Over the last year or so we have seen a marked change in the treatment landscape for men with castrate resistant advanced prostate cancer. The FDA has approved sipuleucel-T (Provenge), cabazitaxel (Jevtana) and last week it also approved abiraterone (Zytiga).

This changed landscape of multiple treatment options creates new problems, of course good problems. Prostate cancer survivors along with their clinicians are now are going to have to make difficult decisions about which drugs to use and in what sequence. Some of these decisions will involve “off- label” uses, which in this climate, might not qualify for insurance reimbursement.

Making these decisions is going to be difficult as we do not have a lot of evidence about how some of these treatments stack up against each other and in what order (or perhaps even they should be mixed in a type of drug cocktail as is done in the treatment of HIV) they should be sequenced. Abiraterone and cabazitaxel haven’t been compared in a head-to-head trial; their pivotal clinical trials were against the then standard of care, docetaxel. Despite this, I can only assume that abiraterone which has fewer serious side effects and can be taken orally may make it the preferred first option.

To add to the dilemma, in a most unusual situation for advanced prostate cancer, there are still a number of other very promising drugs advancing in the pipeline. Both TAK-700 and MDV-3100