How would you treat a patient with low burden metastatic renal cell carcinoma that progressed on cabozantinib who is not a candidate for immunotherapy?

For patients with low volume mRCC and a slow growth rate, I favor treatment with an oligiometastatic disease paradigm. The definition of oligo- disease is not standardized though a numerical cutoff of 5 or fewer metastasis is widely used. It is important to understand that biology is the most critical factor in determining appropriateness for oligometastasis directed therapy. Simply enumerating metastasis is an incomplete understanding of biology. Location of metastasis also appears to be import...

I agree with Dr. @Dr. First Last. My only caveat is that we need to get smarter about application of local approaches like SBRT. It's not clear to me that deferring systemic therapy using SBRT has advantages over deferring systemic therapy without SBRT. The patient likely would have a greater tumor burden upon starting therapy but still likely to be small and there are no data that volume of therapy affects outcome to systemic regimens.