Can radiotherapy offer a realistic possibility of cure for selected patients with metastatic cancer? A new opinion article published in Advances in Radiation Oncology in November 2026 challenges the conventional distinction between curative and palliative treatment in oligometastatic disease, proposing a more precise framework for identifying patients who may benefit from aggressive radiation therapy.
The article, titled “Curative Oligometastatic Radiation Therapy: Why We Should Redefine Intent When Cure May Be Attainable,” was authored by Jonathan B. Wallach, Maria D. Kelly, Ronald Shapiro, Mary McGunigal, Steve P. Lee, Lori Hoffman-Hogg, Gabriela Wechsler, and Ruchika Gutt, on behalf of the Veterans Health Administration Palliative Radiotherapy Task Force.
The authors introduce the term curative oligometastatic radiotherapy (CORT), arguing that selected patients with limited metastatic disease may have a meaningful possibility of cure or exceptionally prolonged survival with durable local control.
Rethinking the Treatment of Oligometastatic Disease
The concept of oligometastatic disease (OMD) was first proposed by Samuel Hellman and Ralph Weichselbaum in 1995. Their hypothesis suggested that metastatic cancer exists along a spectrum, ranging from localized malignancy to widespread dissemination, with an intermediate state in which cure or prolonged disease-free survival may remain achievable.
Over the following decades, the management of oligometastatic disease has evolved considerably.
The presentation of the SABR-COMET trial and a randomized phase II trial of local consolidative therapy in oligometastatic non-small cell lung cancer at the 2018 American Society for Radiation Oncology Annual Meeting marked an important period in the development of metastasis-directed radiotherapy.
These studies contributed to growing interest in local radiation treatment for patients with limited metastatic disease and encouraged further clinical investigation, including phase III trials.
However, an important question remains: When should radiation therapy for oligometastatic disease be considered potentially curative rather than palliative?
What Do Oncologists Believe About the Possibility of Cure?
To examine current clinical perspectives, the Veterans Health Administration Palliative Radiotherapy Task Force surveyed 59 radiation oncologists and 47 medical oncologists practicing at Veterans Affairs facilities.
The findings revealed substantial agreement regarding the potential benefits of high-dose radiation therapy for selected patients with oligometastatic disease.
All 105 respondents who answered the relevant question agreed that high-dose radiotherapy could benefit appropriately selected patients.
Furthermore, 88.7% believed that radiation therapy for oligometastatic disease could contribute to cure, including 88.1% of radiation oncologists and 89.4% of medical oncologists.
Nevertheless, differences emerged regarding how oligometastatic disease should be defined.
Most radiation oncologists considered five or fewer metastatic lesions consistent with oligometastatic disease, while most medical oncologists favored a threshold of three or fewer lesions. This difference was statistically significant (p = .006).
The survey also found that 52.9% of respondents believed local radiotherapy for oligometastatic disease should not be restricted to particular tumor histologies.
The authors referenced the phase II EXTEND trial in oligometastatic pancreatic adenocarcinoma, which demonstrated a progression-free survival benefit with the addition of metastasis-directed therapy to systemic treatment. The subsequent phase III EXPAND trial is investigating whether this approach can improve overall survival.
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When Does Metastatic Treatment Become Curative?
One survey scenario involved a 70-year-old man previously treated with definitive chemoradiation for stage III, p16-positive squamous cell carcinoma of the base of the tongue.
Two years after treatment, he developed a biopsy-confirmed, 2 cm peripheral right lung squamous cell carcinoma considered most consistent with an oligometastatic lesion. His performance status remained excellent, with an ECOG score of 0.
Physicians were asked how they would describe the purpose of radiation therapy to this patient, including whether treatment was intended to achieve cure, prolong survival, delay chemotherapy, or provide palliation.
Overall, 43.4% believed that cure was possible in this scenario.
For the authors, these responses raise an important issue in contemporary radiation oncology: patients with oligometastatic disease may receive similar local treatments despite having substantially different prognoses and therapeutic objectives.
The article argues that treatment terminology should better reflect these differences.
Introducing Curative Oligometastatic Radiotherapy (CORT)
To address this issue, the authors propose curative oligometastatic radiotherapy (CORT) as a distinct treatment classification.
CORT describes radiation therapy delivered to patients with oligometastatic disease when the treating radiation oncologist considers cure, or at least exceptionally prolonged overall survival with durable local control, a realistic possibility.
The proposed classification differs from conventional metastasis-directed therapy in several important respects.
First, CORT requires a curative treatment objective and includes management of the primary malignancy when it has not already been eradicated.
Second, although stereotactic ablative radiotherapy (SABR) would be appropriate in many cases, CORT is not restricted to SABR techniques.
Finally, the classification explicitly recognizes the oligometastatic disease state rather than defining treatment solely by radiation technique or dose intensity.
