ADT is associated with well-recognized side effects and may significantly impact patients’ health-related QOL.270, 271 These side effects commonly include (but are not limited to) decreased libido, erectile dysfunction, hot flashes, depression and other mood disturbances, fatigue, and weight gain. In addition, treatment with ADT may result in significant changes in metabolic function, including reduction in bone mineral density, increased insulin resistance, and changes in blood lipid profiles.272 Given the potential deleterious short- and long-term effects of ADT, its application in the treatment of localized prostate cancer must be based on an individualized risk-benefit balance. While a number of randomized trials have investigated the use of ADT in combination with radiation therapy versus radiation therapy alone,273-286 most of these studies have investigated intermediate- and high-risk cancer populations. However, in a large trial (n=2,028) that included patients in all risk strata, the use of ADT was not associated with improved OS outcome for low-risk patients (HR: 0.93; 95% CI: 0.72 to 1.20).281 Moreover, although trials have demonstrated a benefit to ADT with radiation for intermediate-risk patients, these trials have not consistently sub-stratified intermediate-risk patients into favorable and unfavorable risk for separate outcome reporting. In line with recommendations of other organizations,14 the Panel believes that routine use of ADT in favorable intermediate-risk patients is not recommended given the observed positive cancer outcomes of radiotherapeutic monotherapy for this patient population (acknowledging the exception of unique circumstances such as planned prostate gland volume reduction prior to definitive radiation therapy, in which ADT may be useful). At the same time, the Panel recognizes that the utility of ADT for favorable intermediate-risk localized prostate cancer is currently under investigation (e.g., NRG Oncology/RTOG 0815).