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The oligometastatic state—separating truth from wishful thinking

Nature Reviews Clinical Oncology volume 11, pages 549–557 (2014)Cite this article

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Abstract

The oligometastatic paradigm implies that patients who develop a small number of metastatic lesions might achieve long-term survival if all these lesions are ablated with surgery or stereotactic radiotherapy. Clinical data indicate that the number of patients with oligometastatic disease receiving aggressive treatment is increasing rapidly. We examine the key evidence supporting or refuting the existence of an oligometastatic state. Numerous single-arm studies suggest that long-term survival is 'better-than-expected' after ablative treatment. However, the few studies with adequate controls raise the possibility that this long-term survival might not be due to the treatments themselves, but rather to the selection of patients based on favourable inclusion criteria. Furthermore, ablative treatments carry a risk of harming healthy tissue, yet the risk–benefit ratio cannot be quantified if the benefits are unmeasured. If the strategy of treating oligometastases is to gain widespread acceptance as routine clinical practice, there should be stronger evidence supporting its efficacy.

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Figure 1: Long-term survival after ablation of oligometastases.
Figure 2: Types of immortal time bias.
Figure 3: Oligometastatic disease as the tip of the iceberg.

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Acknowledgements

The work of D.A.P. is supported by an Ontario Institute for Cancer Research Clinician-Scientist grant.

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Authors and Affiliations

  1. Division of Radiation Oncology, London Health Sciences Centre, 790 Commissioners Road East, London, N6A 4L6, ON, Canada

    David A. Palma

  2. Department of Radiation Oncology, Duke University School of Medicine, 508 Fulton Street, Durham, 27705, NC, USA

    Joseph K. Salama

  3. Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, 11100 Euclid Avenue, Cleveland, 44106, OH, USA

    Simon S. Lo

  4. Department of Radiation Oncology, VU University Medical Centre, De Boelelaan 1117, PO Box 7057, Amsterdam, 1007, MB, Netherlands

    Suresh Senan

  5. Clinical Operational Research Unit, University College London, 4 Taviton Street, London, WC1H 0BT, UK

    Tom Treasure

  6. Washington University School of Medicine, 660 South Euclid Avenue, St Louis, 63110, MO, USA

    Ramaswamy Govindan

  7. University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, 60637, IL, USA

    Ralph Weichselbaum

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Contributions

D.A.P., J.K.S., S.S.L., T.T. and R.W. researched the data for this article. All authors wrote the article, made a substantial contribution to discussion of the content for the article, and reviewed and edited the manuscript before submission.

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Correspondence to David A. Palma.

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Competing interests

S.S. declares he receives honouraria and has a research agreement with Varian Medical Systems. He is also a member of trial management committee (with expenses reimbursed) for Lilly Oncology. R.G. is a consultant for Abbott Oncology, Boehringer-Ingelheim, Bristol–Meyers Squibb, Covidien, Genentech, Merck, Pfizer and Roche. R.W. is an advisory board member of Catherex, Inc., a consultant for Bristol–Meyers Squib and RefleXion Pharmaceuticals, and has received a grant and stocks from Reata. The other authors declare no competing interests.

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Palma, D., Salama, J., Lo, S. et al. The oligometastatic state—separating truth from wishful thinking. Nat Rev Clin Oncol 11, 549–557 (2014). https://doi.org/10.1038/nrclinonc.2014.96

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