Mr. Biden's Prostate Cancer: What We Know, What We Don't Know, and What We We Think We Need to Know

There is always interest when cancer is diagnosed for someone in the "public eye." Mr. Biden's situation is unique. Already folks are asking who knew what and when? Does it make a difference?

Cancer is once again front and center with the announcement of Mr. Biden’s prostate cancer. As for every person newly diagnosed, we wish him well. It will not be an easy road for Mr. Biden or his family, with good news, not so good news, twists and turns along the way.

For better or worse, folks newly diagnosed with cancer who live in the public arena have extra burdens when cancer comes into their lives. Questions like: What kind of cancer? How will it be treated? Will they survive and for how long? All these and more will face Mr. Biden, his family and his advisors in the next days and weeks.

Each situation is different, each situation is unique, and for each situation the public doesn’t have all the information it craves, demanding more and more and more and more sometimes getting it and frequently not. And those of us who have to impartially dissect the situation are left to try to accurately portray what is happening based on what we know.

Mr. Biden’s diagnosis is more complex, given the intense recent focus on his health. And now we have the added questions and speculation of what did they know and when did they know it? Does it really make a difference?

I have dealt with these questions and more in the recent past. I was one of the “experts” who led the public responses to numerous “celebrity” cancer diagnoses during my 20 years in various leadership positions at the American Cancer Society.

We would always get the “early call” to comment, and while we tried to maintain a middle and somewhat modest ground about what was in the public record we inevitably saw lots of others willing to share their thoughts and their speculations, even if not based on accurate, available information.

It was frequently a difficult needle to thread, however whenever I made a comment to the media I always did so in the context of my personal credibility and reputation.

That was the measure I stand by as I write this today. Frequently, I found myself at odds with others who were more aggressive and speculative in their views—and those would take over the narrative, never to be brought back from the edge by what we could show were solid, generally acceptable medical principles, facts and data.

Mr. Biden’s diagnosis with advanced prostate cancer is a situation where not only the medical opinions and recommendations are nuanced. He is also a prominent person who finds himself smack in the crosshairs of another controversy, one that is substantial, divisive and ongoing about his prior (and continuing) mental and physical condition—especially regarding who knew what when and when did they know it (see prior blog comments from me here.)

So here goes, with my feeble attempt to break things down into digestible chunks:

Prostate cancer is ubiquitous. Most of the men Mr. Biden’s age (including me) have detectable prostate cancer if you go looking for it. I was taught that in my first months in medical school by our anatomy professor in 1967 (yup, a long time ago with a lot of water under the proverbial bridge!). So no news there.

We still have debates on whether men of Mr. Biden’s age should be routinely screened for prostate cancer. We also don’t know whether routine prostate cancer screening improves health or increases the quality and quantity of life for most men.

That “inside baseball” argument has gone on for decades.

There was widespread excitement back in the latter part of the last century when the prostate specific antigen test (PSA) was first introduced. We embraced the recommendation to screen all men as they aged to find prostate cancer early. We wanted to save lives. It took us years to discover the rest of the story, which wasn’t as clear cut as what we had been told or what we thought.

Well, we did a lot of screening—and we found lots of prostate cancer early. What we didn’t do was figure out if it saved lives. And we still argue that point today.

Gobs of stuff have been written on both sides of that question. Research studies including large numbers of men from many countries have been torn to shreds creating arguments both in favor and against routine screening for the early detection of prostate cancer. Far from me to go into detail on this dispute in this blog other than to say the debate rages on.

To get to a point:

Most experts today agree that routine screening of older men without a family history of prostate cancer is not warranted once they get to Mr. Biden’s age, or even after 75. Instead, they should rely on “informed decision making”, where men make their own decisions on whether they should or should not be screened based on a conversation with their health professional—including men (like me) who may be older and in fairly good health with a reasonable (usually 10 year) minimum additional life expectancy.

My sense is most men don’t have that conversation. And most clinicians don’t understand or even care about the fine details of the discussion: they just go ahead and order the test.

After all, who doesn’t think finding cancer early is a great idea to save lives?

Without going down that rabbit hole, let me upend conventional thinking: Not every cancer found early is a life saved or even made better by an early diagnosis. That is especially true for prostate cancer.

