The ALSYMPCA study provided the basis for the approval of radium-223 for the treatment of metastatic castration-resistant prostate cancer. Researchers described the distribution of radium-223 therapy and long-term outcomes in a large, publicly funded health care system. Starting in January of 2013 and ending in September of 2017, they tracked down every single male patient in the Veterans Affairs (VA) Healthcare System who was treated with radium-223. To the end, or until the last follow-up, patients were monitored. All therapies up till radium were abstracted, but radium itself was excluded. Their major objective was to learn about common procedures, and a secondary goal was to examine the correlation between treatment routine and survival time as assessed by Cox models. Patients with castration-resistant prostate cancer who had metastasized to the bone were identified, and 318 of them received radium-223 treatment through the VA. During the course of the follow-up, 277 (87%) of these patients passed away. About  88% of patients (279/318) were treated in 1 of 5 common patterns: androgen receptor-targeted agent (ARTA) plus radium, docetaxel plus ARTA plus radium, androgen receptor-targeted agent (ARTA) plus radium, docetaxel plus ARTA plus cabazitaxel plus radium, and 5) radium alone. Results showed an 11-month median overall survival (OS) (95% CI, 9.7-12.5). The ARTA-docetaxel-radium group of men fared the worst in terms of survival. The results from any other therapies were the same. Just 42% of patients received all 6 shots; 25% received either 1 or 2. Researchers analyzed the radium-223 therapy patterns most commonly used on the VA population and found their correlation with OS. In a more diverse population, radium may be utilized later in the disease process, as evidenced by the longer longevity in ALSYMPCA (14.9 months) compared to their trial (11 months), and by the fact that 58% of patients did not receive the complete radium-223 treatment.