Debate 3: Oligometastatic Hormone Sensitive Prostate Cancer Management: Systemic Therapy Approach

Oligometastatic prostate cancer (OMPC) represents an intermediate stage between localized and extensive metastatic disease, characterized by a limited number of metastatic lesions. While metastasis-directed therapy (MDT) has gained traction for its potential to delay systemic therapy, systemic therapy itself is falling behind. In our view, this is not appropriate at the current stage. In the context of this controversy, we highlight the points that emphasize the role of systemic therapy in OMPC and point out weaknesses of data available on local treatment concepts. The lack of a standardized OMPC definition complicates the comparison of results across studies. Imaging inconsistencies, ranging from conventional techniques to advanced PSMA-PET/CT, further challenge accurate classification. Additionally, the biological basis of OMPC remains unclear, with no definitive biomarkers distinguishing it from polymetastatic disease. While MDT has demonstrated improved progression-free survival in small trials, its impact on overall survival remains inconclusive. Conversely, systemic therapy with androgen receptor pathway inhibitors (ARPIs) has shown a significant survival advantage in phase 3 trials. Subgroup analyses from large trials indicate a benefit of systemic therapy, particularly in low-volume disease. Combination strategies incorporating MDT and systemic therapy may optimize outcomes. Further research is needed to refine patient selection, integrate molecular biomarkers, and establish the optimal treatment paradigm. Until robust evidence emerges, systemic therapy remains the standard of care for OMPC.