Thanks. I assume with a 3+4 his risk group was favorable intermediate, assuming no concerning staging issues found on biopsy. That would prevent you from getting a PSMA PET scan in most cases. With the high risk evaluation in his Decipher test, that might motivate your RO or urologist, whichever is doing the overall management, to order a PSMA PET scan that your insurance might approve. That could potentially confirm that he actually needs ADT and radiotherapy instead of surgery.

Your thoughts on the post surgery pathology are good. Keep in mind that not only will the gland be removed, but also the seminal vesicles and some number of pelvic lymph nodes will be biopsied for pathology. You should inquire about what fraction of pelvic nodes will be removed/biopsied, which ones (some are more prone to spread cancer out of the pelvis than others) and discuss unilateral or bilateral nerve bundle sparing versus cure rates with the surgeon for those with high risk cancer.

As far as the systemic aspect of ADT goes, just keep in mind it is not curative. It can suppress the cancer, potentially for a very long time, but it is not cytotoxic like radiation or chemo.