The treatment of advanced prostate cancer, and in particular castrate resistant prostate cancer (CRPC), has changed greatly over the last 4 years. Treatment options have expanded and now offer multiple treatment possibilities that did not exist 4 years ago. With the addition of all these new options, so comes the addition of significant economic costs, for instance:

• Provenge: Now almost $100,000 for a standard course of 3 treatments.
• Cabazitaxel: The usual 6 cycles cost about $50,000.
• Zytiga: An 8-month course of treatments costs about $47,000.
• Xtandi: A typical eight-month treatment costs nearly $60,000.
• Xofigo: 6 injections for the cost of $69,000.

Our insurance companies (payers) are all bracing for increased cost to treat men with advanced prostate cancer, many of whom will undoubtedly use some if not all of these new agents either in sequence or in some combination. This will pose a dilemma for payers that attempt to manage the treatment costs of men with advanced prostate cancer. Managing these costs becomes a significant problem given there is virtually no comparative data on the relative effectiveness of these treatments, and no data on which drug will be best suited for which man at what period of his disease.

Without good and solid data payers will not likely be able to manage men with advanced prostate cancer in any meaningful way. Bad decisions for both the payers and the survivors will be made until such time as more data and experience is gathered. A current example of this issue is currently being played over the recent institution of step therapy (requiring a specific order of the use of a drug despite the lack of any medical evidence of any benefit from the order of sequencing) over the use of Zytiga and Xtandi in the post chemotherapy treatment period.

It is true, for the payer with the potential for sequencing these agents and even the possibility of combination therapy, the potential cost of treating these men will likely continue to increase in very significant numbers, especially with the continued development of other, not yet approved treatment options which will also cost many 100,000s of dollars. Until better data is developed it is clear that payers will be left with the relatively blunt instrument of managing access to these agents based on FDA indications and compendium recommendations and their economic costs. Clearly there is a need for additional research in this area that can help both physicians and payers better target the right therapy for the right man with advanced prostate cancer.

Joel T Nowak, M.A., M.S.W.