Steve

Something is "up," question is, what and what do you want to do about it?

We face many dilemmas in our treatment decision making:

When, too soon, too late...and what are the risk versus benefits...
What, too little, too much...mono, doublet, triplet...
With what - ADT, which agent, ARI, which one, radiation, where, which type, which machine...
How long 6, 12, 18, 24 months, or more?

Kind of hurts one's head trying to make a decision.

Here's an example of a choice - https://www.urotoday.com/component/content/article/2662-library-resources/esmo-2024-quick-takes-library-resources/155692-esmo-2024-quick-take-insights-a-focus-on-aranote.html

You could choose to do doublet therapy now, an ADT + ARI for a defined period, come off treatment and monitor. If so, have decision criteria about coming off treatment, did your PSA drop to undetectable in the first three months (or six) and stay there? If yes, then you may be an early responder which may portend a longer progression free survival (I am...).

Given the clinical data you describe, I don't see triplet therapy in play, no need for chemotherapy as it doesn't seem to benefit low volume MHSPC.

As to radiation, surprised your medical time pulled the trigger on imaging at that PSA as it's less than 37% statistical probability of showing where the PCa is. More and more I see people imaging between .5-1.0, I did, it located the recurrence. So, you can wait, if the PSA continues to rise, image again (assuming no issues with insurance) and if it shows where the PCa is, can inform your decision on radiation. You could also just go the nuclear option with radiation and do the prostate bed and whole pelvic lymph node system, they have standard "templates" for that (I liken it smart versus dumb bombs,,). I've had radiation three times, SRT to the prostate bed, WPLN, and SBRT., 69 treatments, 155 Gya, zero side effects. I have an excellent radiologist, and the planning software and delivery systems are advanced. The SRT was done without imaging, the other two were based on imaging, guess which one wasn't successful...!?

If you ask, what would I do...I would wait, let my PSA rise to between .5-1.0, image, then decide. I don't think waiting entails any degree of risk in a treatment decision I could make now not working later, it may inform a better decision. Keep in mind, I'm not a educated, trained, or board certified medical person and given the heterogeneity of PCA, my PCa is not yours.

That's what I did this last go round, waited for the PSA to reach between .5-1.0, imaged, then my medical team and I decided, SBRT + 12 months ADT for micro-metastatic PCa, hold the ARI unless PSA did not drop to undetectable in the first three months, decide at 12 months whether to come off treatment or continue to 24 months. We came off at 12, nine months later, PFS continues, T has returned, life is good, until the next time...!

As others have said, ADT sucks but may be manageable through lifestyle:
Diet
Exercise
Managing stress

I've done 18 months of Lupron, 12 months of Orgovyx. Side effects, yeah, hot flashes, fatigue, muscle and joint stiffness, genitali shrinkage, no loss of libido though (to my wife's dismay...). What changed in my life, nothing, went to the gym, rode my bike, went skiing, took vacations, attended concerts, celebrated birthdays, graduations, anniversaries...

Kevin