@vancouverislandhiker I started on Firmagon, and am currently on Orgovyx, which wasn't yet available in Canada in 2021. They're both GnRH antagonists, so effectively the same thing, but I find the acute side-effects much lessened with a daily pill over a monthly injection (the chronic side-effects of testosterone deprivation are the same, of course).

I'm also on Erleada (Apalutamide), a second-generation ARSI. It used to be that they'd start you on just ADT and then introduce an ARSI only when that failed, but the big realisation (after TITAN, STAMPEDE, and other large trials) is that the outcomes are far better if you start both at the same time while the cancer is still castrate-sensitive. That's certainly been the case for me. I've remained castrate sensitive for over 4 years, while the expectation before was only 18-24 months.

Another change from the past is that they'll now radiate the prostate (and any metastases) with curative intent for oligometastatic prostate cancer. With stage 4, they used to think "why bother, he's dying anyway, just keep him comfortable" but it also turns that it makes huge difference acting as if you can cure oligometastatic prostate cancer, even if the jury's still out on whether it's possible.

Finally, I had that emergency debulking surgery to preserve my mobility. Normally they wouldn't do that, especially near the spine, since it was very high-risk surgery, but it was either that or life paralysed in a hospital bed. Since I didn't die on the operating table, I ended up with a significant reduction in tumour load before the post-op radiation, and that has probably also helped. I wouldn't recommend running that risk, though, unless it was a forced play like it was for me.

If I'd been diagnosed a couple of years earlier, or if I'd lived in a different city (or even had a different radiation oncologist), I might have just been treated palliatively, like they used to do for all stage-4 prostate cancer, and I'd could have been either very sick or deceased by now. My cancer centre, as I mentioned, was one of the few in Canada recognising "oligometasatic" as a separate category and treating it aggressively back in 2021, just like at Mayo. I'll never buy a lottery ticket, because I think I've already used up my full lifetime quota of luck.