Biden's Prostate Cancer Diagnosis: Debunking Misconceptions

Medscape

27-05-2025

This transcript has been edited for clarity.
Hello, everyone. This is Dr Bishal Gyawali, from Queens University, Kingston, Canada. I'm a medical oncologist. I was saddened to hear the recent news of Joe Biden's diagnosis of prostate cancer. At the same time, I also saw misinformation and several misconceptions circulating on social media and some mainstream media as well.I wanted to clarify these, as a medical oncologist and a cancer researcher.
First, let's talk about the stage of the disease. There were some posts about it being stage V or stage IX. The stages of cancer always go from I to IV. There is no such thing as stage V, VI, VII, VIII, or IX cancers.
Stage IV is what we refer to as metastatic or advanced disease; when the cancer from one location goes to a different location, then that becomes stage IV. Joe Biden's cancer is stage IV cancer.
I think part of the confusion came from the Gleason score. For prostate cancerspecifically, we look at something called the Gleason score. This is something you examine with the biopsy sample under the microscope, and you give a score that can go up to 10, where 10 is the most aggressive. Anything over 8 is what we consider aggressive prostate cancer.Biden's prostate cancer had a Gleason score of 9, so it is an aggressive cancer.
From the press release, we also know that it is a hormone-sensitive cancer. Prostate cancers, usually at the initial diagnosis, are often hormone sensitive.That means if you can reduce testosterone — and there are different ways of doing that — then the cancer will likely respond to that. By reducing the level of testosterone in the body, we can control prostate cancer.
Those are some of the misconceptions related to his diagnosis. Then there was some talk about what treatment he might likely get.I think we would be speculating at this point because we don't know many of the other factors that are needed to make a proper treatment decision. I hate to speculate about treatment options, but I'll mention a couple of general points.
The first thing to know is what we consider high-volume disease. Is his disease a high-volume disease?What do we mean by that? We know that it has metastasized to the bone, but is it only bone or has it metastasized to any other organ? If it has involved any other visceral organ, then that would be considered a high-volume, high-risk disease.
Even the metastasis to the bone — at this point, I'm not sure whether it's one bone or it involves multiple bones. If it involves four or more bones, then again, that would be considered a high-volume disease.
Why we want to know that is because if it is a high-volume disease, then we want to offer a treatment that involves not only suppression of androgen or testosterone, what we referred to earlier as the hormone-sensitive disease; so, not just the suppression of hormone using androgen-deprivation therapy, but also treatment with a newer-generation agent such as abiraterone or darolutamide, plus even chemotherapy like docetaxel.
If it's not high-volume disease, then we don't necessarily need to use chemotherapy upfront. There might also be a role of using radiation to the prostate.These are all speculations.
We don't know exactly what the situation is, and we also don't know what the comorbidities are. Does he also have some heart disease or some other comorbid conditions that preclude one or more of these treatments?
The broader point I wanted to make here is that I saw some posts from top people, his well-wishers, former presidents who are saying, 'Biden is a fighter, Joe is a fighter. We know that he's going to fight this and he is going to win this.'
I have a distaste for this metaphor of thinking of cancer as a war and patients as fighters. I have seen that this metaphor has harmed many of my patients.When you think of this as a fight, then giving up is not an option. You feel like it's a war that you can win, when in fact, in many metastatic cancers, especially in stage IV cancers, the disease progresses. Even in stage II and stage III cancers, sometimes the cancer relapses.
Does the cancer progressing or relapsing mean that the person was not a good fighter? Absolutely not. It's not in anyone's capacity to prevent that from happening. It's just bad luck. That does not mean that the person was not a good fighter.
The other harm of this is that when you think of this as a fight, you are also very prone to getting overtreated,and you're getting treated with things that may not even benefit you. Sometimes you get treated until the very end of life.
Even in this example, we talked about if it is a high-volume disease, we can use androgen-deprivation therapy plus abiraterone plus docetaxel. If someone wants to prioritize their quality of life — and Joe Biden is 82 years old — then not doing chemo is a perfectly fine option.You could just do hormone therapy.
There are so many nuances to this, and all patients are different. That's why we have to individualize treatment to the patient. If we keep using this metaphor of cancer being a war or a fight and the patient being a fighter, then it takes all the nuances away and it makes the patientfeel like he or she has to always do everything that is possible, because not doing so, or prioritizing quality of life, or prioritizing treatment options based on other preferences, is considered 'losing the fight.'
That is absolutely untrue, especially for patients who progress despite getting all the treatment, or who die despite getting all the treatment, and for those with early-stage disease who relapse despite doing everything that they could.That makes them feel like they lost the war or they could not fight well, which is absolutely untrue. I think as a community, we should get away from this metaphor of patients being fighters.
One final point about this is that many people are commenting about why this cancer was diagnosed so late at stage IV: 'Why was it not detected earlier? He was a president. A president should have all the facilities in the world. He was a US president. It is embarrassing that a former US president was not diagnosed early and was diagnosed with stage IV, an aggressive stage of disease.'
That, again, is a fundamental misconception about how cancer screening works.Yes, prostate cancer has a screening test called the PSA test. It is a blood-based test where you detect the levels of prostate-specific antigen, or PSA, but it's a very lousy screening test because it gives many false positives. What do I mean by that? For many patients who get PSA testing done and the PSA is high, saying that they have a high risk of having prostate cancer,it turns out not to be prostate cancer. It's a false positive. It's a false alarm.
In many of these cases, when you do a biopsy or a surgery, it turns out to be a very benign form of prostate cancer. It is something that would not have caused death and would not have even progressed to stage IV during the lifetime of that person.This is a problem.
The other problem with screening tests in general — and this is not even about PSA alone but for any screening test — is that there can always be these aggressive cancers that are missed by the screening test. It's not a 100% reliable test.
People talk as ifone should undergo every screening test every month because anything can happen. This time, we talked about prostate cancer. Maybe there is some colon cancer. Maybe there can be lung cancer. That does not mean you get screened every single month for every single disease out there.
Especially for prostate cancer, for the PSA test, the USPSTF guidelines, the US Preventive Services Task Force guidelines, are supposed to be the gold standard, especially for our medical practice. It specifically says that the PSA screening test is not recommendedfor people over the age of 70. It specifically says not to do this screening test if the person's age is more than 70 years because the harms outweigh the benefits.
Joe Biden is 82. Even based on the USPSTF standard guidelines, he would not have been recommended for this screening testbecause that's the recommendation for anyone over the age of 70. His not getting a PSA screening test is the standard practice. It's not malpractice and there is nothing nefarious going on that he was not screened for prostate cancer. At his age, the risks outweigh the benefits, and the recommendation from the guidelines is not to be screened, for all these reasons that we have discussed.
Also, treatment choices and screening choices will vary from person to person, and also will depend on the expected life expectancy remaining, comorbidities, benefits and risks, judgement calls, and each individual's tolerance with the levels of risks and benefits.
As I said, we should not think of a screening test as a 100% foolproof test because no test is 100% foolproof. I don't know whether he underwent a screening test or not. I don't know whether he underwent a PSA test and the PSA did not detect this, or if he did not undergo a PSA test. At his age, PSA screening is not even indicated.
These are a few misconceptions about Joe Biden's diagnosis of prostate cancer that I wanted to clarify today through this video. I wish him all the best and I wish him a speedy recovery. Thank you.