The current treatment status of mHSPC patients in China and the need for further improvement have drawn attention. Recently, at the “4th Annual Conference of the Urology Physicians Branch of the Chinese Medical Association (2024)” held in Beijing, Professor Benkang Shi from Qilu Hospital of Shandong University shared insights on “Long-term Management of mHSPC Patients with Novel Hormonal Therapy Schemes.” Following the conference, “Oncology Frontier – Urology News” invited Professor Benkang Shi to share insights on the diagnosis and treatment status of mHSPC, stratification of key populations, and personalized treatment.
“Oncology Frontier – Urology News”: What is the current treatment status of mHSPC patients? What unmet needs still exist?
Professor Benkang Shi: When discussing the treatment strategy for metastatic hormone-sensitive prostate cancer (mHSPC), we prioritize hormonal therapy, which involves novel hormonal drugs and androgen synthesis inhibitors. Currently, endocrine therapy is the cornerstone of treatment. For patients with bone metastases, consideration should be given to introducing drugs targeting bone metastatic lesions and bone-protective agents to slow down the disease’s impact on the bones. Additionally, since these patients may experience local symptoms such as difficulty urinating, urinary frequency, and urgency, appropriate medications should be provided to alleviate these symptoms. During the course of disease progression, we need to distinguish between widespread systemic metastasis and local metastasis. For bone metastases, if the metastatic sites are fewer than five, despite being clinically considered widespread metastasis, their biological behavior may differ. Therefore, we may initiate hormonal therapy for these patients for a period of six months. For localized lesions such as the primary prostate lesion, treatment can be performed through surgery or radiation therapy; whereas for metastatic lesions, curative treatment can be achieved through various treatment modalities including adjuvant radiotherapy.
The above strategies provide treatment guidance at a holistic level, but there are still some unmet needs. Despite increased public awareness and advancements in screening and early diagnosis of prostate diseases, a significant proportion of late-stage metastatic prostate cancer patients still exist in China, accounting for approximately 50% in urban areas and possibly as high as 60% to 70% in rural areas. For mHSPC, we face four main challenges: first, as mentioned earlier, the diagnosis is often late. Secondly, patients are not stratified, and the majority of patients generally receive hormonal therapy and bone-protective agents. However, the malignancy and type of prostate cancer vary among patients, so there is a need to address how to stratify and determine the presence of gene mutations. Thirdly, most patients in the metastatic hormone-sensitive phase may have other comorbidities; since prostate cancer is more common in middle-aged and elderly men, comorbidities may affect treatment outcomes. Finally, a very small number of prostate cancer patients may not respond well to conventional treatment and may rapidly progress to the metastatic drug-resistant stage. Therefore, we need to identify these issues and select appropriate treatment methods.
“Oncology Frontier – Urology News”: In what special etiological situations of mHSPC patients would you consider intensifying treatment regimens?
Professor Benkang Shi: Firstly, it is important to clarify that mHSPC refers to metastatic prostate cancer in the hormone-sensitive phase, as the occurrence and development of prostate cancer are closely related to the presence of androgens. Therefore, the first choice for prostate cancer drug treatment is usually anti-androgen drugs, which is different from the treatment of other solid tumors and is one of the pioneering examples of using hormonal drugs for solid tumor treatment. As mentioned earlier, mHSPC may exhibit differences in pathological types and malignancy levels. Therefore, although endocrine therapy is fundamental and crucial, specific patients still require intensified treatment. For example, for younger patients and those with high malignancy levels, especially those with low PSA but may have special gene mutations or may have small cell carcinoma or neuroendocrine differentiation, we need to adopt intensified treatment. In addition to endocrine therapy, chemotherapy or targeted therapy may need to be added.
“Oncology Frontier – Urology News”: With increasing age, the incidence of prostate cancer in elderly individuals is also on the rise. What aspects do you think should be considered when treating elderly mHSPC patients?
Professor Benkang Shi: For elderly patients, they may have other comorbidities such as cardiovascular diseases, gastrointestinal dysfunction, or hepatic and renal insufficiency. Therefore, in the selection of drugs, we need to consider the impact of drugs on the patient’s comorbidities. Currently, second-generation anti-androgen drugs that inhibit the binding of androgens to receptors may be used. It is crucial to minimize the use of combination hormone drugs, especially for patients with diabetes or rheumatic diseases.
“Oncology Frontier – Urology News“: What indicators can predict the prognosis of mHSPC patients?
Professor Benkang Shi: Firstly, the rate of decline in prostate-specific antigen (PSA) is an important indicator. When it drops to a certain depth, we can judge the patient’s sensitivity to endocrine therapy and prognosis based on the duration of its maintenance.
Secondly, treatment efficacy can be assessed based on the improvement of clinical symptoms in patients. For example, for patients with urinary retention or hematuria, we can evaluate treatment efficacy by improving clinical symptoms.
Thirdly, for special patients, such as those with neuroendocrine differentiation, their PSA levels may be relatively low at this stage. However, due to the high likelihood of bone metastases, it is necessary to monitor the patient’s bone metastasis during endocrine therapy. Typically, bone scans are performed annually to assess changes in metastatic lesions, and imaging tests (such as chest and abdominal CT scans) are performed to determine the presence of metastases caused by neuroendocrine differentiation.
Professor Benkang Shi
Second-level Professor, Doctoral Supervisor, Director of the Department of Urology, Qilu Hospital, Shandong University
Taishan Scholar Distinguished Expert, Director of Shandong Province Precision Diagnosis and Treatment Laboratory for Genitourinary Diseases, Director of Engineering Research Center
Director of Shandong University Institute of Urological Diseases, Director of Shandong University Minimally Invasive Surgery Institute
Vice Chairman of the Urological Committee of the National Evaluation Committee for Minimally Invasive and Laparoscopic Surgery under the National Health Commission
Vice President of the Andrology and Sexology Branch of the Chinese Medical Doctor Association
Vice Chairman of the Male Reproductive System Tumor Committee of the Chinese Anti-Cancer Association
Vice Chairman of the Urological Tumor Branch of the China Health Promotion Foundation
Vice Chairman of the Urology and Andrology Committee of the Chinese Physician Association
Vice Chairman of the Prostate Cancer Expert Committee of the Chinese Society of Clinical Oncology
Vice Chairman of the Urology Professional Committee of the Chinese Traditional Chinese Medicine Association
Vice Chairman of the Pelvic Floor Medical Committee of the China Elderly Health Care Association
Chairman of the Shandong Provincial Medical Association Urology Branch
Chairman of the Shandong Provincial Medical Doctor Association Urology Branch
Chairman of the Shandong Provincial Health Commission Prostate Cancer Technology Innovation Alliance
Chairman of the Expert Committee of the Shandong Provincial Medical Association Urological Tumor MDT
Recipient of the 4th “National Famous Doctor. Outstanding Achievement” Award
