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When prostate cancer spreads beyond the prostate, doctors often turn to hormone therapy to slow it down. One of the most common drugs used for this is Casodex, also known as bicalutamide. It works by blocking testosterone from fueling cancer cells. But it’s not the only option. Over the past decade, newer drugs have entered the market, each with different benefits, side effects, and costs. If you’re considering treatment options, knowing how Casodex stacks up against the alternatives can help you make a smarter choice - especially if side effects are affecting your quality of life or if your cancer has become resistant to older therapies.
How Casodex (Bicalutamide) Works
Casodex is an anti-androgen, meaning it stops male hormones like testosterone from binding to receptors on prostate cancer cells. Without that signal, the cancer slows its growth. It’s usually taken as a daily 50 mg tablet, often alongside another hormone treatment called an LHRH agonist (like leuprolide or goserelin), which lowers testosterone production in the testicles. This combination is called combined androgen blockade.
Unlike some newer drugs, Casodex doesn’t reduce testosterone levels itself - it just blocks its effect. That means it’s often used early in treatment, especially for men with localized but advanced disease. It’s been around since the 1990s, so there’s a lot of long-term data on its safety and effectiveness. Studies show it improves survival when used with LHRH therapy in men with metastatic prostate cancer.
Key Alternatives to Casodex
Three main alternatives have become standard in recent years: enzalutamide (Xtandi), apalutamide (Erleada), and darolutamide (Nubeqa). All three are next-generation anti-androgens, designed to be more powerful and less prone to resistance than older drugs like Casodex.
Unlike Casodex, these newer drugs don’t just block testosterone - they also prevent it from entering cancer cells and stop the androgen receptor from activating even when bound. This makes them more effective, especially in advanced or castration-resistant cases.
Comparison: Casodex vs. Enzalutamide (Xtandi)
Enzalutamide is one of the most studied alternatives. In the PREVAIL trial, men with metastatic castration-resistant prostate cancer who took enzalutamide lived an average of 8 months longer than those on placebo. Casodex, by comparison, showed a 2-3 month survival benefit in similar populations when used with LHRH therapy.
Enzalutamide also works as a single agent - you don’t always need to pair it with an LHRH drug. This simplifies treatment for some patients. But it comes with a higher risk of seizures (though still rare, under 1%) and more fatigue. Casodex rarely causes seizures and is generally better tolerated in older men.
Cost is another factor. Casodex is available as a generic, so a 30-day supply costs around £20-£30 in the UK. Enzalutamide, still under patent protection in many places, can cost over £4,000 per month without NHS coverage. The NHS does fund it for eligible patients, but access can be slower.
Comparison: Casodex vs. Apalutamide (Erleada)
Apalutamide was approved for non-metastatic castration-resistant prostate cancer - meaning cancer that hasn’t spread yet but is growing despite low testosterone. This is a big advantage over Casodex, which isn’t approved for this stage. In the SPARTAN trial, apalutamide delayed metastasis by over two years compared to placebo.
Side effects are similar to enzalutamide: fatigue, rash, and increased risk of fractures. Casodex doesn’t carry those risks. If your cancer is still contained, apalutamide might be the better choice. If you’re older or have bone health issues, Casodex may be safer.
Comparison: Casodex vs. Darolutamide (Nubeqa)
Darolutamide is the newest of the three. It was designed to cross the blood-brain barrier less than the others, which means fewer neurological side effects like seizures or dizziness. In the ARAMIS trial, it delayed metastasis by 22 months in non-metastatic disease, with fewer falls and cognitive issues than apalutamide or enzalutamide.
It’s also taken as two tablets twice daily, which is more frequent than Casodex’s once-daily dose. But it has the lowest rate of drug interactions and is often preferred for men on multiple medications. Casodex interacts with some antidepressants and blood thinners, so if you’re on other prescriptions, darolutamide might be easier to manage.
When Casodex Still Makes Sense
Even with newer options, Casodex isn’t obsolete. For men who:
- Have early-stage metastatic disease and need a low-cost option
- Are older or have other health conditions that make stronger drugs risky
- Have had side effects from newer anti-androgens
- Are waiting for NHS approval of a newer drug
Casodex remains a solid, well-understood choice. Many men stay on it for years with minimal issues. It’s also used in combination with radiation for locally advanced cases - something newer drugs aren’t always approved for yet.
