225 Actinium PSMA 617(Novartis Pharma AG)

过去十年间，非小细胞肺癌（NSCLC）一直是抗癌新药研发的“绝对主角”，在近十年上市抗肿瘤新药中，28.57%的适应症均为非小细胞肺癌，这相当于每三个肿瘤新药中就有一个是非小细胞肺癌。然而，随着非小细胞肺癌等大肿瘤适应症的市场集中度越来越高，其市场竞争也愈发激烈，越来越多Biotech不得不摒弃原有格局，选择以小品种肿瘤适应症来验证成药性，肿瘤新药的研发格局正在悄然发生改变。‌六大原因从“肺癌独大”到“前列腺癌崛起”‌非小细胞肺癌之所以能长期占据抗癌新药研发的“C位”，其原因无外乎其高发病率、愈发明确的致病机制、逐渐清晰的驱动基因突变、庞大的未满足临床需求以及其患者强大的支付意愿。而从“肺癌独大”到“前列腺癌崛起”，其背后似乎也有着同样的底层逻辑：原因1：发病率、死亡率陡增首先需要明确一点，在全球老龄化加剧的重大趋势下，前列腺癌作为泌尿男性生殖系统最常见的恶性肿瘤之一，无论是发病率还是死亡率均在逐年增长。在发病率方面，过去30年里65岁以上男性发病率增长近3倍，而在柳叶刀最新前列腺癌重大报告还提到，全球前列腺癌新发病例数将从2020年的140万例增加到2040年的290万例，患病人数还将继续翻倍。而在中国2022年恶性肿瘤发病统计结果中，中国男性前列腺癌发病率为13.4/10万，位居男性恶性肿瘤的第6位，趋势与全球层面基本一致。在死亡率方面，到2040年预计全球死于前列腺癌的人数将从2020年的37.5万增长至70万，增幅高达85%，而中国内地前列腺死亡率为4.8/10 万，位居男性恶性肿瘤的第7位。更关键的是，据国家癌症中心去年发布的《2022年中国恶性肿瘤疾病负担情况》表示，在食管癌、胃癌、肝癌等众多肿瘤发病率逐年下降趋势之下，前列腺癌的发病率增速逐年上涨，在恶性肿瘤中仅次于甲状腺癌，远超肺癌。原因2：‌需求端倒逼新药研发前列腺作为雄激素依赖性器官，其生长发育与雄激素受体（AR）信号通路密切相关。早期前列腺癌通过手术、放疗、雄激素剥夺疗法（ADT）等方式可得到有效治疗，但由于前列腺癌早期临床症状通常不明显，因此大多数患者确诊时已是中晚期，这就导致临床手术的实际适配度并不高，反而是药物治疗成为了首选。同时，对晚期患者而言，药物治疗更大的问题其实在于，治疗后病情通常会出现去势抵抗，演变为转移性去势抵抗性前列腺癌（mCRPC），通常情况下，此阶段的患者治疗方式匮乏（中位生存期仅12个月左右）。因此，在迫切临床需求与强大支付意愿之下，开发能提高此类患者的生存率与生活质量的药品，倒逼着创新药企业从中发力。原因3：‌技术可行性突破‌前列腺癌的分子分型逐渐清晰（如HRR基因突变、微卫星不稳定等），为靶向药和免疫疗法提供突破口。原因4：‌政策红利释放‌FDA对“突破性疗法”的加速审批通道、孤儿药资格认定，一定程度上降低了mCRPC等小品种肿瘤适应症的研发风险，理论上可以更快上市。原因5：‌肺癌赛道内卷‌一般而言，药企的研发意愿与其对应的市场规模成正比，这就意味着，理论上抗癌药一定比抗感染药更火，有着强大患者基数的小细胞肺癌一定更受欢迎。但随着大量新药涌入非小细胞肺癌，领域开始陷入内卷，以至于部分小型Biotech耗尽心血研发的新药，甚至连上市的门槛都很难跨过，更别提上市之后的商业化。因此，越来越多Biotech企业不得不尝试弯道超车，即用小品种适应症验证成药性，然后辐射至更大市场适应症，前列腺癌正是选择之一。原因6：免疫治疗劣势虽然近十年里免疫治疗几乎改变了整个肿瘤的治疗格局，但免疫抑制剂也并非万能，前列腺癌由于激素依赖性、低肿瘤突变负荷和免疫抑制微环境等特性，成功触及了免疫疗法的“非舒适区”。2020年的美国癌症研究协会（AACR）线上会议上，阿替利珠单抗联合恩扎卢胺的临床结果公布，未能给转移性去势抵抗性前列腺癌（mCRPC）患者带来任何生存获益，仅在次要终点层面，实现了OS率略优等结果。另一方面，PD-1单药在CRPC中应答不佳，ORR约5%，即使在PD-L1阳性患者中也仅有17%。当下主流的新药类型“有心无力”，临床上又存在强大需求，领域竞争者还不多，这样的适应症，对于新药企业的吸引力能不强吗？加速重构前列腺癌新药格局“迎变”自1941年雄激素剥夺治疗（ADT）成为转移性前列腺癌的标准治疗以来，前列腺癌的临床已历经80余年。而整个发展不仅经历了从传统内分泌治疗向精准靶向的显著转变，期间更可分为共有三个阶段的六个重要事件节点：治疗早期，临床上多以雄激素剥夺治疗（ADT）为核心，通过抑制激素活性控制疾病进展。治疗中期，随着对耐药机制的深入，化疗药物（如多西他赛）和新型内分泌药物（如阿比特龙）相继应用于去势抵抗阶段，延长了患者生存期。期间更是诞生了一系列新型AR与PARP抑制剂。治疗后期，RDC的技术突破成为关键转折，“精准定位+辐射杀伤”实现了对转移病灶的定向清除，也是从“系统性”到“局部精准”的升级，标志着前列腺癌治疗进入多模态联合、分子靶向与放射治疗深度融合的新时代。数据来源：公开数据整理经历过去几年全球医药产业的积极布局，前列腺癌在研新药药物数量迅速增长，药智数据显示，全球前列腺癌领域在研新药数量约856个（包括已上市产品的适应症扩展），其中活跃管线约344个，占比约40%；活跃临床阶段管线242个，占比约28%。靶点方面，前列腺新药主要集中于PSMA（FOLH1）、AR、GnRH receptor等靶点。图：全球前列腺癌上市/在研药物数量和靶点（非适应症产品数量）图片来源：药智数据而在新药技术领域分布层面，242个在研活跃前列腺癌管线中，除化疗药物、疫苗与未知小分子抑制剂外，排名前十的技术领域分别是核药（包含RDC）、单抗、ADC、双抗、PARP抑制剂、酪氨酸激酶抑制剂、AR抑制剂、CAR-T、EZH2抑制剂、PROTAC与CYP11A1抑制剂。数据来源：药智数据数量上看，核药是当下前列腺癌新药研发中的绝对热门，尤其近年来迅速走红的RDC领域；其次，单抗、ADC与双抗等免疫疗法虽然治疗局限性大，临床推进困难，但其研发热度仍是仅次于核药的存在；之后如新型PARP抑制剂、AR抑制剂等小分子靶向技术方向在前列腺癌新药研发中也有一席之地；最后，CAR-T与PROTAC等近几年才出现的疗法，其同样拥有不俗的数量。而结合技术领域特点与数量分布情况，当下前列腺癌研发方向可主要分为四者：① 核药：前列腺癌毫无疑问的热门领域，尤其是万物皆可偶联的趋势下迅速发展的RDC领域。② 免疫疗法：包括单抗、ADC与双抗，虽其在前列腺癌的有效性不具优势，但耐不住这个领域在其他肿瘤方向火啊。③ 靶向制剂：以PARP抑制剂、酪氨酸激酶抑制剂、AR抑制剂、EZH2抑制剂为主要的新一代前列腺癌疗法，这个领域也是目前除核药外最被看好的领域之一。④ 其他：包含CAR-T、PROTAC以及未上榜的其他创新疗法，虽其数量不多，但也具备一定的优势。核药（RDC）前列腺新药最集中领域关于核药的应用，人类已拥有了近百年的经验，而随着靶向性问题的解决，RDC成为现阶段核药应用中最受期待的细分领域。