Why Feeling Fine Doesn’t Rule Out Prostate Cancer

Early prostate cancer typically causes no symptoms at all, and the urinary issues many men associate with the disease are usually caused by something else entirely, according to Brandon Mancini, M.D., MBA, medical director at BAMF Health. For Prostate Cancer Awareness Month, Mancini breaks down when men should actually start thinking about screening, why an abnormal prostate-specific antigen (PSA) test is far from a cancer diagnosis, and how newer tools like prostate MRI and additional biomarkers are helping doctors determine who truly needs further evaluation.

Mancini also discusses one of prostate cancer’s more unusual clinical realities: not every diagnosis calls for immediate treatment. He walks through how he and his patients weigh active surveillance against treatment, and explains how PSMA PET imaging is transforming both how prostate cancer is detected and how it’s treated, offering a level of precision older imaging methods simply couldn’t provide. His message for men who feel perfectly healthy: That alone doesn’t rule out early disease, and knowing your personal risk is the real starting point.

If early prostate cancer often causes no symptoms at all, and urinary issues are frequently something else entirely, what should be prompting men to get screened in the first place?

Brandon Mancini, M.D., MBA: One of the most important things for men to understand is that we don’t want to wait for symptoms. Early prostate cancer typically causes no symptoms at all, and urinary symptoms are actually much more commonly related to benign enlargement of the prostate. Screening is typically driven by age and individual risk. For an average-risk man, the conversation about PSA screening generally starts around age 50. For Black men or men with a strong family history, that conversation should start earlier, around 45 or even 40 for those at particularly high risk. The goal is to identify an important cancer early, when we have the greatest opportunity to cure it.

When a PSA test comes back abnormal, what typically happens next, and why is that number alone not enough to diagnose or rule out cancer?

BM: An abnormal PSA does not mean you have prostate cancer. PSA is prostate-specific, but it isn’t cancer-specific. It can be elevated because of benign prostate enlargement, inflammation, infection and other factors. So, we look at the whole picture, including the PSA level, how it’s changing over time, age, family history, prostate size and other risk factors. Sometimes the first step is simply repeating the PSA. We also now have additional biomarkers and prostate MRI that can help us determine who really needs a biopsy. I like to tell patients that PSA is a risk signal, where it starts a conversation and an evaluation; it isn’t, by itself, a cancer diagnosis.

Not every prostate cancer needs immediate treatment. How do you and your patients decide between active monitoring and moving forward with treatment?

BM: One of the unique things about prostate cancer is that not every prostate cancer needs to be treated immediately. Some cancers are very slow-growing and may never threaten a man’s health. For appropriately selected patients with low-risk disease, active surveillance can be an excellent option. And surveillance doesn’t mean doing nothing; we’re actively following the PSA, using MRI and sometimes repeat biopsies to make sure the cancer isn’t changing. On the other hand, if the cancer has features suggesting that it’s more likely to grow or spread, treatment becomes more important. Our goal is really to find that balance: We don’t want to undertreat an aggressive cancer, but we also don’t want to overtreat a cancer that may never cause harm.

Can you explain what PSMA PET imaging adds to the picture that older detection methods couldn’t, and how that’s changing decisions around diagnosis and treatment?

BM: PSMA PET has really transformed how we image prostate cancer. Traditional CT scans and bone scans largely look for anatomical changes, such as an enlarged lymph node or changes within a bone. PSMA PET allows us to actually target a protein that’s highly expressed on many prostate cancer cells, so we can often see much smaller amounts of disease. That can completely change how we approach treatment. We may discover that cancer has reached a lymph node or bone that looked normal on conventional imaging or identify exactly where cancer has returned after prior treatment. And what’s particularly exciting is that PSMA isn’t just an imaging target; we can also target it therapeutically with radioligand therapies, which is the basis of theranostics.

For a man with no symptoms who assumes he’s fine, what’s the one thing you’d want him to understand about his prostate cancer risk before he decides to skip screening?

BM: The one thing I’d want him to understand is that feeling perfectly healthy doesn’t tell us whether an early prostate cancer is there. That’s really the whole purpose of screening: to find a potentially important cancer before it causes symptoms and, ideally, while it’s still curable. And I think men should also know that getting a PSA doesn’t automatically put you on a path toward a biopsy or treatment. We have much better tools today to determine who actually needs further evaluation and which cancers need treatment. So, I wouldn’t let the absence of symptoms make the decision for you. Know your risk and have that conversation with your doctor.