The rule for people that have had radiation is that once the PSA hits two points above the minimum it ever hit they need to start treatment again. It definitely looks like you are in that position.

It is very common for people to have a PSMA PET scan that finds nothing even though their PSA has risen. The problem is, there’s usually a lot of micro metastasis that the PET scan cannot see. Over time they will get even bigger and can finally be seen by the pet scan.

Normally, when somebody has a reoccurrence with such a high grade prostate cancer (T3b, 4+4) They would immediately be put on ADT and an ARPI. That is really the standard of care at this point. That can get you three or four more years without any more reoccurrences. If you leave it alone, more metastasis Will appear over time and the treatment will be more difficult. Some doctors do believe in waiting for the metastasis to show up and then zap them. With your aggressive case, I would not like to do that personally.

Are you being treated at a center of excellence? You are at the point where you need a Genito Urinary Oncologist, Not just a medical oncologist, one of the ones that specializes in prostate cancer. You’re starting a road to further treatment and you need to get it going so that you do not have this cancer become aggressive. If you mention where you live, I May be able to tell you some GU Oncologists in your area.