所谓RDC，即利用抗体或小分子介导特异性靶向作用，将放射性核素递送至靶位置，从而将放射性同位素产生的放射线集中作用于组织局部，在高效精准治疗的同时降低全身暴露对其他组织造成的损伤。RDC之所以能在前列腺癌中发展迅速，其主要原因有二：一者，众多疗法在前列腺癌的有效性上“有心无力”，而RDC的定向杀伤作用却不受限制，在前列腺癌中表现出优异的疗效‌；二者RDC无需依赖细胞内的代谢途径，‌很大程度上可克服常规药物治疗的耐药性。截至目前，全球共有23款临床活跃管线在研（除上市），其中临床Ⅲ期管线共有三款，临床Ⅱ期的管线共有7款，临床I期的管线共有8款。其中诺华的225Ac-PSMA-617、礼来的Lu-177-PSMA-I&T与阿斯利康的FPI-2265是目前最受期待的三款RDC。适应症阶段药品名称技术类型原研单位管线状态（全球）管线阶段（中国）临床Ⅲ期225Ac-PSMA-617RDCAdvanced Accelerator Applications SA临床Ⅲ期临床Ⅲ期Lu-177-PSMA-I&TRDCCurium;慕尼黑工业大学临床Ⅲ期临床Ⅲ期FPI-2265RDCFusion Pharmaceuticals;RadioMedix Inc临床Ⅲ期临床Ⅲ期临床Ⅱ期177Lu-LNC1011RDC烟台蓝纳成临床Ⅱ期临床Ⅱ期HRS-4357RDC江苏恒瑞医药股份有限公司临床Ⅱ期临床Ⅱ期225Ac-J591RDCConvergent Therapeutics Inc;康奈尔大学临床Ⅱ期临床Ⅲ期67Cu-SAR-bisPSMARDCClarity Pharmaceuticals Pty Ltd临床Ⅱ期临床Ⅲ期[225Ac]Ac-PSMA-R2RDC诺华临床Ⅱ期临床Ⅲ期JH-02RDC晶核生物医药科技（南京）有限公司临床Ⅱ期临床Ⅱ期64Cu-SAR-BBNRDCClarity Pharmaceuticals Pty Ltd临床Ⅱ期临床Ⅲ期临床Ⅰ期[225Ac]-AZD-2284RDC阿斯利康临床Ⅰ期临床Ⅲ期BAY-3546828RDC拜耳临床Ⅰ期临床Ⅲ期18F-OncoACP3RDCPhilogen SpA临床Ⅰ期临床Ⅲ期[177Lu]Lu-BQ7876RDCTomsk National Research Medical Center of the Russian Academy of Sciences临床Ⅰ期临床Ⅲ期225Ac-FL-020RDC上海辐联医药科技有限公司临床Ⅰ期临床Ⅲ期161Tb-SibuDABRDC巴塞尔大学医院临床Ⅰ期临床Ⅲ期TLX-592RDCTelix Pharmaceuticals Ltd临床Ⅰ期临床Ⅲ期177Lu-PSMA-EB-01RDC北京协和医院临床Ⅰ期临床Ⅰ期数据来源：药智数据诺华的[225Ac]Ac-PSMA-617（AAA817）注射液作为目前在研RDC中进展最快的管线，靶向PSMA这个前列腺癌优势靶点，核素选择上使用了Ac-225（α发射器），与Lutetium-177等β发射器相比，具有更高的功效和更少的副作用（短程高能粒子特性）。在其一项终末期转移性去势抵抗性前列腺癌患者的长期生存临床研究中，91%的患者PSA有所下降，其中67.8%的患者下降幅度达到或超过50%。中位随访时间为22个月（6-59个月），68%的患者出现影像学疾病进展，中位OS为15个月，中位rPFS 为9个月。而除了AAA817等临床后期管线外，部分临床阶段前期的管线同样在临床中展现出不俗的实力，比如2025年被FDA授予快速通道的67Cu-SAR-bisPSMA，其认证的关键数据中显示：在所有剂量递增队列中，73%的可评估患者，PSA水平出现下降。在接受治疗的患者中，45%的患者PSA下降超过50%，其中部分患者仅接受了1次67Cu-SAR-bisPSMA的4、8或12GBq剂量。在2、3和4组队列中，患者分别接受了8GBq单次剂量、12GBq单次剂量和12GBq多次剂量的67Cu-SAR-bisPSMA治疗。在这些队列中，约75%的患者PSA下降超过35%，近一半的患者PSA下降至少80%。仍有希望前列腺癌不再是“免疫沙漠”一直以来，前列腺癌都被认为是“免疫沙漠”，其特殊的肿瘤微环境决定了免疫疗法很难起效，但好在对于有反应的前列腺癌患者通常表现出较持久的缓解，这就表示免疫治疗在前列腺癌领域或许仍有希望。多年实践以来，“缺乏有效的生物标志物”被认为是阻碍免疫疗法治疗前列腺癌的主要原因之一，因此，寻找更加有效的前列腺癌相关免疫标志物成为了其目前着重发力的点。并且（抗雄，化疗，PARP抑制剂，镭-223等）的组合疗法也为免疫疗法在前列腺癌领域发光提供了新的希望，也提示我们未来或当以更为开放的眼光设计联合用药方案，以促使前列腺癌从“冷”到“热”的转变。目前免疫治疗用于前列腺癌治疗的临床管线数量仅次于核药，全球共有52款活跃免疫疗法处于临床阶段，其中单抗疗法21款，双抗疗法15款，ADC疗法16款。对于单抗活跃管线，目前已有包括帕博利珠单抗、纳武利尤单抗在内的5款疗法进入了临床Ⅲ期阶段，其余管线则尚处于临床Ⅱ期及之前。技术类型药品名称靶点原研单位管线状态（全球）管线阶段（中国）适应症阶段单抗帕博利珠单抗 PembrolizumabPD-1默沙东批准上市批准上市临床Ⅲ期伊匹木单抗 IpilimumabCTLA4Medarex Inc;百时美施贵宝批准上市批准上市临床Ⅲ期纳武利尤单抗 NivolumabPD-1Medarex Inc;小野药品工业株式会社;百时美施贵宝批准上市批准上市临床Ⅲ期阿替利珠单抗 AtezolizumabPD-L1罗氏批准上市批准上市临床Ⅲ期TLX-591FOLH1Telix Pharmaceuticals Ltd临床Ⅲ期暂无临床Ⅲ期阿得贝利单抗 AdebrelimabPD-L1江苏恒瑞医药股份有限公司批准上市批准上市临床Ⅱ期替雷利珠单抗 TislelizumabPD-1百济神州（上海）生物科技有限公司合作（诺华）批准上市批准上市临床Ⅱ期DKN-01DKK1Leap Therapeutics Inc;礼来百济神州（合作）临床Ⅱ期暂无临床Ⅱ期艾萨妥昔单抗 IsatuximabCD38ImmunoGen Inc赛诺菲（合作）批准上市批准上市临床Ⅱ期GotistobartCTLA4BioNTech SE;昂科免疫;药明生物技术有限公司临床Ⅲ期临床Ⅲ期临床Ⅱ期ENV-105CD105Kairos Pharma Ltd临床Ⅱ期暂无临床Ⅱ期依洛尤单抗 EvolocumabPCSK9安斯泰来制药;安进批准上市批准上市临床Ⅱ期帕博利珠单抗;维博利单抗 Pembrolizumab;VibostolimabPD-1;TIGIT默沙东临床Ⅲ期临床Ⅲ期临床Ⅱ期2141-V11CD40洛克菲勒大学临床Ⅱ期暂无临床Ⅱ期REGN-5678CD28;FOLH1再生元制药临床Ⅱ期暂无临床Ⅱ期依布妥组单抗 EnoblituzumabCD276MacroGenics Inc天境生物（合作）临床Ⅱ期临床申请临床Ⅱ期HMBD-001ERBB3Hummingbird Bioscience Ltd临床Ⅱ期暂无临床Ⅱ期帕妥珠单抗 PertuzumabHER2美国基因泰克有限公司批准上市批准上市临床Ⅱ期BMS-986218CTLA4百时美施贵宝临床Ⅱ期暂无临床Ⅱ期数据来源：药智数据对于双抗活跃管线，目前仅有安进（Xencor、百济神州）的AMG-509进入了临床Ⅲ期，其余管线则处于临床Ⅱ期及之前。