Using fewer (but larger dose) radiation treatments (i.e., hypofractionation) may be more convenient for patients with prostate cancer electing radiation therapy.253 Nevertheless, demonstrating equivalent cancer control and toxicity profiles with such an approach is paramount. A systematic review compared hypofractionated (>2 Gy per fraction, range 2.35 to 3.4 Gy) versus conventionally fractionated (1.8 to 2 Gy) EBRT in patients with localized prostate cancer.253 This review included 10 randomized trials (N=8,278); seven trials used highly conformal radiation therapy, six used IGRT, and two trials reported some form of motion management. In pooled analyses, no differences were noted between hypofractionation versus conventional fractionation with regard to biochemical recurrence-free survival (HR: 0.88; 95% CI: 0.68 to 1.13, 5 trials), metastasis-free survival (MFS)  (HR: 1.07; 95% CI: 0.65 to 1.76, 5 trials), prostate cancer-specific survival (HR: 1.00; 95% CI: 0.72 to 1.39, 8 trials), or OS (HR: 0.94; 95% CI: 0.83 to 1.07, 10 trials). There were also no differences identified regarding acute genitourinary radiation therapy toxicity (Relative Risk [RR]: 1.03; 95% CI: 0.95 to 1.11, 4 trials), late genitourinary radiation therapy toxicity (RR: 1.05; 95% CI: 0.93 to 1.18), or late gastrointestinal radiation therapy toxicity (RR: 1.10; 95% CI: 0.68 to 1.78). Findings were consistent in stratified analyses based on radiation therapy dose (≥74 Gy or <74 Gy), difference in radiation therapy doses between hypofractionation and conventional fractionation, radiation therapy technique (highly conformal versus 3DCRT), and use of ADT (≤50% of >50%). Moreover, three trials (n=92, 139, and 303) published subsequent to the systematic review likewise found no clear differences between moderate hypofractionation (fraction size 2.25 to 2.7 Gy, total 70 to 72 Gy) versus conventional fractionation (fraction size 2.0 Gy, total 74 to 80 Gy) in oncological outcomes, QOL, or adverse events, though some estimates were imprecise.254-257 One randomized trial (HYPO-RT, n=1,200) compared ultra hypofractionation (42.7 Gy in 7 fractions, fraction size 6.1 Gy) versus conventional fractionation (78.0 Gy in 39 fractions, fraction size 2 Gy) in patients undergoing radiation therapy with image-guided 3DCRT, IMRT, or VMAT for intermediate- or high-risk localized prostate cancer.258, 259 Ultra fractionation was found to be non-inferior to conventional fractionation with regard to failure-free survival (HR: 1.00; 95% CI: 0.76 to 1.32), prostate cancer mortality (incidence at 5 years 2% versus 1%, p=0.46), and OS (HR: 1.11; 95% CI: 0.73 to 1.69). In addition, although ultra hypofractionation was associated with increased incidence of acute urinary and bowel symptoms, no differences were found in late symptoms or QOL. Currently, data on long-term control with ultra hypofractionated compared to moderate hypofractionation is less well documented; however, data to date support the use of hypofractionated EBRT. Of note, the recommendations herein are consistent with existing guidance provided by ASTRO/ASCO/AUA.260