Is There Another Bite of the Cherry? The Case for Radical Local Therapy for Oligometastatic Disease in Prostate Cancer

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The clinical paradigm of oligometastatic disease is topical. This concept for a step-wise progression of cancer which occurs initially with an intermediate state of limited metastasis before acquiring widespread metastatic behaviour was proposed 20 yr ago [1]. Despite this earlier clinical conjecture, it is unlikely that this represents a new biological phenomenon. This clinical scenario must have existed previously. So why has it gained clinical prominence lately? It is likely that the oligometastatic paradigm represents greater clinical awareness reflecting factors that include more trial patient enrolment with comprehensive followup and closer disease monitoring, thereby highlighting earlier limited disease recurrences; improved multimodality functional imaging for earlier detection, and finally perhaps the ability to provide a second bite of that elusive ‘‘salvage’’ cherry for oligometastasis with recent advances in radical ablative therapies that include stereotactic body radiotherapy (SBRT). As with all new technological developments, my favourite quote from the philosopher author Robert Pirsig outlines the caution needed: ‘‘There is an evil tendency underlying all our technology – the tendency to do what is reasonable even when it isn’t any good’’ [2]. These new opportunities provide hope for our prostate cancer (PCa) men, but is it beneficial? In this month’s issue of European Urology, Ost et al [3] have tried to better define a utility for radical PCa ‘‘metastatic-directed therapy’’ using SBRT as the salvage modality of choice. The literature on PCa oligometastatic disease is awash with small single institution reports describing heterogeneous cohorts and have been summarised in a previous review [4]. The authors have attempted to improve analysis by pooling and grouping