Prostate Experts See Familiar Scenario in Biden's Cancer Diagnosis

New York Times

20-05-2025

Some Americans say they don't understand how former President Joseph R. Biden Jr. could have only recently learned that he had an aggressive form of prostate cancer that had already spread to his bones. How could the former commander in chief, a man with access to high-quality medical care, not have known earlier that he had such a serious condition?
Mr. Biden, 82, has not disclosed details about when the cancer was discovered, or whether he had been regularly examined for prostate cancer. It may be that he had not been screened. Guidelines from professional organizations that advise doctors and public health officials recommend against screening for men over age 70.
But many men, in consultation with their doctors, continue screening into their 70s, which is not unreasonable if the man is healthy and has a life expectancy of at least 10 years, said Dr. Scott Eggener, a prostate cancer specialist at the University of Chicago.
Prostate cancer experts also say, though, that even if Mr. Biden had been screened regularly, it's entirely possible the cancer was not detected till recently. They said that some men suddenly find out they have advanced prostate cancer even after being screened regularly year after year and told they have a clean bill of health.
It is unusual, but it does happen.
'I have an entire collection of what I call rocket PSAs,' said Dr. Ian Thompson, a prostate cancer specialist at the University of Texas Health Science Center in San Antonio. These are men, he said, who are screened year after year with the PSA, a blood test that can pick up signs of prostate cancer. Year after year, their PSA is very low. Then, suddenly, it soars.
He also sees men with advanced prostate cancer who have normal results on their PSA screening tests.
Other physicians, too, like Dr. Otis Brawley, have experience with both of these scenarios.
Every Wednesday, Dr. Brawley, a prostate cancer and screening specialist at Johns Hopkins University in Baltimore, sees men with cancers similar to Mr. Biden's.
Many of his patients have been diligent about regular prostate screening and yet, he said, they have advanced disease. He said he's seen a half dozen men like that in the past year alone.
'How the hell did I get metastatic disease?' he said they ask him. 'Whose fault is this?'
The answer, Dr. Brawley tells them, is that it is no one's fault. Fast-growing and aggressive prostate cancers can suddenly spring up between screenings.
And, occasionally, aggressive prostate cancers arise without giving any hint of their presence on the PSA.
One of Dr. Brawley's patients had such a stealth prostate cancer. He had received multiple normal PSA test results. Then, one morning, he woke up and fell to the floor. His hip broke because he had metastatic cancer that had spread from his prostate and eaten away at the bone. Even after that diagnosis, his PSA remained normal.
One reason that can occur, said Dr. Philipp Dahm, a urologist at the University of Minnesota, is because fast-growing prostate cancer cells can become so deranged that they stop releasing the prostate protein sought by the PSA.
Dr. Brawley said too many doctors overestimate the PSA's power as a diagnostic tool. It 'is not a perfect test,' he said.
Guidelines from medical experts and professional organizations in the United States, Canada and Europe are cautious about screening.
The U.S. Preventive Services Task Force guideline, set in May 2018 and now being updated, is typical, said Dr. Barnett Kramer, who formerly directed the division of cancer prevention at the National Cancer Institute. It says men ages 55 to 69 can consider being tested after discussing the risks and possible benefits with their physician.
Its guidelines and those from professional organizations also call for ending screening around age 70. One reason is that about half of men have some cancer in their prostate by their 70s or 80s, although most have no symptoms. Nearly all of these cancers will cause no harm if left alone — they are slow-growing and will never leave the man's prostate. The condition will not imperil his health.
But, the theory goes, if the men are screened, the test is likely to find cancer. And when it does, the men are likely to be treated with surgery or radiation that will not extend their lives. They were not at risk for a deadly cancer and, Dr. Thompson noted, treatments can have devastating effects, sometimes arising years afterward.
Radiation damage to the bladder is one of the delayed and horrific side effects, he said. It can cause pain and bleeding, and, he said, it is 'very difficult to manage.' He also sees men diagnosed with bladder cancer that resulted from their radiation treatment years earlier.
Immediate and permanent effects from treatment often include impotence and incontinence.
Part of the problem, says Dr. Brawley, who is also the senior author of the American Cancer Society's prostate cancer screening guidelines, is that many men have a mistaken idea about the benefits of screening. Compared with other cancers, prostate cancer screening has the least persuasive evidence.
'There are 12 studies telling me mammograms save lives for women over age 50,' Dr. Brawley said. 'There are half a dozen studies telling me colorectal screening save lives,' he added. Lung cancer screening also was shown to save lives, he said.
But with prostate cancer? The best evidence is from a European study that showed a small benefit from screening for men in the Netherlands and Sweden, but not in other European countries, Dr. Brawley noted.
'That's the best we've got,' he said.
Dr. Peter Albertsen, a prostate cancer specialist at the University of Connecticut, pointed to a rigorous study that randomly assigned men whose cancers were found with screening into three groups: they either had surgery, received radiation therapy or received regular monitoring of early-stage prostate cancer. There was no difference in health outcomes among the three groups.
'In most cases, it doesn't matter if you watch it or treat it,' he said, reflecting the fact that most of these cancers were not dangerous.
That may be why it is so difficult to show a screening benefit.
What, then, would a prostate specialist tell a U.S. president, in his early 80s and not in unusually good health for his age, to do about prostate testing? Some observers have said a doctor in that situation should of course tell a president of any age to be tested because a president's health is of national and global concern.
Dr. Thompson disagrees, reasoning essentially that presidents are patients, too.
'It presumes the doctor knows more about the patient's priorities than the patient,' he said.
Instead, Dr. Thompson would engage in 'a complex conversation that takes some time and would involve back-and-forth with the patient,' he said.
He added that it would include 'a discussion that the potential benefit, that is small to begin with, diminishes with time,' meaning that the older the men are, the less likely they are to have any benefit from screening, or treatment. And, he said, the discussion should also note that 'the side effects that can affect quality of life increase with age.'