In the past, prostate cancer that had spread (metastasized) beyond the gland was considered amenable only to systemic therapy, using hormonal treatments or chemotherapy. These approaches help slow the cancer’s advance, but they also can cause a host of side effects.
With the emergence of high-tech imaging, specialists can now identify advanced prostate cancer before it becomes widespread. And, using precision radiotherapy or surgery, they can selectively treat these pockets of oligometastatic disease, an intermediate or transitional stage between localized and more extensive polymetastatic cancer.
This approach, known as metastasis-directed therapy, may help some men delay or even avoid the use of conventional androgen-deprivation therapy and other systemic therapy in oligometastatic cancer, thereby sparing them the side effects while potentially prolonging their survival.
“The identification of oligometastatic cancer has increased dramatically in recent years,” says Rahul Tendulkar, MD, a Cleveland Clinic radiation oncologist. “The prognosis is steadily improving with the advent of metastasis-directed therapy.”
What Is Oligometastatic Disease?
Oligometastatic cancer refers to disease that has spread to five or fewer sites beyond its origin point. In addition to prostate cancer, some of the most common types of oligometastatic disease include non-small cell lung cancer, kidney cancer, colorectal cancer, and breast cancer.
Dr. Tendulkar outlines three primary oligometastatic scenarios in prostate cancer:
- “De novo” oligometastatic disease, or limited metastases identified at the time a man is first diagnosed with prostate cancer.
- Oligorecurrent disease, diagnosed after a man has received initial curative treatment for prostate cancer, such as surgery or radiation to the prostate.
- Oligoprogressive disease, or pockets of cancer that continue to grow in certain areas despite successful systemic therapy throughout the body.
Because it has spread beyond the original site, oligometastatic disease is technically considered stage 4 cancer. However, it differs from polymetastatic cancer in that the disease is not widespread throughout your body; rather, you have only a small number of tumors in isolated spots. As such, you may not need the more intensive systemic therapy required for polymetastatic disease.
How Is Oligometastatic Disease Diagnosed
Oligometastatic prostate cancer often affects nearby pelvic lymph nodes and bones, commonly the pelvis, spine and ribs. Although many men with oligometastatic disease experience no or mild symptoms, some may experience pain in the affected bones. These symptoms may accompany prostate-specific symptoms, such as more frequent, painful, or difficult urination, blood in the urine or semen, or a feeling of incomplete bladder emptying.
Today, most oligometastatic prostate cancer is identified through advanced imaging called prostate-specific membrane antigen positron emission tomography (PSMA-PET). PSMA is a protein found in high amounts on most prostate cancer cells. In the imaging study, a radioactive tracing agent injected into a vein attaches to the PSMA-positive cancer cells, making them visible on whole-body PET imaging.
“Ever since PSMA-PET scans were approved for clinical use, it has opened our eyes to detect recurrences and progression much earlier than we otherwise would have,” Dr. Tendulkar explains. “Historically, we relied on bone scans, which were not very sensitive or specific for prostate cancer, and by the time there was enough cancer to see on a bone scan, it was widespread. But now, you often can find a recurrent prostate cancer involving one or two sites only, and oftentimes those recurrences may be amenable to local treatment, such as radiation therapy or surgery.”
Treatment Options for Oligometastatic Disease
The standard-of-care treatment option for men whose cancer has spread beyond the prostate is systemic therapy with conventional androgen-deprivation therapy medications like leuprolide and relugolix (among others), as well as second-generation hormonal drugs known as androgen receptor pathway inhibitors: abiraterone, apalutamide, darolutamide and enzalutamide. From there, other systemic treatments, such as chemotherapy and (for men with certain gene mutations) targeted therapy drugs, can be employed.
These systemic treatments slow the growth of advanced prostate cancer and extend men’s lives, but they cannot cure the disease—in the case of hormonal therapies, the cancer eventually becomes resistant to the treatment and continues to progress. Moreover, since hormonal therapies cut levels of testosterone, they can cause an array of side effects that greatly affect quality of life.
Identifying the cancer in the oligometastatic state allows for metastasis-directed therapy, which targets the individual tumor sites using surgery or, most commonly, a state-of-the-art treatment known as stereotactic body radiotherapy (SBRT). Compared with conventional radiotherapy, SBRT can be administered more precisely and in fewer treatment sessions.
Prognosis and Survival Rates
Research has found that metastasis-directed therapy with SBRT, compared with observation alone, can delay cancer progression and the need for systemic treatment among men with oligorecurrent prostate cancer. In this same setting, two other trials found that the combination of SBRT and hormone therapy reduced cancer progression more significantly than either treatment alone. Moreover, in a meta-analysis of data from seven studies involving a total of 574 men with oligometastatic disease, researchers reported a benefit of metastasis-directed therapy at reducing cancer progression and prolonging the effectiveness of hormonal therapy (The Lancet Oncology, February 2026).
Dr. Tendulkar notes that SBRT is about 90% to 95% effective at controlling cancer at the individual tumor sites. And for men with oligoprogressive disease, in whom systemic therapy is largely effective except for in a few spots, metastasis-directed therapy with SBRT can delay the need to advance to a next-line systemic therapy, which may be more toxic and expensive. “We have a limited number of lines of systemic therapy that are going to work, so we want to try to maximize the effectiveness of each one and try to delay things further,” he says.
Researchers also are studying combination treatment with SBRT and a radiopharmaceutical agent that attaches to and destroys PSMA-targeted cancer cells. The LUNAR trial found that adding the investigational PSMA-targeting drug (177Lu-PNT2002) to SBRT delayed cancer progression, compared with SBRT alone (18 months versus seven months). “So there’s interest in whether you can introduce some type of radiopharmaceutical as an alternative to hormonal therapy as a combined treatment with SBRT,” Dr. Tendulkar says. “It’s something that is showing some promise.”
Living with Oligometastatic Disease
Dr. Tendulkar notes that studies examining metastasis-directed therapy for oligometastatic prostate cancer are relatively new, so it remains to be seen how effective the treatment will be over the long term. However, treatment with SBRT in this setting appears to be safe, he adds: “As long as we have good patient selection and as long as we’re careful and thoughtful about how we use SBRT, it’s a very powerful tool.”
If you’re diagnosed with oligometastatic cancer, get opinions from multiple specialists, including radiation and medical oncologists, as well as surgeons. “We are using multiple modalities of treatment for oligometastatic disease,” Dr. Tendulkar says. “It really is a team effort.”
Also, ask your doctor these questions:
- What is the extent of the disease, including the number and location of tumor sites?
- Am I a candidate for metastasis-directed therapy?
- What treatment(s) do you recommend, and what are the pros and cons of each?
- What side effects can I expect from these treatments, and how will they be managed?
Dr. Tendulkar cites the example of one of his patients who underwent prostate cancer surgery and radiotherapy and experienced a subsequent rise in prostate-specific antigen (PSA) levels, suggesting cancer recurrence. A PSMA-PET scan identified a lone tumor that had spread to his bone. He did not want hormonal therapy, so he underwent metastasis-directed therapy with SBRT.
“Nine months later, his PSA basically went to zero, and it’s remained that way for four years. He said he has had no side effects,” Dr. Tendulkar says. “It’s possible he might be cured from metastatic prostate cancer. I would say this it not the norm, but it’s at least an anecdote that maybe a cure is possible in this setting, where it was unthinkable five years ago.”
