I recently heard a fascinating presentation by Dr. Paul Okunieff, a leader in radiation oncology. Dr. Okunieff recently relocated to my home state to become the director of the University of Florida Shands Cancer Center. He discussed his pioneering work on treating patients with just a few sites of metastatic cancer (a condition known as oligometastatic disease, oligo meaning “few”) with stereotactic body radiotherapy (SBRT). I will admit that I have never been a fan of chasing after metastatic disease with radiation. After hearing Dr. Okunieff’s presentation, though, I definitely felt that his approach was worth pursuing in larger clinical trials.

Prior to the 1970s, with very limited chemotherapy options, local therapies (such as surgery or radiation) were pursued more frequently for metastatic cancers. Even today, for metastatic tumors with few effective chemotherapies (such as melanomas and sarcomas), removal of multiple metastases may be performed. For colon cancer, resection of liver or lung metastases can lead to long-term survival in some patients. Resections of solitary brain metastases have long been undertaken, including for patients with lung cancers. However, most oncologists would understandably object to local therapy (either surgery or radiation) in a patient with lung cancer and 2 metastatic deposits in the contralateral lung and 2 in the liver. The argument is that metastatic cancer is a systemic disease: if we can see 2 metastases, there are probably hundreds of micrometastases that we cannot see on scans. If we use local therapy, it’s like playing whack-a-mole: as soon as one metastasis is destroyed, another will pop up and so on and so on…

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