Arguments abound about such “cancers” as DCIS or small cancers in the thyroid and kidney for example and whether they cause harm. Some experts question whether these “indolent cancers” should even be called “cancer”.

We now know that many prostate cancers—depending on their characteristics—can be left alone with no threat to life, or followed over time to see if they become more aggressive.

Next question:

Why was Mr. Biden’s cancer found late, when it was aggressive and had already spread and when cure is unlikely? After all, he was President of the United States. Shouldn’t he have had better medical care?

It is very plausible that if Mr. Biden was a typical “everyman”, he could have had a conversation about the benefits and risks of the PSA test with his doctor. He may have been told that the odds of him having a clinically significant prostate cancer diagnosed at his age was remote. And in any case, the doctor may have told him, even if it is diagnosed and treated it is unlikely to extend or improve his life or the outcome of his disease.

I know about that conversation: I have had it as a doctor with my patients, and as a patient with my doctors.

Mr. Biden (or, in this discussion, Mr. Everyman) would then have a choice to either take the test or not.

Let’s assume that Mr. Everyman took the test. It could have been normal even with an aggressive cancer (although less likely). It may have been elevated, but in fact related to a benign enlargement of the prostate or an infection—which explains most of the abnormal PSA tests over the years Mr. Everyman was eligible to take the test.

The better news on this front is that we now have ways to parse the PSA test, to help us figure out whether a high level of antigen means cancer. We can do specialized MRIs and prostate biopsies to determine whether there is something which raises concern and needs to be investigated further.

Ultimately it is up to Mr. Everyman to make the decision—at least theoretically (more about that later).

Let’s consider another scenario:

Mr. Biden had a PSA test every year, and it was always normal through age 75 or 80. He has been told it is likely he would not develop a life-threatening prostate cancer at this point in his life. He decides not to take the test after that discussion. I personally have received that same advice.

Now he has urinary symptoms and goes to see his doctor. They do a rectal exam and find a nodule.

That, my friends, is the “uh oh” moment: Nodules are not good. They usually don’t happen until the cancer is advanced. They are not useful for early diagnosis. According to valid medical studies, doing routine rectal exams on older folks are not valuable when it comes to finding disease early (whether most clinicians are aware of that is not certain to me).

So, Mr. Everyman has done everything he is supposed to do: he made an informed decision with his clinician not to take the routine test; he went to the primary care clinician when he had symptoms, which more likely than not are due to something other than cancer; a nodule is found, and the proverbial cat is now out of the bag.

Then, you might ask using what doctors call the “retrospectoscope” when you look at things in hindsight and proclaim, “Wow!!! How could this have possibly happened?”

Another important inconvenient nuanced point:

Our recommendations regarding screening for the (usually) early diagnosis of cancer are based on research and impacts on huge populations of folks. Mammograms and colon cancer screening are but two examples where the recommendations of experts impact millions of people. As I have written, the problem with population health is the population.

Populations of millions are not examples of one, and sometimes emotions surrounding “the one” can have a great influence on our need to make recommendations for millions—understanding there are benefits and risks to everything we recommend folks should do for their health. The reality is that inevitably someone will have a bad disease even if they followed every health recommendation to the letter.

Let’s address the third aspect of Mr. Biden’s case:

Given the world we live in today, there is no surprise that camps are taking sides on what the Bidens or anyone else knew about his illness and when did they know it?

It was no mystery to me—having written on this question—that people would start theorizing that there had been a cover-up to Mr. Biden’s diagnosis just like there was for his metal decline.

I certainly don’t know the answer to that question, although with all the attention being paid to the subject I have little doubt that information may start to leak out when it comes to the timing and revelation of his cancer diagnosis.

From a medical perspective, it is a “yawner.” It doesn’t make a difference: the situation is what the situation is. We wish him well.

The conspiracy folks (and others who just are flustered about what they are now learning regarding the coverup) will say this is a moment of convenience, an opportunity to deflect the controversy and the introspection, a moment to shift the discussion from scrutiny to sympathy. Sort of like the pivot Mr. Trump makes when facing tough issues in the public domain, such as suggesting we reopen Alcatraz to move away from discussions about the impact of tariffs.

You can take your side and pick your fight. I understand the question; I can’t get suggest an answer to the debate.