技术类型药品名称靶点原研单位管线状态（全球）管线阶段（中国）适应症阶段双/多抗AMG-509CD3;STEAP1Xencor Inc;安进;百济神州临床Ⅲ期临床Ⅰ期临床Ⅲ期PT-217CD47;DLL3Phanes Therapeutics临床Ⅱ期临床Ⅰ期临床Ⅱ期MGD-019CTLA4;PD-1MacroGenics Inc临床Ⅱ期暂无临床Ⅱ期AMX-500CD3;FOLH1Amunix Inc;Vir Biotechnology Inc;赛诺菲临床Ⅱ期暂无临床Ⅱ期沃达利单抗 VudalimabCTLA4;PD-1MD安德森癌症中心;Xencor Inc临床Ⅱ期暂无临床Ⅱ期LAVA-1207FOLH1Lava Therapeutics BV临床Ⅱ期暂无临床Ⅱ期数据来源：药智数据对于ADC活跃管线，目前尚无任何一款新药进入临床Ⅲ期，但临床Ⅱ期管线数量较多，已有11款新药处于该阶段，并且其中含有不少中国Biotech企业。技术类型药品名称靶点原研单位管线状态（全球）管线阶段（中国）适应症阶段ADC德达博妥单抗 Datopotamab deruxtecanTACSTD2;Topo I第一三共制药;阿斯利康批准上市注册申请临床Ⅱ期戈沙妥珠单抗 Sacituzumab govitecanTACSTD2Immunomedics Inc云顶新耀医药科技有限公司（合作）批准上市批准上市临床Ⅱ期维替索妥人单抗 Tisotumab vedotinCD142;TubulinGenmab A/S;Seagen Inc；再鼎医药（上海）有限公司（合作）批准上市注册申请临床Ⅱ期HS-20093CD276上海翰森生物医药科技有限公司葛兰素史克（合作）临床Ⅲ期临床Ⅲ期临床Ⅱ期德伊菲妥单抗 Ifinatamab deruxtecanCD276;Topo I第一三共制药;默沙东临床Ⅲ期临床Ⅲ期临床Ⅱ期维恩妥人单抗 Enfortumab vedotinNECTIN4Seagen Inc;安斯泰来制药批准上市批准上市临床Ⅱ期FOR46CD46;Tubulin加利福尼亚大学旧金山分校临床Ⅱ期暂无临床Ⅱ期YL-201CD276苏州宜联生物医药有限公司临床Ⅲ期临床Ⅲ期临床Ⅱ期纬迪西妥单抗 Disitamab vedotinHER2荣昌生物制药（烟台）股份有限公司批准上市批准上市临床Ⅱ期维汀-拉迪妥单抗 ladiratuzumab vedotinSLC39A6;TUBA3C;TUBB1;TUBB2Seagen Inc;默沙东临床Ⅱ期暂无临床Ⅱ期度嗪沃瑞妥单抗 Vobramitamab duocarmazineCD276MacroGenics Inc临床Ⅱ期暂无临床Ⅱ期PDS0301IL-12PDS Biotechnology Corp临床Ⅱ期暂无临床Ⅱ期数据来源：药智数据当然，免疫治疗在前列腺领域的研发困难肯定不少，其推进也很难在短期内取得较好的反馈。比如2023年1月，默沙东官方宣布，帕博利珠单抗联合恩扎鲁胺和雄激素剥夺疗法（ADT）治疗转移性激素敏感性前列腺癌的一项Ⅲ期临床试验（KEYNOTE-991）就因为无效而停止，而此次临床试验的失败意味着帕博利珠单抗在不到一年的时间内第三次在前列腺癌领域失败。不过，部分双抗与ADC产品在该领域的表现却相对更好，比如2024年11月安进注册了STEAP1/CD3双抗Xaluritamib（AMG 509）治疗转移性去势抵抗前列腺癌的三期临床试验；MGC018虽然在不良事件上折戟，但其单药在治疗mCRPC患者时，显示出了不错的抗肿瘤活性，其（3mg/kg，Q3W）剂量组的ORR达25%。故整体而言，免疫治疗在前列腺癌治疗方面纵然困难重重，却也有不少值得期待的地方，毕竟作为现阶段全球新药研发的主力方向之一，全肿瘤制霸始终还是最终结局。经久不衰新一代靶向制剂登场小分子靶向抑制剂作为前列腺癌多年以来的主力疗法，在经历多年技术更迭之后，如今的技术分类已呈现出多样化构成。整体上来看，前列腺癌小分子靶向在研管线主要由几大类构成，分别是PARP抑制剂、AR抑制剂、EZH2抑制剂、GnRHR拮抗剂、GnRHR激动剂与雄激素合成抑制剂等，其中PARP抑制剂、AR抑制剂的占比数量最多。图片来源：药智网新型PARP抑制剂其实，既往PARP抑制剂多用于卵巢癌、乳腺癌等治疗领域，但随着DNA损伤修复机制与PARP抑制剂的作用关系研究深入，其应用与前列腺癌的想象空间也得以被逐步实现，越来越多的研究结果证实了PARP抑制剂在前列腺癌中的治疗效果。2015年《新英格兰医学杂志》发表的TOPARP-A研究结果首次显示了PARP抑制剂在前列腺癌中的抗肿瘤活性，随后TRITON2研究、GALAHAD研究及TOPARP-B研究等多项Ⅱ期临床试验相继发现携带DNA修复基因胚系和/或体系突变的mCRPC患者对PARP抑制剂敏感，其中绝大多数为HRR基因突变。药品名称技术类型靶点原研单位管线状态（全球）管线阶段（中国）适应症阶段SaruparibPARP抑制剂PARP-1阿斯利康临床Ⅲ期临床Ⅲ期临床Ⅲ期氟唑帕利 FuzuloparibPARP抑制剂PARP江苏恒瑞医药股份有限公司;江苏豪森药业集团有限公司批准上市批准上市临床Ⅲ期HWH-340PARP抑制剂PARP人福医药集团股份公司临床Ⅱ期临床Ⅱ期临床Ⅱ期塞纳帕利 SenaparibPARP抑制剂PARP-1;PARP2上海君实生物医药科技股份有限公司;南京英派药业有限公司批准上市批准上市临床Ⅱ期甲苯磺酸尼拉帕利 Niraparib TosylatePARP抑制剂PARPTESARO Inc;默沙东再鼎医药（上海）有限公司;强生;武田批准上市批准上市临床Ⅱ期TSL-1502PARP抑制剂PARP-1;PARP2Tasly Pharmaceuticals Inc临床Ⅱ期临床Ⅱ期临床Ⅱ期Mefuparib HydrochloridePARP抑制剂PARP-1中国科学院上海药物研究所;辰欣药业股份有限公司临床Ⅱ期临床Ⅱ期临床Ⅱ期帕米帕利 PamiparibPARP抑制剂PARP百济神州;默克雪兰诺有限公司批准上市批准上市临床Ⅱ期IMP-1734PARP抑制剂PARP-1上海瑛派药业有限公司Eikon Therapeutics Inc临床Ⅱ期临床Ⅱ期临床Ⅰ期HS-10502PARP抑制剂PARP-1江苏豪森药业集团有限公司临床Ⅰ期临床Ⅰ期临床Ⅰ期KBP-2205PARP抑制剂PARP凯复（苏州）生物医药有限公司临床Ⅰ期临床Ⅰ期临床Ⅰ期数据来源：药智数据截至目前，全球共有11款用于前列腺癌的PARP抑制剂活跃管线在研，其中阿斯利康的Saruparib与恒瑞医药的氟唑帕利是目前仅有的两款前列腺癌适应症Ⅲ期管线；剩下绝大多数管线则均处于临床Ⅱ期或临床I期。