How do you decide on the sequence of systemic and local therapy for patients with oligometastatic NSCLC?

Since patients are already metastatic, systemic progression is the deadliest threat to these patients, so systemic therapy is most important. It will help select out patients with favorable biology that may benefit from aggressive local treatment. The trial that showed a PFS benefit sequenced systemic therapy first, and then treated with SBRT/definitive RT/resection. I'd be hesitant to treat an asympomatic oligometastasis prior to systemic therapy, because it is very likely that the patient will progress systemically, as most patients do. In this study, 1/3 (25 of 74) of the patients progressed on chemotherapy and could not be randomized, so one would surmise without chemotherapy the number of patients progressing would be substantially hig...