I think your points are valid, it seems logical that doctors deep dive into all these areas before suggesting treatment. A couple thoughts I have on this:

- Genetic testing. I'm two months since RARP and ~6 from initial "oh shit" moment and I literally just did this consult, blood draw and submission for this. It was scheduled back in October for this weeks test. The only reason my doctor really wanted it was because I had kidney cancer before. Yes, you can test for BRCA1 and BRCA2, but I learned a lot when spending over an hour with the genetic counselor. First, this is a comprehensive 70 gene test that is still new and evolving and is designed for every person, not just PC cancer patients. That's a lot of people to test. And, because it's new, it isn't staffed to handle this volume right now, hence the wait. It's also around $5,000 to have this test done. It also is not any real indication of anything that may impact treatment - from what my counselor told me - it MAY have an impact, but she stressed repeatedly to not read these results as another "oh shit" but rather as a possible reason because this science is very, very, new. I think all of these factors, particularly that treatment may not change whatsoever as the result of them, likely played a role in you not getting one. By the way, my urologist was very "no big deal" about this test, because he said it won't change what needs to happen now but it's good to have done given your history - so he had zero concerns about doing it 6 months later. Now, if BRCA1/2 are problems then it might change the recommendation that "well, with your Gleason 7 + Decipher 0.68 + BRCA1/2 you might consider ADT now because..." then that's valid, but still only valid after the initial treatment. For me, I would still want to get deeper into this genetic test because I was told pretty clearly, this is more about "maybe why it happened" and not necessarily an indication of what it will do in the future. Like Decipher, it's more of a data gather tool to say that X number or men with these parameters have a Y increased chance of recurrence down the road.

- Family history, etc. This all comes out in the genetic test, so I think the same reasons apply. I was asked, from several doctors, anecdotal history questions that directly impact IF I should have a genetic test, such as breast cancer or PC history. Those answers, along with my kidney cancer, said "yes, let's test". Every consult I had, the history of family disease was on the intakes and questionnaires - so, at least for me, I was asked about history repeatedly but not a "deep dive", per se.

- Baseline testosterone. I don't know how having a baseline upfront is helpful since you have the cancer in the first place. I don't know any of the costs or anything of doing this, but I wasn't given a T test either and would assume this occurs much later, before you go on ADT. What change would occur in your initial treatment if your T was high or low? The cancer still needs addressed. Perhaps that's why this didn't come into play.

I guess the thought I have is that having these things done when first diagnosed was unlikely, at least as far as my knowledge, to impact your initial treatment of "let's get it out or zap it now".

Let's say you had BRCA1/2, would surgery be different? No. Would radiation be changed to accommodate a genetic result? No. Would treatment options after the initial treatment be changed? Maybe. Would it open you up to more "fringe" treatments such as proton or TULSA? Probably, but you have to talk to specialists from those areas since they are not yet considered mainstream due to the lack of long term efficacy results.

I get your frustration and if you are now in secondary treatment I can totally get how you might be super pissed that maybe if these things had been done up front then maybe things would be different now. I just don't know if you had any of these things on day 1 how it would have changed much of that initial treatment - and maybe I'm off base, perhaps you've been informed that these things would be night and day differences - but it's just not how these things were explained to me from any doctor I consulted with.