Technologic improvements have allowed radiation treatment to be administered with greater precision, improved safety, and an enhanced potential for disease control. Higher, and theoretically more efficacious, doses can now be delivered routinely. This concept of “dose escalation” is exemplified in the treatment of prostate cancer, with multiple randomized clinical trials (RCTs) showing a benefit when higher total doses of radiation are delivered to the prostate.1-5 However, these benefits have been shown only for intermediate end points, such as biochemical disease-free survival, local progression, or development of distant metastases. To date, an improvement in overall survival has not been demonstrated even in studies with a decade or more of follow-up. An overall survival benefit resulting from a moderate increase in radiation dose is particularly difficult to elicit in prostate cancer given its heterogeneous presentation, long natural history, and recent improvements in the care of advanced disease that allow patients who have developed metastatic disease to survive for many years.