What I can say is that contrary to the public thinking, it is in fact plausible from a fact-based medical perspective that things are “res ipse loquitor”: the thing speaks for itself.

It is also possible he was diagnosed earlier, that the disease was not considered life-threatening, that Mr. Biden, his family and his physicians elected to keep things to themselves and that the cancer subsequently and quickly became more aggressive. He won’t be the first President to make that choice for privacy when it comes to medical matters.

The other reality is that while screening is helpful for many cancers, others grow so quickly that they only become evident in the interval between when the test is done. There are numerous examples of such cancers such as breast cancer detected by patients even though they may have recently had a mammogram that was definitely negative, even on review. For those very aggressive cancers, screenings simply would not have made a difference.

Then there is the “step two” of the questioning that says:

“Gee, Dr. Len… Thanks for all that information about finding prostate cancer early. But this was the President of the United States. Shouldn’t he have done that PSA test or had a rectal examination even if we knew most people should have the option NOT to do so?”

That is more difficult to answer. I understand the question and appreciate the incredible level of his responsibility. But whether he should have every test known to man is not or what the interval of those tests should be is something I cannot respond to with facts as opposed to speculation.

The reality is that there a lot of things we could do to a lot of people. And if we did those things—as we already know happens—we could find lots of “diseases” that would never improve a person’s life, such as indolent cancers in the kidney, breast, thyroid and—tah dah—the prostate.

We simply don’t have answers for every question or scenario. And sadly sometimes even applying the best medical advice and practice doesn’t find a disease early or the patient doesn’t respond to a treatment as expected.

I am going to go back to my earlier comments and emphasize that we are where we are. The rest is commentary and speculation.

At this moment, we should recall that this is a very public man who has had many personal tragedies in his life, including cancers and addiction in his family. He now faces an illness which directly affects him and confronts his mortality. It is a time when he and his family must gather their thoughts, seek advice and make decisions about his treatment and the directions they choose to go. Not inconsequential, simple or easy for him or for them

For everyone else questions, innuendo and intrigue will no doubt take center stage.

Such is the situation for many people in the public eye who are diagnosed with a serious illness, but none recently I recall having as much impact or raised as many questions as this one. Inevitably lots of opinions, some facts, thoughts, speculation and conspiracy will be voiced in the public square.

My concern?

That amid one man’s tragedy, the focus on our humanity and humanity will be lost. In the world of influencers, social media and 24/7 news cycles demanding controversy to attract attention in the crowded field of public interest and public opinion, the vox populi will rule.

In my personal opinion Mr. Biden’s prostate cancer is not likely going to alter or influence the arc of history. Maybe this is a moment when we take a step back and reflect on the lost art of humanity and humility this moment demands.

The question: Should this one man’s sadness fuel tragic speculation for many others?

Time to motor on.

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Addendum:

I had the opportunity to share some thoughts this morning on Mark Halperin’s Morning Meeting—a show I thoroughly enjoy in its twice daily iterations.

One of the comments made during my discussion concerned Dr. Ezekiel Emanuel’s perspective offered earlier today regarding Mr. Biden’s diagnosis.

Dr. Emanuel—who, yes, is the brother of Rahm Emanuel and Ari Emanuel, both preeminent in their own rights—is exceptionally intelligent, well versed in oncology and health policy, and very comfortable sharing his opinions.

I know—and I agree with Dr. Emanuel—that Biden had the cancer during his time in office. That’s a no brainer that all of us agree on. As noted in my blog, most men have prostate cancer when they are in their 70s and 80s. But that doesn’t mean routine prostate screening for an older man is always helpful in averting a bad outcome the disease.

I don’t know if Dr. Emanuel made any comments about early detection and whether Mr. Biden’s medical care was deficient. It’s a nuance that escapes many folks who may now believe it was a missed diagnosis or simply an appropriate personal decision.

Dr. Emanuel has written about his own medical trajectory: namely, that he is going to stop medical treatments when he reaches age 75. (Here is the article, and here is a PBS interview he gave on the topic.) I was so intrigued at the time—and even a bit astonished—by that statement that I looked up his age: it was 57.

I remain curious how he will feel about mortality and medical treatment when he actually gets to age 75 or age 82 and is fortunate enough to remain in good physical and mental health, God willing.

Inquiring minds…