At EAU26: 41st Annual EAU Congress, held 13–16th March 2026 in London, Prof Bertrand Tombal (Chair, Division of Urology, Clinique Universitaires Saint-Luc, Brussels, Belgium) delivered a plenary presentation on optimal management of oligorecurrent prostate cancer titled ‘The Road to Cure: Does intensification matter?’. He reflected on how advances in imaging, evolving treatment strategies and persistent evidence gaps are reshaping the management of oligorecurrent prostate cancer. In the conversation below, he discusses why the concept remains controversial, the promise and limitations of metastasis-directed therapy and how clinicians should navigate an increasingly complex treatment landscape.
The first challenge is the definition itself. “Oligo” simply means “a few”, but what we call oligorecurrent disease has changed dramatically because of the technologies we use to detect metastases. Historically, metastases were identified using bone scans and CT imaging. By the time disease was visible on those scans, it was usually relatively advanced, and metastatic prostate cancer represented the final phase of the disease trajectory.
Over the past two decades, however, imaging has become far more sensitive. Whole-body MRI was one of the first technologies to demonstrate this shift. As early as 2006, we showed that patients classified as non-metastatic on conventional imaging often already had small metastatic deposits when examined with more sensitive techniques. Later, PSMA PET imaging became widely adopted, largely because it is easier to implement.
The result is that we now detect very small numbers of metastases in patients with high-risk prostate cancer or biochemical recurrence. But this creates a major gap: most of our treatment strategies and clinical trials were designed for patients diagnosed with older imaging methods. We are applying evidence generated in one population to a very different one.
Imaging has clearly become more precise, but there is still an important unresolved issue. Regulators such as the FDA and EMA do not fully recognise the impact of newer imaging technologies because we have not conducted the definitive studies to show whether they actually improve patient outcomes. Ideally, we would compare two groups of patients: one assessed with conventional imaging and one assessed with modern imaging from the start. Would those diagnosed earlier live longer? The honest answer is that we don’t yet know. That uncertainty means clinicians must remain cautious. Improved detection does not automatically translate into improved survival.
Metastasis-directed therapy (MDT) is conceptually simple: instead of relying solely on systemic therapy, we directly target metastatic lesions using surgery or radiotherapy. The rationale only works if the lesions you see are truly the only ones present. If a patient actually has five metastases but imaging only reveals two, then targeting those two will not meaningfully change the course of the disease.
Nevertheless, MDT has been widely adopted despite limited evidence. Much of the supporting data comes from small phase II studies with heterogeneous patient populations and non-validated endpoints. This widespread use, without definitive proof of benefit, highlights another major knowledge gap.
First, we must remember that oligorecurrent disease is essentially an imaging definition — a snapshot in time. That snapshot does not reveal whether the patient has slow-growing disease or rapidly progressing cancer. Imaging does not tell us how aggressive the cancer truly is. For patients with slow-progressing disease, targeting visible metastases may be sufficient. But for patients with aggressive disease kinetics — high Gleason scores or short PSA doubling times — MDT alone is unlikely to be enough. In those cases, systemic therapy remains essential. The only combination clearly shown to improve overall survival in this setting is androgen deprivation therapy (ADT) plus an androgen-receptor pathway inhibitor such as enzalutamide. MDT or potentially PSMA-targeted therapies may then complement that backbone.
PSMA radioligand therapy is scientifically intriguing because it may target microscopic disease beyond what imaging detects. But we must also consider cost and the question of when to use such therapies — earlier in the disease course or reserved for later stages where they already have proven benefit.
The central message is that clinicians must distinguish between two scenarios. If metastases are visible on conventional imaging, this is not truly oligorecurrent disease; it is low-volume metastatic disease. In that situation, the standard of care is systemic therapy with ADT plus an androgen-receptor pathway inhibitor. The more complex scenario arises when metastases are detected only with modern imaging. Here, the biology of the tumour matters enormously. We recommend stratifying patients according to disease kinetics — what I sometimes describe as the “cat versus tiger” analogy. A “cat” tumour is slow-growing, with lower Gleason scores and longer PSA doubling times; a “tiger” is aggressive. For slow-kinetic disease, metastasis-directed therapy alone may be appropriate. For aggressive disease, systemic therapy should be the foundation, with MDT potentially added on top.
Cite: Rethinking oligorecurrent prostate cancer: A conversation with Prof Bertrand Tombal. touchONCOLOGY. 1st April, 2026
Disclosure: Bertrand Tombal is a consultant, member of the Advisory Board and the Speakers Bureau, has received honoraria/honorarium and grant/research support from Astellas, Bayer and Johnson & Johnson. This short article was prepared by touchONCOLOGY in collaboration with Prof Bertrand Tombal. Views expressed are the author’s own and do not necessarily reflect the views of Touch Medical Media.
Editor: Sophie Nickelson (Editorial Director)
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