The announcement Sunday that former President Joe Biden was diagnosed with advanced prostate cancer has some people wondering how the disease wasn’t spotted sooner.
As president, Biden had access to VIP care, which goes above and beyond the health testing and health care offered to average patients. Members of the White House compound have access to medical staff 24 hours a day through the White House Medical Unit and special facilities are set aside for them at military hospitals. Presidential physicals typically leave no stone unturned when it comes to physical health and fitness for office, and presidents, including Biden, typically share some information from their medical checkups.
So how could an 82-year-old president who’s been out of office for only a few months have stage IV cancer that has spread to his bones?
Experts say they understand that the circumstances might prompt fear and suspicion, but they’re also not unheard-of. And although many men are familiar with what prostate cancer screening entails, some might not realize that typical screening is no longer recommended once men reach Biden’s age.
Dr. Oliver Sartor, a prostate cancer researcher at Tulane University, said he’s already fielded calls about Biden’s diagnosis.
“I’ve already been contacted by a friend of mine. He said, ‘How could this possibly have happened? And it must have been a cover-up,’ ” Sartor said, “And I said, ‘No, no, no, not necessarily. There are variety of possibilities.’ ”
Biden’s health in office has been the subject of intense interest.
Biden has kept a low profile since leaving office but recently appeared on “The View” with his wife, Jill, to push back on assertions that his declining health was being hidden from the public.
“They are wrong,” Biden said. “There is nothing to sustain that.”
The former first lady added, “The people who wrote those books weren’t in the White House with us, and they didn’t see how hard Joe worked every single day. He’d get up, he’d put in a full day, and then at night, I’d be in bed reading my book, and he was still on the phone, reading his briefings, working with staff.”
Screening for prostate cancer
Prostate cancer is a significant health concern for men. It is the second leading cause of cancer death in American males, killing about 35,000 each year, according to the American Cancer Society.
Among recent presidents, George W. Bush, Barack Obama and Donald Trump have had prostate cancer screening results reported as part of their annual physicals. Biden’s medical reports during his presidency did not mention prostate cancer testing.
President Trump said Monday that he was surprised that “the public wasn’t notified a long time ago” about Biden’s diagnosis.
“I just had my physical. You saw that? You saw the results of that particular test. I think the test is pretty much standard to anybody getting a physical,” Trump said during a news briefing.
Prostate cancer specialists say that’s not necessarily the case, however.
Dr. Bilal Siddiqui, a cancer oncologist and prostate cancer researcher at MD Anderson Cancer Center in Houston, said there are two potential explanations for Biden’s late-stage diagnosis.
“The first is actually the possibility that he wasn’t being screened, which would actually be reasonable,” he said.
Since the 1990s, men have been able to get a blood test to check for levels of a protein called prostate-specific antigen, or PSA, that might indicate the presence of prostate cancer. But the test has a high rate of false-positive results, up to 70%, according to the American Urological Association. Someone whose results show elevated levels may need a biopsy to rule out cancer.
Many medical associations say that whether to have the test should be a shared decision between a man and his doctor. Even then, screening isn’t recommended for men of all ages.
The majority of prostate cancers are slow-growing. In some cases, treatment can actually do more damage than the disease itself. Common side effects may include incontinence and erectile dysfunction. For that reason, the independent experts who review screening studies for the US Preventive Services Task Force recommend against screening for men 70 and older. Similarly, the American Cancer Society says men without symptoms who have a life expectancy of less than 10 years should not be screened. Biden is 82 years old, and the average life expectancy for a man in the US is about 76.
Not all prostate cancers are the same
Another possibility is that Biden had an “interval cancer,” meaning it presented itself in the interval between regular screenings.
Interval cancers are aggressive and can progress quickly, Siddiqui said.
“It’s certainly possible that even within a six-month or a one-year period between screening, the cancer can grow fast enough to emerge as a metastatic cancer,” he said.
In particularly rare cases, the cancer may not even produce PSA or might make very low levels that wouldn’t raise alarm on a screening.
“These are the most aggressive cancers, the ones that don’t produce PSA, and so there are several possible explanations for why this diagnosis could have appeared,” Siddiqui added.
Dr. Otis Brawley, an oncologist and screening epidemiologist at Johns Hopkins University, said he’s had nine patients in the past year who are being treated for metastatic disease who were referred to him after having recent and normal PSA tests.
He explains the differences in types of prostate cancer to patients by comparing them to cats. There are housecats and alley cats, Brawley said, and then there are tigers and lions.
“They’re all cats,” he said.
Doctors are learning to use tumor genetics to tell the difference between tame, slow-growing cancers that don’t need attention and the ferocious ones that may resist even the best treatments, he said.
Biden’s health history and future
In 2019, as Biden was preparing to run for office, his physician, Dr. Kevin O’Connor, released a statement on his health that included a detailed medical history.
The statement notes that Biden had experienced a common condition called benign prostatic hyperplasia, or BPH. In nearly all men, the donut-shaped prostate swells with age, growing from the size of a plum to the size of a medium apple. In the process, it can choke off the urethra, the tube that empties the bladder. Men with BPH often have to get up in the middle of the night to pee and may have difficulty emptying their bladder. Biden’s medical records say this condition was treated first with medication and then with surgery.
Brawley says it’s not clear whether BPH is related to the development of prostate cancer.
“The problem is, so many men get prostate cancer, and so many men get BPH,” he said. “The only thing that I’m willing to say is, they are both associated with the prostate, and they’re both associated with the aging male.”
There is some evidence that a medication that shrinks the prostate, finasteride, may help prevent prostate cancer, Brawley said, so they may be connected, but it hasn’t been definitively proved.
Even if Biden did have prostate cancer that had gone undetected while he was in office, doctors say, it wouldn’t have affected his memory or thinking.
“In general, prostate cancer, on its own, should not cause any cognitive issues. It’s very, very rare for prostate cancer to spread to the brain,” Siddiqui said.
But treatment, which typically involves medications to block the hormone testosterone, can have adverse effects on the brain and body.
“What that can lead to is symptoms of low testosterone, fatigue, hot flashes, night sweats but also muscle loss, increased bone fragility and risk of fractures, weight gain and memory issues and slowed cognition,” Siddiqui added.
Sartor said he’s hopeful for Biden’s prognosis.
“The bad news is, it is no longer curable. Once prostate cancer is metastatic, to the bone, it is no longer considered to be a curable cancer, but it is typically well-controlled for several years,” he said.