Tall Allen

I'm sorry to hear the bad news about your father. The good news is that more new treatments have been approved this year than have been approved in many years combined.

The traditional approach is to use hormone therapy first until and if that fails, then second line hormone therapy (e.g., ketoconozole), then various chemos. When new drugs get FDA approval, they are tested first among those with "Castrate Resistant Prostate Cancer (CRPC)" then expanded to those with hormone-responsive metastatic disease, and then possibly to others. Once the FDA approves a new drug for ANY indication, a doctor can prescribe it, but insurance will probably not pay for it. They are mega-expensive.

If you are looking for hope, there are many possibilities that your father may wish to try at some point as the disease evolves.

There is a host of new drugs that have been FDA approved in the past year for CRPC metastatic disease. Among the hormone therapy drugs, Zytiga (abiraterone) is the first testosterone blocker that does not seem to incur resistance. MDV 3100 has completed Phase 3 clinical trials and is on fast track for FDA approval, and there are several others (e.g., TAX-700 and ARN-509).

If you go to clinicaltrials.gov and enter those names and "prostate cancer" it will show you the clinical trials that are still recruiting and you can check the qualifications and where they are being conducted. Many of them are at MD Anderson, which is near you. I think Zytiga/abiraterone has expanded trials to patients with any metastatic disease, not just CRPC.

The vaccines : Provenge, Yervoy (both approved this year) and Prostvac VF (in trial) are so far for CRPC as well, but keep checking -- the drug companies are eager to expand their markets to those with just metastatic disease.

Alpharadin, is about to be approved for CRPC, and Samarium153, which is already available, are radioactive medicines that target bone metastases. Radiation, like IMRT or CyberKnife, can irradicate or debulk tumors that are large enough to show up on bone scans.

Denosumab (Xgeva) was FDA approved in the past year to prevent skeletal problems from bone mets, and actually seems to prevent bone metastases from prostate cancer. Zometa (zoledronic acid) also seems to be effective at accomplishing this.

A Phase III trial of XL – 184 (Cabozantanib) will be announced any day now. The FDA so far has denied their request for approval as a palliative and is insisting on them showing a survival benefit. The trial is expected to be for CRPC.

For further down the line, there are various chemo cocktails, many featuring Jevtana (Cablitaxel) which seems to last a lot longer than Taxotere (docetaxel), the old standby.

If your father is willing to try some of these approaches to extend life and not just go for palliative care for the pain, you might want to hook up with an Oncologist, perhaps at MD Anderson, who is willing to work with you. His doctor is probably right that the first step is some kind of hormone therapy, perhaps with or followed by radiation on the known metastases. Even with that, there are several choices of hormone therapy. Hormone therapy is his first best hope at stopping the progress of the disease.

You should be aware that when you read statements like "Provenge (or whatever new drug) increases survival by four months" that four months is the average and there is wide variance around that average. Many new drugs do not work at all in a large percent of cases, and many of them have added years of life in a lucky few.

A lot will depend on what your father is willing to go through. Many tough decisions lie ahead.

- Allen