同时，值得注意的是，目前PARP抑制剂靶向制剂的研发方向不再是以往的单药治疗，更多的还是选择与其他制剂进行联合。比如：强生的“甲苯磺酸尼拉帕利”与醋酸阿比特龙联用，并结合泼尼松治疗mCRPC，可以精准靶向患者的雄激素受体与BRCA1/2突变两大致癌驱动因素。其临床结果显示，疗法能显著延长携带BRCA1/2突变的mCRPC患者的影像学无进展生存期（rPFS）。辉瑞Talzenna联合恩扎卢胺治疗具有HRR（同源重组修复）基因突变的转移性去势抵抗性前列腺癌（mCRPC）成人患者，在其关键Ⅲ期研究TALAPRO-2中，HRR突变队列的研究结果显示，甲苯磺酸他拉唑帕利联合恩扎卢胺相比对照组疗效显著：①降低55%的疾病进展或死亡风险；②完全缓解率（CR）高达38.4%（对照组为18.5%）；③客观缓解率（ORR）达67.1%（对照组为40%）。新型AR抑制剂自20世纪60年代AR信号通路靶向治疗问世以来，ARi通过竞争AR结合点来拮抗其主要内源性配体—睾酮和二氢睾酮对AR的激活，对于前列腺癌的治疗作用显著。第一代AR抑制剂（如醋酸环丙孕酮）虽证实了AR阻断策略在前列腺癌临床治疗中的有效性，极具开拓意义，但却因AR亲和力弱（阻断作用有限）且易产生耐药性等多种原因，使其临床应用显著受限。而如今新型AR抑制剂，从多个阶段抑制雄激素信号以及AR受体的激活，包括竞争性抑制雄激素与AR的结合，阻止AR的核转位以及抑制AR与DNA的结合和AR介导的基因转录。其对AR的特异性和亲和力较上一代ARi更强，提供了更有效的雄激素阻断作用，上市后研究及临床实践中也极少发生抗雄激素撤除综合征。药品名称技术类型原研单位管线状态（全球）管线阶段（中国）适应症阶段氘恩扎鲁胺 DeutenzalutamideAR抑制剂海创药业股份有限公司普克药业（合作）注册申请注册申请注册申请CC-94676AR抑制剂新基公司;百时美施贵宝临床Ⅲ期临床Ⅲ期临床Ⅲ期普克鲁胺 ProxalutamideAR抑制剂中国药科大学;苏州开拓药业股份有限公司Applied Biology（合作）批准上市临床Ⅲ期临床Ⅲ期HRS-5041PROTAC/AR抑制剂成都盛迪医药有限公司;江苏恒瑞医药股份有限公司临床Ⅱ期临床Ⅱ期临床Ⅱ期ONCT-534AR抑制剂Oncternal Therapeutics Inc临床Ⅱ期暂无临床Ⅱ期盐酸普萘洛尔 Propranolol hydrochlorideAR抑制剂Wyeth Pharmaceuticals Inc批准上市暂无临床Ⅱ期TQB3720AR抑制剂正大天晴药业集团股份有限公司临床Ⅰ期临床Ⅰ期临床Ⅰ期RO-7656594AR靶向药物美国基因泰克有限公司临床Ⅰ期暂无临床Ⅰ期AC-176AR抑制剂Accutar Biotechnology Inc临床Ⅰ期临床Ⅰ期临床Ⅰ期RG-6537AR抑制剂美国基因泰克有限公司临床Ⅰ期暂无临床Ⅰ期数据来源：药智数据因此，纵然数量不及RDC与免疫疗法，但新型AR抑制剂在整个前列腺癌治疗领域同样拥有举足轻重的地位，也因此被众多新药研发企业争相布局。截至目前，全球共有10款新型AR抑制剂（活跃）处于临床阶段，其中海创药业的氘恩扎鲁胺目前已处于注册申请阶段，BMS的CC-94676与开拓药业的普克鲁胺则仅次于氘恩扎鲁胺，处于临床Ⅲ期阶段，其余众多管线则处于临床Ⅱ期及之前。其中氘恩扎鲁胺与CC-94676是目前新型AR靶向制剂最具代表意义的在研药物：氘恩扎鲁胺作为海创药业自主研发的AR抑制剂，是前列腺癌领域首个氘代机制的创新药物，具有潜力成为患者的新治疗选择。综合评估下，氘恩扎鲁胺展现出独特的药代动力学优势，有效降低了恩扎卢胺的中枢神经系统相关不良反应的发生风险，显著提升了用药安全性，是目前国产替代的显著例子。同时，在其一项氘恩扎鲁胺联合雄激素剥夺治疗（ADT）的Ⅲ期临床试验中，其结果显示，氘恩扎鲁胺组较对照组显著延长rPFS，疾病进展或死亡风险降低42%（HR=0.58，95%CI：0.439-0.770；p=0.0001）。长期rPFS率亦显著改善（12个月：29% vs 6%）。CC-94676作为BMS一款创新性雄激素受体（AR）降解剂，其通过依赖CRL4CRBN E3连接酶的途径，对野生型以及突变型AR均显示出高效降解能力，在针对高级前列腺癌的动物模型研究中，BMS-986365展现了其显著的靶向活性，不仅降解了AR，而且抑制了AR信号传导路径，进而有效地抑制了肿瘤的生长。其在治疗对恩扎卢胺产生耐药性的晚期mCRPC模型方面，展现出显著的治疗潜力。实验结果表明，该药物能实现63%～92%的肿瘤体积减小，这一发现为解决mCRPC患者面临的耐药问题提供了一种潜在的治疗方案。最后，除了上述新型PARP抑制剂与AR抑制剂外，其实前列腺癌领域还有不少其他靶向抑制剂与创新疗法，比如EZH2抑制剂、CYP11A1抑制剂、CAR-T与PROTAC等等，这些疗法的新药数量虽不及RDC、免疫疗法等热门方向，但其仍具有不可小觑的成药潜力。总结对于创新药企而言，任何新药创新背后一定有着其底层逻辑，而前列腺癌之所以在近几年里迅速崛起，一方面有患病市场的大幅增长的原因，也有患者支付意愿的推动与非小细胞肺癌等领域的竞争激烈，更关键的其实在于迫切临床需求的倒逼。总而言之，前列腺癌治疗兴起已足以预见，更关键的还是技术赛道的选择。目前来看，RDC作为前列腺癌领域研发最热的领域，其在有效性与安全性方面的成果显著，但受限于放射性领域强监管的市场行业，对于大多数玩家而言，或许也只能是眼热而已。反而是小分子靶向制剂（新型PARP、新型AR）与免疫疗法对于绝大多数玩家而言，或许才是最优选择。至于最后，到底是哪种疗法会具备颠覆形成成就，谁能笑到最后，则需要更多有效性、安全性数据的横向对比，未来方可窥得全貌。不过可以肯定的是，未来前列腺癌的治疗绝不可能仅凭某款单药就能彻底解决，联合治疗趋势之下，百花齐放或许才是硬道理。来源 | 博药（药智网获取授权转载）撰稿 | 博药内容中心责任编辑 | 八角声明：本文系药智网转载内容，图片、文字版权归原作者所有，转载目的在于传递更多信息，并不代表本平台观点。如涉及作品内容、版权和其它问题，请在本平台留言，我们将在第一时间删除。合作、投稿 | 马老师 18323856316（同微信） 阅读原文，是受欢迎的文章哦

