Local treatment of the primary tumor in mHSPC in the ARPI era: incremental value or overtreatment?

The treatment landscape of metastatic hormone-sensitive prostate cancer (mHSPC) has changed substantially with the introduction of androgen receptor pathway inhibitors (ARPIs), which have improved survival outcomes and raised the threshold for demonstrating additional benefit from local interventions. In this setting, the role of local treatment of the primary tumor remains clinically relevant but requires reassessment, taking into account modern systemic intensification.

This expert opinion discusses the current role of local treatment of the primary tumor in mHSPC patients eligible for ARPIs therapy, focusing on prostate radiotherapy and surgery. It examines the evidence supporting radiotherapy in the androgen deprivation therapy era, the uncertainties emerging in the ARPI era, the implications for toxicity and local symptom control, and the rationale for ongoing trials evaluating local treatment in combination with contemporary systemic therapy.

In the ARPI era, local treatment should be considered within an individualized, multidisciplinary framework rather than as an automatic standard for patients with mHSPC. Its main value may increasingly lie in preventing local progression and genitourinary complications in selected patients, while a definitive overall survival benefit on top of intensified systemic therapy remains unproven.