Side Effects: What to Expect
Side effects vary across these drugs. Here’s a quick breakdown:
| Side Effect | Casodex (Bicalutamide) | Enzalutamide (Xtandi) | Apalutamide (Erleada) | Darolutamide (Nubeqa) |
|---|---|---|---|---|
| Hot flashes | High (60-70%) | High (50-60%) | High (50-60%) | Medium (40-50%) |
| Fatigue | Medium (20-30%) | High (40-50%) | High (40-50%) | Medium (25-35%) |
| Rash | Low (5-10%) | Low (5%) | High (15-20%) | Low (5%) |
| Seizure risk | Very low (<0.1%) | Low (0.8%) | Low (0.5%) | Extremely low (0.1%) |
| Bone fractures | Low (5%) | Medium (8%) | Medium (10%) | Low (6%) |
| Drug interactions | Medium | High | High | Low |
Hot flashes are common with all hormone therapies. But if you’re already dealing with heart issues or depression, the fatigue and cognitive effects of enzalutamide or apalutamide could make things harder. Darolutamide tends to be the gentlest on the nervous system.
Cost and Access in the UK
In the UK, Casodex is widely available as a generic. The NHS covers it without restrictions. The newer drugs - Xtandi, Erleada, and Nubeqa - are also available on the NHS, but only for specific situations. For example:
- Enzalutamide: Approved for metastatic castration-resistant prostate cancer
- Apalutamide: Approved for non-metastatic castration-resistant disease
- Darolutamide: Approved for non-metastatic disease and some metastatic cases
If you’re not eligible for NHS funding, private prescriptions for these drugs can cost between £3,000 and £5,000 per month. Casodex, at £25/month, is a major financial advantage.
What If Casodex Stops Working?
Some men develop resistance to Casodex over time - meaning their cancer starts growing again despite treatment. This is called anti-androgen resistance. When that happens, switching to a next-generation drug like enzalutamide or darolutamide often helps. Studies show that about 30-40% of men who fail Casodex respond to enzalutamide, even if they’ve been on it for years.
It’s not guaranteed, but it’s a real option. Many oncologists will try switching before moving to chemotherapy or newer agents like abiraterone (Zytiga). Casodex isn’t a dead end - it’s often a stepping stone.
Choosing the Right Option for You
There’s no single best drug. The right choice depends on:
- Stage of your cancer (localized, metastatic, or castration-resistant)
- Your age and overall health
- Other medications you’re taking
- Your tolerance for side effects
- Cost and NHS access
If you’re newly diagnosed and want to start with something affordable and well-tolerated, Casodex is still a great first step. If your cancer is aggressive or resistant, or if you’re young and want to delay chemotherapy as long as possible, the newer drugs offer better outcomes - if you can access them.
Many men start with Casodex and switch later. Others go straight to a newer drug if their oncologist believes it’s the best path. Talk to your doctor about your goals: Is it about longevity? Quality of life? Cost? Each drug answers those questions differently.
What’s Next?
Research is moving fast. Drugs like seviteronel and darolutamide combinations are in late-stage trials. Some men are now being treated with combinations of two anti-androgens, or with AR-targeted therapies alongside immunotherapy. Casodex may eventually be replaced in most cases - but for now, it’s still a vital tool in the prostate cancer toolbox.
If you’re on Casodex and doing well, don’t rush to switch. If you’re struggling with side effects or your cancer is progressing, ask your doctor about alternatives. You have options - and knowing the differences gives you more control.
Is Casodex still used today for prostate cancer?
Yes, Casodex is still widely used, especially in early-stage metastatic prostate cancer and as a cost-effective option. Many men start with it because it’s well-tolerated and affordable. It’s often combined with LHRH therapy and remains a standard in treatment guidelines, even as newer drugs become more common.
Can you switch from Casodex to Xtandi or Nubeqa?
Yes, switching is common when Casodex stops working or causes intolerable side effects. Studies show that many men respond to next-generation anti-androgens like enzalutamide or darolutamide even after Casodex resistance develops. Your oncologist will monitor your PSA levels and scans to determine the best time to switch.
Which is safer: Casodex or the newer anti-androgens?
Casodex has fewer neurological side effects like seizures and dizziness compared to enzalutamide and apalutamide. It’s generally safer for older men or those with balance issues or a history of seizures. However, it can cause liver enzyme changes, so blood tests are needed. Darolutamide is the safest of the newer drugs in terms of brain-related side effects and drug interactions.
Does Casodex cause breast tenderness or enlargement?
Yes, this is one of the most common side effects of Casodex. Up to 40% of men experience breast tenderness or gynecomastia (breast enlargement). This happens because Casodex doesn’t lower estrogen levels - it only blocks testosterone. Some men take tamoxifen or radiation to reduce this. Newer drugs like darolutamide have much lower rates of this side effect.
Is Casodex better than abiraterone (Zytiga)?
They work differently. Casodex blocks testosterone from acting on cancer cells. Abiraterone reduces testosterone production in the body, including from the adrenal glands. Abiraterone is often used after Casodex fails, or in combination with prednisone. Neither is universally better - the choice depends on cancer stage, side effect profile, and whether you can take steroids (which abiraterone requires).
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