The news broke yesterday: Former President Joe Biden has prostate cancer. Kirsten Greene, MD, an expert in prostate cancer at UVA Health, says her friends and family have been calling and texting her all night. “Everyone wants to know, ‘What does it mean?’ ‘How did this happen?’ ‘How long will he live?” she says.
Greene, too, has questions. How could Biden, 82, just a year out of office, have an aggressive, metastatic form of prostate cancer? Yes, prostate cancer is one of the most common cancers in men: 1 in 8 men will have it during their lifetime. But these days, most prostate cancer gets caught 10 to 15 years before any kind of symptoms start. How could this have been missed?
Greene has two theories on what might have led to Biden’s prostate cancer going unnoticed.
Theory #1: Biden Stopped Getting Screenings at the Recommended Age
According to Greene, “Prostate cancer screening usually stops around age 75, following the U.S. Preventive Services Task Force recommendation. At that point, we engage in shared decision-making with the patient, going over risks and benefits of regular screenings.”
If Biden had a lower-than-concerning PSA level when he was 75 — about 6 or 7 years ago — it would be perfectly reasonable for him to decide with his doctor to stop getting screened. If so, Greene says, “it could be the prostate cancer grew and manifested, unnoticed, over time,” after screenings were stopped.
Theory #2: This Prostate Cancer Flew Under the Screening Radar
The other possibility, Greene says, is extremely uncommon. “He could have been screening, but his PSA levels were below the concerning threshold. It’s very unlikely, but it can happen.”
To understand this scenario, we have to back up a little bit to understand the prostate gland and PSA itself.
What is PSA & How Does it Relate to Cancer?
Prostate cells make prostate-specific antigen, or PSA, as a normal part of their function. It’s normal. This enzyme, or chemical, breaks down other molecules to liquify and clean out sperm after ejaculation.
In the late 1980s, Greene says, researchers discovered that too much of this chemical could point to problems. Urologists started testing men’s blood for high levels of PSA in the 1990s.
What Does a High PSA Mean?
“An elevated PSA — above a threshold of 4.0 — isn’t always cancer,” Greene says. “For instance, men can have larger prostates. A really big prostate makes more PSA.”
Other causes include infection, inflammation, and trauma (like from a biopsy). All of these can “cause cell turnover or cell disruption, making little prostate cells burst,” she says. This floods your bloodstream with PSA.
Cancer cells usually do this, too, making the PSA test an effective way to screen for prostate cancer.
Which takes us back to Greene’s 2nd theory. If cancer causes high PSA levels, and Biden was still getting PSA tests, how could his doctors have missed his cancer?
The Prostate Cells That Lose Their Memory
Greene explains. “While most prostate cancer results in high PSA levels, some cancers are so aggressive that the abnormal prostate cells forget how to make PSA altogether. His PSA might not have been high at all.” She notes that neuroendocrine prostate cancer also causes cells to lose the ability to make PSA.
“So this is the caveat,” Greene says. “The PSA is not a perfect test.”
Still, this kind of aggressive prostate cancer remains very uncommon. PSA screenings catch most prostate cancers and save lives.
Whatever the reason for this late diagnosis, “it’s so sad and unfortunate that he was caught at this point in time,” Greene says, expressing a sentiment we’re seeing across the news.
How Bad is Biden’s Prostate Cancer?
We know 3 things from these first headlines. Biden’s prostate cancer:
- Has a Gleason score of 9
- Expanded into his bones, or metastasized
- Is hormone-sensitive
What do these things tell us about his diagnosis?
Gleason Score
Doctors use the Gleason grading system to assign a number to sample prostate cells that they’ve removed (biopsied). The number reflects how much the cancer cells vary from the healthy cells. A higher number means a bigger difference between the cancer and the noncancer cells. The bigger the difference, the faster the cancer will grow.
A slow-growing and nonthreatening prostate cancer will earn a Gleason score of 6, the lowest possible. The fastest-growing and most dangerous cancer gets the highest possible grade of 10. Biden’s Gleason score is a 9, making it just one point shy of being the worst.
Metastatic
When cancer is called metastatic, it means the cancer cells that started in one organ or tissue have spread out to other parts of the body. Metastatic cancer is usually harder to treat for a number of reasons.
“Bone and lymph nodes are the most common places for prostate cancer to spread,” Greene says.
Newly Diagnosed with Prostate Cancer?
You have a lot of choices.
Hormone-Sensitive
Prostate cancer often thrives in the presence of testosterone, Greene explains. Biden’s doctors noted his to be hormone-sensitive, which could make treatment outcomes very favorable.
That’s because the first line of treatment for any prostate cancer is androgen deprivation therapy, or ADT. “ADT tricks the body into shutting down testosterone production. This will often stop the cancer entirely, slowing it down dramatically, for years.” Greene adds that many formulations and combinations of these hormone-related drugs exist, and none of these are “medical castration,” since they’re not permanent.
Of course, there’s no cure for prostate cancer. ADT only works for a time. Greene says, “All prostate cancer will acquire the ability to grow in a testosterone-free environment.”
A Large Number of Cancer Treatment Options
While most of the numbers attached to Biden’s diagnosis sound pretty scary, Greene remains optimistic. “There are so many treatments available,” she reassures.
After ADT, she says, comes chemotherapy. “If chemo doesn’t work, there’s Pluvicto, a radioactive molecule. Or Provenge, a vaccine made with your own body’s own white blood cells.”
Greene’s even positive about the prospects for treating the cancer that’s grown into Biden’s bones. “There’s amazing radiation,” she says. “Fantastic targeting. There’s even genetic testing that could help doctors tailor treatment for specific genetic changes causing the cancer.”
When Is It Cancer?
Cancer doesn’t always cause symptoms. Sometimes it does.
Reasons to Stay Hopeful About Biden’s Prostate Cancer
“People live for years with this,” Greene says. “This isn’t like Senator McCain’s brain cancer.” Nor is it like Biden’s own son, Beau, who died from brain cancer.
As for Biden’s ability to undergo any of these treatments, Greene says the best medicine at this point starts with a conversation. “The key to all of this is shared decision making,” she says. “The discussion is about whether they’re going to prolong the length of life or improve the quality of life. We ask, ‘How can we treat your cancer in a way that’s consistent with how you want to live?’”
Lastly, Greene notes that some of the questions she’s fielded so far go back to the infamous 2024 presidential debate. Biden’s bumbling performance led many to wonder if he was too old to run for president. Eventually Biden dropped out of the race.
With this prostate cancer diagnosis, some have asked Greene if she thought that Biden might have been suffering from cancer during the debate. Maybe the cancer had metastasized to his brain? Could that explain how badly he did?
“That’s not something we know,” Greene says. “But probably not. Brain metastases are really uncommon with prostate cancer.”
