Do you offer local consolidative therapy for patients with polymetastatic driver mutation-positive NSCLC who respond well to targeted therapy?

This is a great question. In phase II prospective study, Gomez and colleagues (Gomez et al., PMID 31067138) demonstrated a PFS and OS benefit with local consolidative therapy in patients whose disease did not progress after first-line systemic therapy. In my opinion, local consolidation therapy to oligometastatic sites should only be offered to those patients who have "good systemic control" of the disease with the current systemic therapy and can "tolerate the local consolidative therapy" without "significant side effects or morbidity." This should usually be reserved for those patients with good performance status. Additionally, we also have to be aware of the added toxicity of combining systemic therapy with local consolidative therapy. ...

For truly polymetastatic patients, I tend to take an approach of consolidation of oligoprogressive or oligoresistant lesions while these patients continue on highly effective systemic therapy. Driver mutations adenos can have durable responses to generally well-tolerated therapy for many years and we can reserve radiotherapy for clones that become non-responsive. CURB trial from Tsai et al. demonstrated that ablative radiotherapy to oligoprogressive NSCLC is a viable approach with a highly significant benefit in PFS. Saying that I think many of us wish to continue to push the boundaries of oligometastatic disease to demonstrate potential benefit in patients with more pronounced systemic disease burden. SABR-COMET-10 will give us phase 3 dat...