iStock, Love Employee While Novartis and Bayer got there first, AstraZeneca, Bristol Myers Squibb and Eli Lilly are all vying to bring their radiopharmaceutical assets to a market projected to be worth over $13 billion by 2033. When the FDA approved a small and peculiar eight-amino acid peptide therapy in 2018, it also signed off on a field that today provides a precise and personalized approach to treating cancer. Novartis’ Lutathera belongs to a class called radiopharmaceuticals, which combines a radioactive substance and a biological agent into one therapeutic molecule. Lutathera carries lutetium-177, a beta-emitting isotope of lutetium that releases high-energy radiation as it degrades, in turn damaging a cancer cell’s DNA and ultimately leading to its death. Meanwhile, the drug’s eight-residue backbone allows it to specifically home in on subtype 2 somatostatin receptors, proteins typically highly expressed on specific types of cancer cells. This specific structure gives Lutathera—and radiotherapies more broadly—their characteristic precision. Radiopharmaceutical drugs “can generally shrink tumors effectively without causing much side effects,” Andrew Tsai, an analyst at Jefferies, told BioSpace in an email. The use of radioisotopes gives this modality its marked efficacy, Tsai continued, adding that these treatments might also lead to a more durable, longer-lasting therapy. “Lethality of radiation on cancer is robust, and there is no resistance mechanism to the modality,” he explained. Of course, the use of radioactive agents, no matter how targeted, is still bound to cause some toxicity. According to Tsai, radiotherapies can lead to the accumulation of radiation in various organs, which “could limit the dosing potential” of the modality. There is also a limit to how precise radiopharmaceuticals can get, and they still sometimes lead to unintended off-target side effects such as dry mouth and alopecia. On a more practical level, supply constraints also pose a roadblock to radiopharmaceuticals. “Having access to radioisotope[s] has been rate limiting in many instances even for clinical trials,” Tsai said. Another barrier, he continued, is that the practice has yet to penetrate sufficiently into current medical practice; both patients and physicians remain uninformed or uncomfortable about the tech, and there is a need to improve their awareness. Here, BioSpace looks at the current state of radiopharmaceuticals through five leading players—Novartis, AstraZeneca, Bristol Myers Squibb, Eli Lilly and Bayer—including their strategic moves and key upcoming milestones in a space projected to be worth more than $13 billion by 2033. Novartis Seeks to Maintain Radiopharma Leadership Radiopharma assets: Lutathera, Pluvicto Novartis is the clear frontrunner in the radiopharmaceutical race. The Swiss drugmaker already has two commercial products on the market: Lutathera, indicated for gastroenteropancreatic neuroendocrine tumors (GEP-NETs), and Pluvicto, for metastatic castration-resistant prostate cancer (mCRPC). Compared with its competitors, Novartis has also fleshed out “industry-leading radioligand research and production sites” globally, Geoff Towle, vice president of