Alternative Medications to Bicalutamide for Prostate Cancer Treatment

Efficacy and Safety

Enzalutamide demonstrates significantly better progression-free survival compared to bicalutamide in castration-resistant prostate cancer patients, with a median time to progression of 15.7 months with enzalutamide versus 5.8 months with bicalutamide (HR 0.44) 1, 2, 3, 4
The American College of Physicians and the National Comprehensive Cancer Network recommend enzalutamide as a category 1, preferred treatment option for patients with metastatic CRPC without prior novel hormone therapy 5
Enzalutamide reduced the risk of progression or death by 76% compared to bicalutamide (HR 0.24) in the STRIVE trial 3, 4

Enzalutamide has not been associated with significant hypercholesterolemia, unlike bicalutamide 6
The incidence of cardiac disorders did not differ between enzalutamide and placebo arms in clinical trials, with major adverse cardiovascular events occurring in only 5% of patients on enzalutamide versus 3% on placebo in the PROSPER trial 1, 2, 4, 7

Common side effects of enzalutamide include fatigue (33-34%), diarrhea (21%), hot flushes (20%), hypertension (12%), and headache (12%) 1, 5
Seizure risk with enzalutamide is low (0.6-0.9%) but should be considered in patients with seizure history 1, 2
Mental impairment disorders were reported in 5% of enzalutamide patients versus 2% on placebo 4, 7

Apalutamide is FDA-approved for non-metastatic CRPC with PSADT ≤10 months and has not been associated with significant cholesterol elevation in clinical trials 4, 7
Apalutamide demonstrated significant improvement in metastasis-free survival compared to placebo (40.5 vs 16.2 months) 4, 7

The National Comprehensive Cancer Network recommends enzalutamide as the first choice for CRPC treatment, due to its superior efficacy and no significant impact on cholesterol levels 1, 2, 3, 5
Apalutamide is recommended as the second choice for non-metastatic CRPC with PSADT ≤10 months 4, 7

Patients receiving enzalutamide have no food restrictions, and concurrent prednisone is permitted but not required 5
Regular monitoring for side effects including fatigue, hypertension, and mental status changes is recommended 4, 5
All patients should continue LHRH agonist/antagonist therapy when switching from bicalutamide to enzalutamide 1, 5
Cost considerations may influence treatment selection, as enzalutamide is more expensive than bicalutamide 3, 8