The authors draw a parallel with surgical oncology, where curative metastasectomy has been recognized for decades.
For example, a 2011 meta-analysis involving patients undergoing liver resection for colorectal metastases reported 10-year overall survival rates ranging from 12% to 36%, with recurrence becoming unlikely after 10 years.
This experience provides a historical basis for considering curative treatment strategies in selected patients with metastatic disease.
Which Patients May Be Candidates for CORT?
The proposed framework emphasizes careful patient selection, particularly because aggressive radiation treatment may involve additional toxicity.
The authors identify several characteristics associated with favorable long-term outcomes that could help determine eligibility for CORT.
Limited metastatic burden
Patients with up to three metastatic lesions may be particularly suitable candidates.
Favorable tumor biology and effective systemic treatment options
Examples include many hormone-sensitive prostate cancers and hormone receptor-positive breast cancers.
Other malignancies may also qualify when favorable molecular characteristics and effective targeted therapies are present, such as ALK-positive lung cancer.
Control of extracranial disease
Adequate control of disease outside the central nervous system is considered an important prognostic factor.
Absence of intracranial metastases
The proposed criteria favor patients without intracranial disease.
Good performance status and limited comorbidities
Patients with preserved functional status, limited competing medical conditions, and adequate immune function may be better positioned to tolerate aggressive treatment.
Favorable tumor marker profiles
Low tumor marker levels, including circulating tumor DNA (ctDNA) when applicable, may help identify patients with more favorable disease characteristics.
The authors also discuss the potential relevance of undetectable ctDNA and histology-specific thresholds, including a PSA level of 0.8 ng/mL or lower in oligometastatic prostate adenocarcinoma.
Long disease-free interval
For patients with oligorecurrent disease, a prolonged interval between initial treatment and metastatic recurrence may indicate a more favorable prognosis.
Importantly, these characteristics are proposed selection criteria rather than an established, validated scoring system.
Why Treatment Intent Matters in Clinical Practice
The proposed CORT classification extends beyond terminology.
According to the authors, identifying patients with a meaningful possibility of cure could influence treatment planning, radiation dose selection, multidisciplinary management, and communication with patients.
In situations where long-term disease control or cure may be achievable, clinicians and patients may reasonably consider more aggressive radiation doses, frequently using ablative techniques, despite the potential for increased toxicity.
A clearer classification could also help reduce differences in oligometastatic treatment approaches between institutions.
Additional potential benefits include improved integration with definitive-intent systemic therapies, more consistent clinical trial populations, better data collection, and greater alignment between radiation oncology and surgical oncology terminology.
For patients, defining treatment intent more precisely may help explain why an intensive local treatment strategy is being recommended despite the presence of metastatic disease.
Nevertheless, the authors emphasize that treatment decisions must remain individualized, with careful consideration of prognosis, anticipated benefits, and potential adverse effects.
The Next Step: Developing a CORT Scoring Framework
The Veterans Health Administration Palliative Radiotherapy Task Force intends to develop the proposed selection criteria into a point-based framework for future prospective clinical trials.
The objective is to identify patients with a high probability of cure or prolonged disease-free survival who may derive the greatest benefit from aggressive local treatment.
Several ongoing phase III trials are expected to contribute evidence relevant to this approach.
These include:
- SABR-COMET-3, investigating stereotactic ablative radiotherapy in patients with one to three metastases.
- SABR-COMET-10, evaluating patients with four to ten metastatic lesions.
- SABR-SYNC, studying patients with up to ten oligometastases and an uncontrolled primary tumor.
The authors acknowledge that the proposed framework does not currently incorporate genomic signatures or detailed molecular mutation profiles, despite their emerging importance in predicting outcomes in oligometastatic disease.
Future refinements may therefore integrate molecular biomarkers with established clinical and disease-related prognostic factors.
Defining Cure in an Era of More Precise Cancer Treatment
The introduction of curative oligometastatic radiotherapy reflects an evolving discussion about the objectives of cancer treatment in patients with limited metastatic disease.
Although the presence of metastases has historically been associated with predominantly palliative treatment strategies, clinical experience and randomized trials have demonstrated that selected patients can achieve prolonged disease control following aggressive local treatment.
The CORT proposal seeks to distinguish patients for whom cure may be a reasonable therapeutic objective from those receiving metastasis-directed treatment primarily for disease control, symptom relief, or delayed systemic therapy.
The framework remains a proposal requiring prospective evaluation, and its application will depend on further evidence regarding patient selection, long-term outcomes, and treatment-related toxicity.
For the authors, the central consideration is not simply whether radiation therapy can be delivered to metastatic lesions, but whether the patient’s disease characteristics justify pursuing a potentially curative treatment strategy.
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