Two recent phase III randomized trials examining ADT and prostate radiotherapy versus ADT alone in men with metastatic prostate cancer demonstrated no difference in OS. However, subgroup analyses from these trials suggested that patients with lower metastatic burden may derive greater benefit from local therapy. In STAMPEDE Arm H, a prespecified subgroup analysis using the CHAARTED definition demonstrated an OS benefit for patients with low-volume metastatic disease treated with ADT plus prostate radiotherapy.74 Importantly, these trials were conducted largely prior to routine use of contemporary systemic therapy intensification. More recent data from the PEACE-1 trial evaluated prostate radiotherapy in the setting of intensified systemic therapy, including abiraterone with or without docetaxel, and demonstrated improved disease control endpoints and reduced serious genitourinary events with the addition of prostate radiotherapy, although no OS benefit was observed. Taken together, these data support a conditional recommendation for prostate radiotherapy in combination with ADT in select patients with mHSPC. The HORRAD trial reported on 432 patients randomized either to ADT alone or ADT with EBRT to the prostate.104 Median PSA was 142ng/mL, and 67% of patients had more than 5 osseous metastases by conventional imaging. OS was not different (HR=0.9; 95% CI: 0.7 to 1.14; p=0.4), but median time to PSA progression was improved in the EBRT arm (HR=0.78; 95% CI: 0.63 to 0.97; p=0.02). A hypothesis was generated that survival might be improved in a subgroup of patients with low metastatic burden (HR=0.68; 95% CI: 0.42 to 1.10). In the STAMPEDE trial, 2,061 men with metastatic HSPC were randomized to ADT alone versus ADT plus prostate radiation given at moderate doses and with unconventional fractionation (36Gy in 6 fractions over 6 weeks, or 55Gy in 20 daily fractions).74Radiotherapy improved failure-free survival (HR=0.76; 95% CI: 0.68 to 0.84; p<0.0001), but not OS (HR=0.92; 95% CI: 0.80 to 1.06; p=0.266) similar to HORRAD. An additional pre-specified analysis utilizing the CHAARTED definition of low-volume cancer encompassing 40% of the population was performed. Low-volume metastatic disease demonstrated a benefit to ADT plus radiation (HR=0.68; 95% CI: 0.52 to 0.90; p=0.007) with 3-year survival 73% with ADT alone versus 81% with ADT and radiotherapy. Toxicity is important to minimize in patients who will not be cured of their metastatic disease. There was no significant difference in grade ≥3 toxicity with the addition of radiotherapy (HR=1.01; 95% CI: 0.87 to 1.16; p=0.94). More recently, the PEACE-1 trial evaluated prostate radiotherapy in the context of intensified systemic therapy for patients with de novo mHSPC using a 2×2 factorial design. Patients received ADT with or without docetaxel and were randomized to receive abiraterone, prostate radiotherapy, both, or neither. In patients with low-volume metastatic disease treated with abiraterone, the addition of prostate radiotherapy improved radiographic PFS (HR=0.65; 99.9% CI: 0.36 to 1.19; p=0.019), whereas no radiographic PFS benefit was observed with radiotherapy in patients not receiving abiraterone (HR=1.08; 99.9% CI: 0.65 to 1.80; p=0.61). Prostate radiotherapy did not improve OS in patients with low-volume disease (HR=0.98; 95.1% CI: 0.74 to 1.28; p=0.86) or in the overall study population. However, radiotherapy was associated with delayed progression to castration-resistant disease in patients with low-volume metastatic disease (HR=0.74; 95% CI: 0.60 to 0.92; p=0.0069) and reduced the incidence of serious genitourinary events regardless of metastatic burden, without an increase in grade ≥3 toxicity. Physicians have suggested these results point to the benefits of local therapy raising the question whether radical prostatectomy might have the same results. These trials are ongoing, and at present the use of surgery should be considered investigational and only conducted within the context of a trial. In earlier studies such as  STAMPEDE trial,74 no patients received concurrent abiraterone acetate and only 18% received early docetaxel, limiting conclusions regarding the integration of prostate radiotherapy with contemporary systemic therapy.  More recent data from PEACE-1 demonstrate that prostate-directed radiotherapy can be safely delivered in combination with intensified systemic therapy, including abiraterone with or without docetaxel, and is associated with improved disease control and reduced serious genitourinary events, although no OS benefit has been demonstrated.