radiotherapy for mHSPC?

 

Dr.Philip Kwong:These results show that we have to choose the patients very carefully and can’t use the same treatment for all patients.For high-risk patients or those with high-volume disease，the disease is very aggressive and there are many metastases.We need to treat them aggressively with systemic treatments like ADT plus ARPI or chemotherapy.For these patients，boosting the primary prostate cancer probably won’t change the scenario very much.But for low-volume disease，especially very small volume disease，the systemic treatment is already very good at controlling the disease.Boosting the primary tumor in this case is likely to improve survival.Nowadays，with PSMA PET-CT，we are finding more and more patients with oligo-metastasis.For these patients，we will not only give radiotherapy to the primary tumor but also consider giving precise radiotherapy to the oligo-metastasis.This will certainly improve overall survival and disease control.So we have to choose the patient very carefully to avoid overtreatment.

 

邝维基（Philip Kwong）教授：这是一个后续讨论，实际上是我之前演讲的延续。对于寡转移患者，我们可以采取更集中的局部治疗或更精准的治疗，期望在获得最佳疗效后减少患者的治疗强度。对于mHSPC，传统观念是对所有患者进行同样的治疗直到病情进展。但对于病灶较小或风险不高的患者，或许我们可以减少用药，甚至停用部分药物。分子测序是一种比较新的方法，我们还处于初期研究阶段，但随着对不同分子和突变的深入了解，我们或许能识别出对激素更敏感或对其他抑制剂更敏感的患者，从而为所有患者提供量身定制的方案。我们正在进行大量的研究，希望在四五年后能取得更积极的成果，将其应用于大多数患者。

 

Oncology Frontier:Currently，de-escalation therapy is a research hotspot in the mHSPC field.How can we achieve precise de-escalation of treatment based on molecular typing and liquid biopsy?

 

Dr.Philip Kwong:This is a follow-up discussion，actually a continuation of my previous talk.For patients with oligo-metastasis，we can give more local or precise treatment，and then hope to continue with less treatment for the patient.For mHSPC，the traditional concept is to give the same treatment to all patients until progression.But for patients with small volume disease or less risky disease，we might be able to use fewer drugs or even stop some drugs after achieving the best response.Molecular sequencing is a newer approach，and we are still in the infancy stage.But with a better understanding of different molecules and mutations，we might be able to identify patients who are more sensitive to hormones or other inhibitors and tailor-make the treatment for all patients.We are doing a lot of studies，and hopefully，in four or five years，we can have more positive results and apply it to most patients.