If after surgery + radiation + ADT, your PSA is still rising, then yes you should be concerned — and at the same time focused on a solution.

What does that mean - “2 are too far north to zap”?

Where exactly are the 4 metastases located?

Why exactly does your new Clinical Oncologist believe that “2 are too close to previous Photon Beam and 39 Salvage treatments”? What is the specific concern?

You indicated that your previous ADT experienced “was so terrible.” What was that experience? (Did you engage in resistance-training exercises to minimize the ADT side-effects?)

How old are you?

Since your prostate cancers are PSMA-positive, have you discussed this option?: https://www.oncologynewscentral.com/drugs/info/fda-approves-combo-regimen-for-metastatic-hormone-sensitive-prostate-cancer