@prettypass2000
The PSMA pet test cannot see metastasis smaller than 2.5 mm. According to a UCSF radiologist even 5 mm tumors are hard to see.

@prettypass2000

I've posted these before...

If even today's most sensitive imaging cannot see micro -metastatic disease, not sure what a surgeon can do to outdo imaging...

As I said, my urologist, who was very experienced and skilled, was opposed to surgery to remove lymph nodes when I had BCR.

I was thinking I had responded to this post but scrolling through didn't see it.

So, he's high risk given the clinical data you describe minus one perhaps critical piece, his PSADT and PSAV.

I don't think his medical team has laid out all his options:

Do nothing, continue to monitor. It could be some time before treatment is "necessary..."

MDT mono therapy which may delay the need for systemic therapy.

Doublet or triplet systemic therapy though in low volume cases the latter is generally of marginal value.

ARI mono therapy, EMBARK

There is the PATCH trial with the use of Estrogen.

I think the outcomes of treatment that drive the decision are:

PFS
RPFS
Patient preferences:

Desire to delay systemic therapy

Concerns with radiation side effects.

What would I do were I he?

MDT + short term systemic therapy, 6 months. I would likely use Orgovyx. I would hold on the ARI and add only if PSA did not drop to undetectable. Of course if you have to do that you are likely pushing systemic to 18-24 months...

If his PSA drops to undetectable in the first 3-6 months then that is a favorable sign for longer PFS and RPFS..

From my foxhole he is now managing this as a chronic disease, I'm in the "advanced PCa is incurable"...camp, rather it is manageable.

I think the group discussion provides a great degree of information to inform your discussions both you and your husband as well as his medical team.

Try not to go down the Alice in Wonderland rabbit hole with the horror stories about treatment surfaces. They are statistical, population based and historical, often not reflecting changes brought about by medical research and consequent advances. Where will your husband fall in the side effects impacts, unknown.

There are mitigating strategies, diet, exercise, managing stress, his medical team has options too.

The other thing I throw out because of the difficulty of measuring OS impacts of treatment is change the thinking from day 10-15 years to say 3-5, will this work for the next 3-5 years? Yes, great, we likely have more choices by then.

The good news, he had choices, the bad news, he had choices. I am also in the camp that says with a plethora of choices there are many good ones, there is no black and white checklist that says if that then this. "Plethora" can also lead to "paralysis by analysis."

After surgery and SRT failed using SOC from the NCCN guidelines my subsequent treatment decisions have been "hybrid" combining the guidelines with changes from CTs entering mainstream clinical practice and my preferences.

Like I've said about radiation, 69 treatments, SRT, WPLN and SRT, 155 Gya, side effects, none. I didn't lose my libido during ADT, still could achieve erections and orgasms. So, I may not be the one to ask...as I'm one or more standard deviations outside the "mean!"

Kevin