"What are the latest treatment options besides radiation, Zytiga, Lipton? "

Zytiga is a first-generation ARSI from the 1990s. The second-generation ARSIs that have come out since about 2018 (Apalutamide, Darolutamide, Enzolutamide, and Flutamide, collectively known as the "lutamides") have shown dramatically-better results in many/most cases, both in overall survival and in slowing or preventing progression of the disease, but not every drug is available for every cancer situation, not everyone can tolerate them, and not every insurance plan in the U.S. will cover them, so it's important to have a conversation with your medical team.

To give one example, Apalutamide for mCSPC in the TITAN trial was so successful that they had to unblind the trial halfway through and make it available to the placebo group as well, because it would have been unethical to deny that group life-saving treatment. The study ended after 4½ years without reaching median overall survival yet, despite some of the participants having had fairly severe, high-load metastatic cancer at the beginning, and some having started on the placebo.

Beyond that, there have been significant advances in imaging and in treatment. Recognising "oligometastatic" as a separate category that can be treated aggressively with curative intent (that doesn't mean that it can be cured; just that it's worth trying) has been huge for those of us with stage 4b prostate cancer.

Using multiple attacks up-front at the same time (e.g. radiation, surgery, ADT, ARSI, and even chemo for high-load) has also made a difference in our survival prospects. And better radiation therapy, along with the ability to deliver radiation intravenously when metastases are widely scattered, all mean that even those of us diagnosed with stage 4b fairly young (I was 56 at time of diagnosis with oligometasatic PCa to my spine in 2021) at least have a shot at still living to old age now.

Note that all of these are things that the local urologist at the (non-teaching) hospital might not know about, depending on how much they keep up, so it's important to get to an interdisciplinary cancer research centre of some sort (e.g. a Center of Excellence in the U.S. or a regional Cancer Centre in Canada) to be sure of receiving the latest treatments.