Well, first thing, throw the BS penalty flag on your urologist.

He violates several of my rules:

Please know your stuff. As a member of my medical team, you should have a thorough knowledge of my cancer and of the latest developments in research, and be ready to formulate a plan of attack.

Be curious. Do not close your mind to new hypotheses and don’t ignore clues that might lead you toward the best results. Please rid yourself of the temptation to make your day easier by delivering perfunctory care.

I would review the NCCN Guidelines for Advanced PCa. They provide a framework on which to base decisions regarding the workup of patients with prostate cancer, risk stratification and management of localized disease, post-treatment monitoring, and treatment of recurrence and advanced disease. The NCCN Prostate Cancer Panel emphasizes a shared decision-making approach in all disease settings based on patient preferences, prior treatment exposures, the presence or absence of visceral disease, symptoms, and potential side effects. Here's two useful links, you can find others

Mainstream treatment for de novo advanced PCa more and more involves doublet or triplet therapy.

As others have said, tests such as the Decipher can assist in decision making based on clinical data. However, what you know is GS 9, Grade Group 4, Advanced PCa , as my urologist told me on that infamous day in 2014, damn Kevin, that's a pretty aggressive cancer....ugh!

The difference is, "back in the day", imaging was limited to PET/CT and options were few, surgery, radiation, there were no ARIs, chemotherapy was a measure of last resort, treatment approaches were linear and sequential, each destined to fail, then death. Today the approach is to combine treatments, bring them forward in the disease stage and "overwhelm" it., thus the doublet and triplet therapy for de novo,

I've attached a picture which as they say, a thousand words...you want a multi-disciplinary team with you as the center of gravity!

Final thought, an aggressive PCa requires an aggressive treatment approach, just saying.

Kevin