I think there could be 3 broad reasons to consider not combining RT with ADT for high risk prostate cancer: Disease risk: If a patient falls into a more favorable part of the high risk spectrum (e.g. high risk by PSA only, MRI without ECE/SVI/LNI/larger nodule size, or perhaps lower-risk genomic cl...

"High risk" is a very heterogeneous group. A single (+) core with Gleason 8, with nonpalpable disease, with PSA < 10 ng/mL is "high risk" (I consider that sort of case to be a "technical" high risk case). 12/12 (+) cores with Gleason 5+4 and a PSA of 40 ng/mL is "high risk" (I consider that sor...

It is reasonable to omit ADT and treat with EBRT only in cases where the patient refuses ADT or if there is a major comorbidity (heart, CV disease, severe depression, Parkinson's, etc.) where ADT may increase the risk of adverse outcome.