the company’s radioligand therapy solid tumor strategy, told BioSpace in an email. Despite enjoying a comfortable lead, Novartis continues to strengthen its radiopharma portfolio. In May 2024, the company paid $1 billion to acquire Mariana Oncology and its promising pipeline, anchored by MC-339, an actinium-based therapy being studied in small cell lung cancer (SCLC). Novartis also recently launched two pivotal trials for the next-generation radiotherapy AAA817, which is under development for prostate cancer, Towle shared. Like Pluvicto, AAA817 targets the prostate-specific membrane antigen (PSMA) but instead carries an actinium-based payload, which could deliver higher potency . Aside from building out the pipeline, Novartis is also seeking to expand the indications for its current products. Pluvicto, for instance, is currently under review by the FDA for use in earlier-stage mCRPC, with a regulatory verdict expected in the first half of 2025 , Towle said. This approval, if granted, would allow the use of Pluvicto ahead of chemotherapy and would highlight the “potential for radioligand therapy to become an established pillar of cancer care,” he added. These strategic moves, according to Towle, place the company in a strong position to “realize the $10 billion business potential of our candidates in clinical trials or pre-clinical trials,” and bring radioligand therapies beyond prostate and neuroendocrine tumors to other areas of high unmet patient need, including breast and lung cancer. AstraZeneca Zeroes in on Radioconjugates Radiopharma assets: FPI-2265, AZD2068 AstraZeneca bought entry into the radiopharma market in March 2024, with the up to $2.4 billion acquisition of Fusion Pharmaceuticals. Despite being a relative newcomer to the space, AstraZeneca has set its sights high. In a company presentation last month, the pharma announced that radioconjugates are expected to be a strong driver of its business by 2030 and beyond. “Our aim is to build a substantial radioconjugate portfolio to offer treatment options for patients with a broad range of tumor types,” Puja Sapra, AstraZeneca’s senior vice president for biologics engineering and oncology target discovery, told BioSpace in an email. In particular, the pharma envisions that radioconjugates will complement existing radiation therapy and help reach other cancer types that have been difficult to treat. AstraZeneca’s radiopharma pipeline is anchored by FPI-2265—the centerpiece of the Fusion acquisition—which consists of a small molecule drug that targets PSMA and carries an actinium-225 radioisotope that can inflict irreparable damage to cancer cells. FPI-2265 is being assessed in the Phase II AlphaBreak study in patients with PSMA-positive mCRPC, with a readout expected in the second half of 2025, according to Sapra. AstraZeneca is also working on AZD2068, another radioconjugate from Fusion, designed to target cells expressing the EGFR and cMET markers. The