How aggressive would you be in irradiating asymptomatic bone metastases in a patient with metastatic prostate cancer?

I used to tell patients who were referred to me for asymptomatic bone mets to defer treatment until they began having pain (unless there was an impressive radiographic lesion or concerns of impending pathologic fracture or cord compression). But the multicenter, randomized trial presented at the Ame...

Yes, if to avoid a path fracture.

Patients with impaired renal function, even on hemodialysis, can still receive effective therapy for metastatic prostate cancer, including ADT and potent ARSI's such as darolutamide, enzalutamide, abiraterone, and apalutamide, which are largely metabolized in the liver. Choices depend on costs, age,...

I'd need a bit more clinical information before deciding what to do. For example, if there are only one or two bone mets after some form of definitive therapy, I'd treat them with definitive intent with SBRT for oligometastatic disease.

OTOH, if there are multiple mets, I wouldn't treat them at all ...