What is the recommended length for ADT in the setting of N1 disease receiving definitive radiation?

In such cases, I typically recommend two years of ADT + abiraterone based on the results of the STAMPEDE high risk localized/N+ subgroup (Attard et al., PMID 34953525). At 6 years, the addition of abiraterone led to an absolute benefit of 13% in metastasis-free survival (82% vs. 69%; HR 0.53), and at 6 years, there was an 8% benefit in prostate-cancer-specific survival (93% vs. 85%). Of note, these patients either had significant high risk features (ex. median PSA ≈ 35, ≥T3 ≈ 90%, Gleason ≥ 8≈ 75%) or were N+ by conventional imaging. It is unclear how these findings will translate to patients diagnosed with N+ disease by more sensitive imaging modalities such as PSMA-based PET/CT.