I'm an oncologist. Speculating about Biden's cancer is dangerous.

Washington Post

26-05-2025

Ravi Parikh is a genitourinary medical oncologist at Winship Cancer Institute of Emory University.
In the days since former president Joe Biden's cancer diagnosis, amid the typical outpouring of support for a public figure diagnosed with cancer, two leading conspiracy theories have emerged.
The first is that Biden's team willfully ignored prostate cancer screening. Pundits — some of them doctors — have speculated about the president's screening history, suggesting that regular PSA testing (a blood test that screens for prostate-specific antigen) might have caught the cancer earlier. Major news outlets have subtly propagated this narrative as well, running flashy headlines questioning how Biden's doctors could have missed his condition. And, more egregiously, many across the political spectrum have insinuated that the president delayed his own diagnosis as part of a broader cover-up of his health issues.
The second conspiracy theory involves attempts to tie Biden's diagnosis to his poor performance in the June 2024 presidential debate. Some have implied that his cancer explains his perceived cognitive decline, changes in energy levels or recent lack of public appearances.
As an oncologist who predominantly treats Stage 4 prostate cancer, I find these narratives dangerous. They risk further stigmatizing the many patients I care for who are surviving and thriving with Stage 4 cancer.
For starters, it is not helpful to speculate how long the president's cancer had been growing or whether earlier PSA testing would have prevented it. Why? Because it doesn't change his current prognosis or how we treat it now. The cancer was reportedly discovered after a routine physical exam revealed a prostate nodule, followed by imaging that showed spread to his bones. If the first time Biden heard about his cancer was at diagnosis, then our role as physicians is to focus on treatment, not hindsight.
It is possible earlier PSA screening might have caught it sooner. But national guidelines recommended against PSA screening for anyone over age 70, much less an 82-year-old man, due to elevated risk of false positives or invasive biopsies that can outweigh the benefits of earlier detection. It's also possible Biden's cancer progressed between tests. So though the health of the president is certainly of public concern, there's no reason to make any patient — or his supporters — feel guilty about an unpredictable cancer.
Moreover, it is very unlikely that the president's cancer contributed to any cognitive or functional impairment. Prostate cancer almost never spreads to the brain, and Biden's office reported that the president was asymptomatic except for mild urinary issues.
Throughout my career, I've treated hundreds of men with Stage 4 prostate cancer. It is incurable but treatable. When a patient first comes to see me, I focus on four steps.
First, we address symptoms such as bone pain from metastases, urinary issues, weight loss — often in coordination with radiation oncology, palliative medicine and nutrition specialists.
Second, and most importantly, we discuss goals: How aggressive should we be? What are the patient's priorities? What trade-offs between quality of life and cancer control are acceptable? Treatment for Stage 4 prostate cancer is so effective nowadays that we have the luxury of offering a range of options that consider a patient's preferences.
Next, I describe the treatment options. The backbone of treatment is androgen deprivation therapy (ADT), which reduces testosterone, the fuel for prostate cancer growth. We often add pills such as androgen receptor signaling inhibitors that further inhibit testosterone signaling. Depending on disease burden, we may also consider radiation or chemotherapy; genetic testing can help us identify targeted therapy options. If one treatment fails, we have several other standard options before considering experimental therapies or hospice.
Finally, we talk survivorship — living well with cancer. This includes managing side effects such as hot flashes, monitoring for recurrence and addressing broader health needs. Patients with prostate cancer often live long enough that other conditions, such as heart disease or diabetes, may pose greater risks than the cancer itself, so we screen for those, too. And ADT can reduce bone density, so we screen for that as well as encourage weight-bearing exercise.
And yes, we discuss cognition. ADT — not prostate cancer — can impact cognitive function. If someone has signs of cognitive issues, we weigh this when recommending treatment. But unless a patient has severe dementia, it rarely changes the treatment plan.
The chatter around Biden about preventability, debility and prognosis does a disservice to patients living with metastatic prostate cancer. These narratives perpetuate the harmful myth that Stage 4 prostate cancer means imminent death or total debilitation — and they can lead to social isolation, workplace bias and psychological distress.
In reality, prostate cancer is a serious but manageable illness. If one treatment fails, we have several other standard options before considering experimental therapies or hospice. Of all Stage 4 cancers, prostate cancer most closely resembles a chronic disease like diabetes or high blood pressure.
Biden already is, and will continue to be, a 'metastatic survivor' — someone managing cancer as a chronic condition. Though statistics suggest that most men with Stage 4 prostate cancer won't survive five years, these numbers come from an older era of less effective treatment — and an inequitable system of care where many patients didn't receive access to guideline-based treatment.
I feel empathy for the president and his family. The day a patient gets diagnosed with Stage 4 cancer is one of the worst days in his life. Patients often carry the emotional weight of guilt, fear and uncertainty — compounded in Biden's case by already intense public scrutiny, a 'tell-all' book release and political implications.
After the president's diagnosis, I asked several of my patients what they thought. They're undergoing the same treatments he will. Their responses weren't pity or anger: They were of encouragement. With permission, here's what they said:
'I've been living with this for seven years. My PSA is undetectable, and I still play golf once a week.'
'The hot flashes aren't fun, but they're worth it to watch my grandkids grow up.'
'I thought it was a death sentence. But I'm still here five years later. He'll be fine.'
For these patients, and most others, Stage 4 prostate cancer wasn't an immediate death sentence and has not caused physical or mental disability. The question they are asking isn't 'What if?' — it's 'What's next?' I hope Joe Biden, and the rest of the country, can ask the same.