asset is currently in a Phase I study for advanced solid tumors. Findings are expected in 2026 at the earliest, according to the pharma’s latest pipeline document. Aside from its pipeline, AstraZeneca is also working on “molecular imaging and computation pathology,” which according to Sapra would “enhance the delivery and monitoring” of radioconjugates. The end goal, she continued, is to “deliver the right treatment to the right patient.” BMS Leads the Way in Actinium-Based Radiotherapies Radiopharma assets: RYZ-101, RYZ-801 A few months ahead of AstraZeneca, Bristol Myers Squibb made a major radiopharma play in December 2023 with the acquisition of RayzeBio and its actinium-225-based platform for $4.1 billion. “RayzeBio is pioneering the use of Actinium-225,” which is an alpha-emitting radioisotope, Ben Hickey, the company’s president under BMS, told BioSpace in an email. “We believe alpha-emitting isotopes represent the next generation of therapeutic radionucleotides due to their higher potency as compared to beta-emitting isotopes.” Novartis’ Lutathera and Pluvicto carry beta-emitting lutetium-177. With the RayzeBio acquisition, BMS gained ownership of the biotech’s lead asset RYZ-101, which targets somatostatin receptor type 2, a protein commonly expressed on certain solid tumors. BMS is running three clinical trials for RYZ-101: A Phase III study for GEP-NETs and Phase I studies in unresectable metastatic breast cancer and extensive-stage SCLC. The SCLC study will read out later this year , while pivotal data for GEP-NETs are expected in 2026, according to Hickey. “If successful, we believe RYZ101 could be the first [actinium-255-based radiopharmaceutical therapy] approved In the U.S.” BMS is also advancing RYZ-801 , which consists of a proprietary peptide bound to an actinium-225 radioactive payload. RYZ-801, which targets the GPC3 protein, entered the clinic late last year for hepatocellular carcinoma, with enrollment currently ongoing, according to Hickey. Aside from these two clinical assets, the acquisition of RayzeBio gave BMS what Hickey called an “IND-generating engine” that can produce “several therapeutic candidates in the coming years.” BMS currently has several preclinical programs ongoing, he said. Beyond beefing up its radiopharma pipeline, BMS is also building up manufacturing capabilities. Hickey said the pharma’s facility in Indianapolis “is now fully operational” and can contribute to clinical supply, while BMS works to ramp up the site to support commercial-scale operations. Eli Lilly Enters Radiopharma Space With Dealmaking Flurry Radiopharma asset: PNT2001 and PNT2002 Ahead of both BMS and AstraZeneca, Lilly entered the radiopharma arena in October 2023 with $1.4 billion to acquire Point Biopharma—a transaction that formally closed in December that year. Less than a year later, in May 2024, Lilly doubled down on radiopharma with an agreement with Aktis Oncology worth up to $1.1 