Yes, one thing is for sure, you need do your own homework and analysis and not just rely on what the "experts' think. It's sort of a team effort and you are the leader of the team, not your Oncologist or Radiologist. They are just team members (with valuable input.)

If I have to do SRT, including the Pelvic area is a tough call given that I was Gleason 3+4 with PSA < 0.02 up to 16 month after surgery and no adverse post-RP pathology (clean margins, 14 negtive lymph node removed, etc.) BUT, and that's a big BUT, there seems to be an emerging trend in treatment that your chances of a cure, especially at your secondary treatment, is to essentially hit it with everything you got as early as possible.

If the go hard and early is the ticket, that would mean SRT including the pelvic area at PSA between 0.03 and 0.1 (SBRT is showing it is just as effective with only 5 treatments instead of the traditional 30 lower dose treatments), with ADT (6 months), and followup chemotherapy.

The other side of the coin reads "overtreatment/side effects with no benefit" Which translates to higher chance of Grade 3 side effects on the RT if you include the pelvic area, some unpleasant side effects from the ADT, and even more unpleasant I imagine from chemo. But the theory is, your best chance of eradicating the cancer is BEFORE it spreads and when micrometastases are at a minimum. It seems this common thinking that, "it's early" lets just start with "this" and then if it gets to the point we can see something on a scan we'll do "this also." By the time you can see something on a scan outside the prostate/prostate bed, I suspect the chances of a cure pretty low. You're just trying to slow it down.

So "on paper" (assuming you have support from your MO and Radiologist and no battle with insurance), it seems like it should be an easy decision to throw the kitchen sink at it as early as possible. Feel a lot crappier for longer in the short term, but with a higher chance of being cancer free in the long term. At age 55 am I going to completely lose erective function from SRT, no. Is ADT going to make my penis fall off? No. In fact my girlfriend would probably enjoy seeing me on ADT so I can experience what she's been going through with menopause the last 4 years. Will Chemo kill me at this age with this stage of cancer? No. Will all this stuff boil down to accelerating my aging for a while, probably.

So does it boild down to there's just not enough trial data on what I would term "early aggressive" treatment protocols to justify insurance paying for it all that early? (I'm guessing insurance won't pay for Doxatel if you have no tumors on your PSMA PET scan??? ) I'm sure of course there's also just not wanting to deal with bad side effects unless you're sure you need the treatment. Not a lot of people want to volunteer for chemo with a 0.1 PSA and their oncologist says they have no confirmation of metastatic disease?

I believe within the next 10 years, the medical technology will either have a cure or like HIV will be able to indefinitely keep the cancer at bay for the rest of your life which is already the case for man of those diagnosed within 10 or 15+ years or so of their life expectancy.