Whether to do a prostatectomy or Radiation could depend on whether or not the cancer has spread beyond the prostate, you say localized, but has he had a PSMA pet scan?. To see If it has spread, he needs to have a PSMA pet scan before he goes on hormone therapy. That will show whether or not the cancer has spread anywhere else in his body. A bone scan and CT scan will not do the same thing. His age is another factor, If older than 74 or so, then radiation is a better choice since surgery can be hard on the body. If he’s in great shape, that may not be an issue The results of radiation or surgery are about the same, But if you have surgery, it allows you to have radiation later. If you have radiation, the amount of surgery they can do later is very limited.

There are also choices Like MRIdian SBRT radiation which causes less damage to nearby tissue and other treatments like Focal Therapy, NanoKnife, cryotherapy, HIFU,, TULSA-PRO, etc. None of them use radiation.

He should also have a decipher test, It tells how quickly/soon the cancer can spread and is a real valuable tool.

You really don’t want to use Firmagon. It requires monthly shot shots in the stomach, and it causes a lot of problems for some people. No reason to go there.

Orgovyx would be your best bet, works Just as well as the other treatments and doesn’t require going into the doctors office to get a shot.

As for abiraterone, It is a good place to start along with Lupron or Orgovyx. Because he is a Gleason nine putting him on two drugs, gives him a better chance of having a long time without reoccurrence. If he has high blood pressure and other heart issues, you are probably much better off starting up with a lutamide, Like Darolutamide or Enzalutamide. Both of them essentially work the same but Darolutamide has fewer side effects. I started off with abiraterone and went from no high blood pressure to taking three pills a day to treat my high blood pressure. It also caused me to have 3 afib events, something I had not had for 15 years. I am now taking Darolutamide And my cancer has been undetectable for 13 months, something abiraterone only did for one month in 2 1/2 years. The thing is, abiraterone gave me 2 1/2 years with a very low PSA, and prevented my cancer from spreading, now a lutamide is giving me more time without spread.

I have osteoarthritis and being on the drugs has really not been an issue. My arthritis has gotten worse but I get no aches or pains I can say the drugs caused.