billion. The deal gave Lilly access to the biotech’s proprietary discovery engine to develop novel radiotherapeutic assets against certain cancer targets. But Lilly wasn’t done. In July 2024, the company entered into another strategic alliance , this time with Radionetics Oncology, for $140 million upfront. The partners will work on radiotherapies targeting small-molecule G-protein coupled receptors for the treatment of various solid tumors. Under the deal, Lilly also has the exclusive right to acquire Radionetics for $1 billion. From the Point acquisition, Lilly gained ownership of the biotech’s lead asset PNT2002, a PSMA-targeted lutetium-177-based therapy being proposed for patients with mCRPC whose disease has progressed after hormonal treatment. A Phase III readout in December 2023 for PNT2002 was disappointing : The asset reduced the risk of death or disease progression by 29% versus androgen receptor blockage—an effect that met statistical significance but fell below what analysts had hoped for. Regulatory filings for PNT2002 are “pending,” according to Jefferies’ Tsai. Lilly has other radiopharma bets in the clinic, including PNT2001, which targets the PSMA protein and carries a 225-actinium radioisotope payload. The asset is currently in Phase I development for prostate cancer. According to a Feb. 7 Jefferies note, Lilly also has a preclinical radiopharma candidate that uses 225-actinium. Another, PNT2003, delivers lutetium-177 and targets the somatostatin receptor to address GEP-NETs. Bayer Builds Radiopharma Pipeline Beyond Xofigo Radiopharma assets: Xofigo, 225Ac-Pelgifatamab, 225Ac-PSMA-Trillium Aside from Novartis, the only other company on this list with an FDA-approved radiopharma asset is Bayer. Xofigo , a radium-223 dichloride radioactive drug, was cleared by the FDA in 2013 for the treatment of castration-resistant prostate cancer with symptomatic bone metastases and with no known visceral metastatic disease. Unlike Novartis’ Lutathera and Pluvicto, however, Xofigo does not include a targeting moiety. Instead, the drug takes advantage of radium’s chemistry, which allows it to bind to bone minerals, in turn helping localize the drug to sites of high bone turnover. Xofigo’s market performance has been underwhelming, peaking at €408 million in 2017 . Bayer did not report specific sales for Xofigo last year. But the pharma is attempting to carve out a space in today’s radiopharma space, inking a strategic collaboration with Bicycle Therapeutics in May 2023. For $45 million upfront and up to $1.7 billion in milestones, Bayer gained access to Bicycle’s proprietary peptides, which it will use to develop targeted radiotherapies for several undisclosed cancer targets. As per its pipeline page , Bayer has at least two clinical-stage radiopharmaceutical therapies in development: 225Ac-Pelgifatamab and 225Ac-PSMA-Trillium, both actinium-based candidates in early-stage studies for advanced prostate cancer.