Well, your clinical data- GS, Grade Group, PSADT and the cribform you describe from either your biopsy or pathology report indicate high risk PCa.

You day three months after surgery your PSA was .26...from my foxhole as a layman that us not BCR, rather it is indication of micro-metastatic PCa already outside of the prostate bed and those lymph nodes taken during your surgery.

You don't say what your PSA was prior to surgery nor any imaging you and your medical team may have done to try and determine whether to the best of imaging capabilities your PCa was confined to the prostate or had spread. It's immaterial now, you deal with facts and the clinical data you have.

You could do another PSA test and if, well, when it dies, rise to between .5-1.0, image with a PSMA which may show where your PCa is. Keep in mind it won't show all, sone sites just too small to be seen.

An aggressive PCa such as yours may necessitate an aggressive approach. If you have not, read the NCCN guidelines on advanced PCa. They can serve as a starting point in discussions with your medical team on imagine and treatment guidelines.

Also, do a literature search on triplet there for advanced PCa. You will want to discuss that with your medical team, ADT + ARI + Chemotherapy.

If you have not already, bring a radiation and medical oncologists on board your medical team. It may be time to move to them as you leads while the urologist supports.

I say radiologist since depending on imaging results, radiation could be an option.

Mine is also aggressive, though less so than yours and I have been aggressive in my approach.

You say you have had great care, I think that remains to be determined on how your medical team acts now. I fired one of my medical team, a urologist, Director of Urology at a NCCN Center and a major North American Urology Association when he failed to actively listen to me and be open to a more aggressive approach. He had a superiority complex, was unwilling to consider any treatment outside of standard of care and in my mind, was only recommending perfunctory care. I am convinced I would not be here now had I not thanked him for the consult, left, never went back and found a medical team that supported triple therapy though it was not mainstream then.

Given what you describe, my journey and what I know now, not sure your medical team has demonstrated a proactive and aggressive approach to treating you. I will say this, you need to drive the discussion in your consults, it should be evidence based, that's why I say NCCN as a starting point but clinical trials are fair game for discussions during consultations. When I mentioned the PATCH trial and motherly using an ARI from the EMBARQ trial, my oncologist was open to discussion and consideration.

Kevin