A lengthy response (that addresses all of your questions/comments) —>

Somewhat similar to your situation, I was diagnosed at 56y/o with low-grade, localized disease and was on active surveillance for about 9 years before my Gleason 6 became a Gleason 7(3+4).

During the last few of those 9 years, I obtained referrals to specialists in the various treatments and evaluated each treatment regimen to determine what was best for me, so that when/if the time came that I needed to make a treatment decision, I was fully informed and prepared to pull the trigger.

Regarding your recent MRI:
> Did the MRI report mention the terms extracapsular extension, seminal vesicle invasion, or perineural invasion?
> Did you get a 2nd opinion on the MRI scan?

Regarding your recent biopsy:
> What % were “4” and what % were “3”?
> Did the biopsy report mention the terms cribriform pattern or intraductal carcinoma?
> Did you get a 2nd opinion on the biopsy tissues?

You mentioned that “…. I have now had a PSMA PET scan, and it was clean. They couldn't even get a strong result from the primary site, which I was told was not unexpected.”
> what were the SUVmax scores mentioned in the PSMA PET scan report?

Regarding the proposed 5 rounds of proton (that’s called Proton SBRT) - In this 2023 Mid-Year Prostate Cancer Patient Conference, Dr. Rossi mentions Proton SBRT with some caveats: https://www.youtube.com/live/WTqPnSRYtW4
—> Starting at timestamp 4:30:45: Proton SBRT

Similarly, I was offered the opportunity to be part of a clinical trial; I opted out of that opportunity, my attention being singularly focused in treating my disease. I did however chose to have my proton radiation treatment results submitted into a registry (https://clinicaltrials.gov/study/NCT02040467). Hopefully, it will help someone make a decision one day.

As for the use of ADT, NCCN guidelines do not recommend ADT for a 3+4=7 (see attached NCCN guidelines) unless there are other risk factors.

Most side-effects of ADT are easily minimized/avoided with resistance-training exercise. Here are just a few that I’ve bookmarked:

> Drs. Scholz and Moyad talking about exercise and hormone therapy (at a virtual PCRI conference): https://m.youtube.com/watch

> A paper on The Benefits of Exercise During Hormone Therapy: https://static1.squarespace.com/static/54c68ac6e4b06d2e36a4b8c9/t/55cb7275e4b0d97ae7ff60af/1439396469154/The+Benefits+of+Exercise+During+Hormone+Therapy_Insights+August+2015_PCRI.pdf

> A study about the benefits of exercise to counteract the adverse effects of ADT: (They describe a good resistance-training program): https://journals.lww.com/acsm-msse/fulltext/2023/04000/resistance_exercise_training_increases_muscle_mass.2.aspx

If you do what it takes, you’ll do very well with the hormone therapy side-effects - it’ll just be an annoyance; if you don’t do anything, hormone therapy can be your worst nightmare (like your wife indicated). For me, it was a walk in a park.

If it were me and I had any other risks beyond just a vanilla Grade Group 2, I would bump that treatment up a notch and take the 6 months of ADT (just out of caution).

As for my 28 sessions of proton radiation, it was a piece of cake. My wife later told me that if she hadn’t known I was undergoing radiation treatments, she wouldn’t have realized it from any change in me. And the short amount of time that I was gone each day for treatment were no different than any other time when I simply left to go shopping or to the gym.

As for the hormone therapy side-effects, they were greatly minimized by following a rigorous resistance-training program.

You have many good options available to you. Let the data guide your decisions.