Stopping Eligard in Metastatic Prostate Cancer

Core Principle: Continuous ADT is Standard of Care

The National Comprehensive Cancer Network recommends that immediate continuous castration is the preferred treatment for metastatic hormone-naïve prostate cancer and should be maintained throughout the disease course 1, 2
The European Society for Medical Oncology suggests that even when the disease progresses to castration-resistant prostate cancer (CRPC), castrate levels of testosterone must be maintained while additional therapies are applied 3, 4
The androgen receptor remains active even in castration-resistant disease, making continued testosterone suppression essential for any subsequent treatment to work effectively, as stated by the National Comprehensive Cancer Network 5, 3

The American Society of Clinical Oncology recommends that leuprolide should be continued as long as the patient has reasonable life expectancy where disease control matters for quality of life 3

The European Association of Urology suggests that the only scenarios where discontinuation is appropriate include patient develops severe, intolerable side effects that significantly impair quality of life more than the cancer itself 1
The American College of Physicians recommends that discontinuation may be considered if the patient has very limited life expectancy from other causes where ADT side effects outweigh any cancer control benefit 6
The National Comprehensive Cancer Network states that discontinuation may be considered if the patient has documented global disease progression requiring complete change in systemic therapy approach, though even then ADT is typically maintained 4
The American Society of Clinical Oncology suggests that discontinuation may be considered if the patient explicitly chooses comfort-focused care and accepts rapid disease progression 6

The Journal of Clinical Oncology reports that testosterone levels will recover within weeks to months if ADT is stopped 7
The Annals of Oncology states that disease will progress rapidly in most cases, with potential for severe complications including pathologic fractures, spinal cord compression, and urinary obstruction if ADT is stopped 6
The Annals of Oncology suggests that survival will be significantly shortened compared to continued therapy if ADT is stopped 1, 2

The National Comprehensive Cancer Network recommends that if the patient's concern is side effects or treatment burden, consider intermittent ADT instead of stopping entirely 8, 3, 4
The European Society for Medical Oncology states that intermittent ADT allows treatment breaks while maintaining overall disease control, though it requires close monitoring of PSA and testosterone levels during off-treatment periods 3, 4

The American Society of Clinical Oncology suggests that the conversation with the patient should explore why the patient wants to stop ADT, and discuss specific symptom management strategies, consider intermittent therapy, or address individual symptoms (osteoporosis prevention, hot flash management, sexual dysfunction treatments) 5

The Prostate Cancer Clinical Trials Working Group 3 (PCWG3) guidelines recommend continuing ADT therapy, such as leuprolide, until the patient is no longer clinically benefiting from the treatment, rather than discontinuing at a predetermined timepoint 9, 10
Continuation of therapy is advised even if there is progression by PSA or isolated disease sites, as long as the patient is otherwise tolerating the treatment and experiencing overall disease control 11, 12
The decision to discontinue therapy should be based on comprehensive assessment of the patient's clinical status rather than an arbitrary time limit 9, 13

Disease remains responsive in the majority of metastatic sites 12
Disease-related symptoms remain controlled 10
PSA progression is slow or isolated 11
Patient experiences clinical deterioration directly related to disease progression 10, 11
Multiple sites of disease show progression requiring change in systemic therapy 9
Patient develops castration resistance requiring therapy modification 14

Continuous ADT remains the backbone of treatment for metastatic prostate cancer, even when additional agents are added for treatment intensification 15, 16
The PCWG3 guidelines specifically note that therapy may be continued if progression is slow and disease-related symptoms remain controlled 11

Imaging studies as clinically indicated to assess disease status 12, 17
Assessment of bone health and consideration of supportive measures to prevent skeletal-related events 18

Discontinuing leuprolide based solely on PSA progression without considering overall clinical benefit 9, 11
Stopping therapy at an arbitrary timepoint without evaluating continued clinical benefit 10, 13
Failing to distinguish between isolated progression in limited disease sites versus global disease progression 12
Overlooking the need for continued testosterone suppression even when adding other systemic therapies 15, 16