In asymptomatic patients with castrate resistant prostate cancer who have failed chemotherapy and have progressive PSMA-avid vertebral body metastases, when do you prescribe lutetium 177 (Pluvicto) vs prophylactic spinal radiation?   

It's rarely either/or. I would say that pretty much any patient like the one described in the question should be getting Pluvicto as it has a demonstrated OS benefit. But sometimes the patient may also need more immediate palliation with EBRT before Pluvicto can get up and running. The main issue h...