Men have more options in prostate cancer treatments

• Multiple options exist for treating advanced prostate cancer
• Prostate cancer drugs can cost $35K-$100K a year without insurance
• Figuring out which patients will do well on which drugs is mostly a game of chance

Jim Kiefert of Olympia, Wash., has been battling prostate cancer for 23 years. The retired school administrator, 74, has never been more optimistic about his prospects than he is now.

For the first time ever, thanks to a handful of drug approvals over the past 2½ years, there are now multiple options for treating advanced prostate cancer. The newest drug, enzalutamide, which goes by the brand name Xtandi, came on the market last week with the best survival data ever seen in prostate cancer.

None of the new drugs is a cure. Enzalutamide extends life by just five months, according to research. But they work extremely well for some patients and have far fewer side effects than most predecessor drugs, said Stuart Holden, who practices at Cedars-Sinai Medical Center in Los Angeles and is medical director of the Prostate Cancer Foundation.

The only downside, Holden said, is that he now has a choice of drugs to prescribe for the first time, but no way of deciding which drug is best.

"It's a far better problem to have than when we had no options," he said.

Prostate cancer is the most common non-skin cancer in America, with 242,000 cases expected to be diagnosed this year, and 28,000 deaths. Although not all prostate cancers turn lethal, there is no way yet to distinguish between the benign ones that will stay put in the prostate, and the dangerous ones that will start creeping into the bones, the mostly likely place they spread.

Jim Kiefert's cancer had already spread by the time it was discovered shortly before his 51st birthday. After surgery and 35 rounds of radiation, he was told he had one to three years to live.

He gave up his beloved red meat, and began an exercise routine he still follows three days a week, including 200 sit-ups, 200 push-ups, 1.5 miles on a treadmill and 5 miles on a recumbent bike. He also started taking Lupron, a drug that deprives the body of most testosterone, a process that is known as chemical castration.

It's the standard of care for advanced cancers that have spread beyond the prostate because most prostate cancers feed on testosterone. But its side effects are legion: erectile dysfunction, loss of energy and libido, urinary problems and others. Kiefert said he didn't feel like himself.

For decades, men who relapsed while on Lupron or similar drugs were usually given chemotherapy, and, if that failed, told to wait for death.

Back when Kiefert got sick, there was little money for prostate cancer research, and no new drugs reaching the market. Patients didn't want to talk about their disease, and when men went to Washington to lobby, they were usually going to support their wives' effort to raise funds for breast cancer research.

That began to change in the early '90s, when troubled financier Michael Milken began publicizing his own prostate cancer battle and bringing attention to the lack of funding for research. In 2005, the Department of Defense began investing heavily in prostate cancer research, and pharmaceutical companies, which had largely ignored the disease, began to get interested, said Howard Scher, chief of the Genitourinary Oncology Service at New York's Memorial Sloan-Kettering Cancer Center. That collaboration among activists, academics, the government and drug companies has led to more than 100 clinical trials and was instrumental in most of the new drugs reaching the market, he said.

Kiefert is the beneficiary of two of them.

By the time Lupron stopped working for him about six years ago, Kiefert, who leads a local prostate cancer support group for the advocacy group Us TOO, was able to join a trial for Provenge, the first cancer vaccine. It ramps up the body's immune system and aims it at the cancer.

Provenge bought him 2½ years without any cancer growth -- long enough for him to qualify for a trial of enzalutamide late last year. Now, Kiefert's prostate-specific antigen number, a measure of the progression of the disease, is down from 30 to 4.5 -- as good as it's been in decades.

Enzalutamide is "the best innovation in prostate cancer therapeutics in two to three decades," according to Leslie Michelson, chairman and CEO of Private Health Management, an agency that coordinates medical care for higher-income clients.

Prostate cancer drugs -- both new and established -- can easily cost $35,000-$100,000 a year without insurance.

Scientists are now trying to understand who is likely to respond well to the drug, and why some patients fail to respond, said Scher, the principle investigator on the enzalutamide trials.

Most trials are conducted on patients who have advanced disease. The drugs might be more effective if started earlier, but that's yet to be proved, Scher said.

Now, figuring out which patients will do well on which drugs is mostly a game of chance. "In the future, the hope is we'll be smarter and be able to pick out the right therapies at the right time," said Philip Kantoff, chief clinical research officer at the Dana-Farber Cancer Institute and Harvard Medical School.

For his part, Kiefert had his knees replaced last year. The doctor told him they came with a 30-year guarantee, "and I plan on wearing them out!"

Some of the recently approved prostate cancer drugs that have been shown to prolong life:

Provenge. A vaccine approved by the FDA in April 2010 that primes a man's immune system to attack an existing tumor. Sold by Dendreon. It costs $93,000 for a standard course of three treatments.

Cabazitaxel. A new form of chemotherapy, approved in June 2010, and sold by Sanofi-Aventis under the name Jevtana. The typical six cycles cost about $50,000.

Abiraterone. Approved in April 2011, and sold by Janssen Biotech under the brand name Zytiga, it deprives tumors of testosterone. An eight-month course of treatments costs about $47,000.

Enzalutamide. Approved in August 2012, enzalutamide, sold under the name Xtandi and developed by Medivation and Astellas Pharma, blocks the ability of testosterone to enhance cancer growth. A typical eight-month treatment costs nearly $60,000.

Radium 223. Still awaiting FDA approval, this drug from Bayer HealthCare would carry radioactive particles deep into the bone where tumors are spreading, and kill cancer cells.

Sources: Lee Kalowski, Credit Suisse Group; Howard Scher, Memorial Sloan-Kettering; Philip Kantoff, Dana-Farber Cancer Institute