Making Sense of President Biden's Prostate Cancer Diagnosis

Former President Biden revealed this week that he has a diagnosis of advanced, aggressive prostate cancer that has spread to his bones. I have heard this question asked repeatedly. How could that diagnosis be missed in the president who has an annual physical presumably by the best doctors in the country? That is a very important question and the answer is very important also. I have not heard a full answer to the question. The doctor being interviewed gives some reasons the diagnosis could be missed, and then encourages older men to talk with their doctor. Talk to their doctor about what? That is not an answer that helps you understand how this can impact you or your family. If you are an older man or if you care about an older man, you deserve a better answer than that.

Here is the full recommendation on prostate cancer screening from the US Preventive Service Task Force:

For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one. Before deciding whether to be screened, men should have an opportunity to discuss the potential benefits and harms of screening with their clinician and to incorporate their values and preferences in the decision. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs. Clinicians should not screen men who do not express a preference for screening.

The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older.

They are saying that prostate cancer screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. They flatly state that prostate cancer screening should not be done in men older than 70. That is the most likely reason the former president’s cancer was missed. Let’s explore the reasons to screen or not screen.

Gleason Score Distribution:

Gleason Score 6: Represents well-differentiated, low-grade cancer. These cancers are generally slow-growing and have a favorable prognosis. The percentage of prostate cancers with a Gleason score of 6 can be quite high, with some studies showing it as the most common score at diagnosis. For example, one study found that 41% of prostate cancers in men aged 70-75 had a Gleason score of 6.

Gleason Score 7: Represents moderately differentiated, intermediate-grade cancer.

Gleason Score 8 (Grade Group 4): Represents poorly differentiated, high-grade cancer. These cancers are considered aggressive and have a higher risk of spreading. The percentage of prostate cancers with a Gleason score of 8 varies, with one study finding it in 11% of prostate cancers diagnosed on needle biopsy.

Gleason Scores 9 & 10): Represent very poorly differentiated, high-grade cancer. These cancers are the most aggressive and have the highest risk of spreading. The percentage of prostate cancers with Gleason scores of 9 or 10 is generally lower than other scores. For instance, one study showed 12% of men diagnosed with prostate cancer had a Gleason score of 9-10.

Former president Biden who is 82 years old has prostate cancer with a Gleason’s score of 9 and it is no longer confined to the prostate gland. It has spread to the bone. Prostate cancers with a score of 8 or higher are considered high risk. Prostate cancer is the second most common cancer diagnosis and it is the second leading cause of cancer death in men. Less aggressive screening recommendations are having an impact. The rate of prostate cancer death rate decreased by half from 1993 to 2022, its decline has slowed more recently and that is likely due to cancers being found at a later, uncurable stage. The easiest screening test is a PSA and that picks up 75% of prostate cancers. Medicare does pay for an annual PSA test after the age of 70, despite guidance from the US Preventive services task force that does not recommend the test.

Let’s tell it like it is. The most probable reason that the diagnosis of prostate cancer was missed in former President Biden was that he did not get a PSA screening test. I am in my late 70s, and I still get an annual PSA test. I have some physical problems mostly due to prior treatment for a cancer called lymphoma. I can still get around and my mind is as good as it ever was. If I have an elevated PSA, I would want to have a biopsy. If my Gleason score is six or seven, I would do nothing. Studies have shown that the risk of dying from prostate cancer within 10 to 15 years with a score of 6 or within 10 years with a Gleason score off 7 is very low, even without immediate treatment. The risk of spread to bone and other organs is also low. On the other hand, only about a third of men with higher grade prostate cancer that has spread to bone are alive in five years.

So, why not screen all men? The PSA may be elevated in some patients with prostate enlargement. That is a false positive. That is probably not the biggest issue. An elevated PSA is sort of like chest pain. Once you refer someone to a cardiologist with stable chest pain. They are very likely to have overtesting and overtreatment that is very expensive and not necessary. Counterproductive financial incentives lead to stress testing, heart artery catheterization, and heart artery stents. In a similar way, once a patient with an elevated PSA is referred to a urologist for a biopsy, that may lead to overtesting and over treatment. That is the most likely reason for the US Preventive Services Task Force recommendations.

When the doctors on television said that you should talk to your doctor, these are the items you should discuss and you should definitely begin with your primary care doctor. If you are 70 years old or older, your primary care doctor should send you to a urologist for a biopsy only. If your Gleason score is 6 or 7, I would do nothing more that periodic followup. If your Gleason score on the biopsy is 8 to 10, I would get treatment. Overtreatment occurs if your score is 6 or 7. Without treatment, you will likely die of something else. If your score is 9 or 10 you will likely die of prostate cancer if you don’t get treatment. About 20% of older men with prostate cancer have a form that will likely kill them. That is all there is to it. Flatly denying screening and treatment to men over 70 makes no sense to me.

Of course, in older men, the general health is a big factor. If someone is 80, in a nursing home with declining memory, prostate cancer screening and aggressive prostate cancer treatment does not make sense. There was a patient in my practice who was 89 years old, and shot his age twice on the golf course. He functioned like a 70 year old. When he was 80, aggressive treatment for aggressive prostate cancer would make sense. I hope this piece helps you understand how to best deal with prostate cancer. If you know these simple facts about this very common cancer, you can protect yourself and avoid overtesting and overtreatment. I hope you will comment.

Addendum from a urology colleague/classmate:

I’ve been practicing urology for 47 yrs and have lots to offer about this “missed diagnosis “ in our former president. Bottom line: This was atrocious treatment and substandard care.

All the medical organizations and society standards are based on statistics and cost of care and cost to diagnose and treat diseases.

I contend that appropriate medical screening for cancer should be performed at regular intervals if you are relatively healthy and life expectancy of at least 5 yrs (arbitrary) depending on comorbidities same is true for colonoscopies. I continue to screen for psa elevation yearly in all my patients to 85 and sometimes even 90 years old.

That’s enough for psa however today we have tests that supplement an elevated psa and its interpretation.

Old thinking is elevated psa

Biopsy is outdated thinking for many patients. Today we look at PSA velocity or how rapidly the PSA increases as well as a history of benign prostatic hypertrophy (BPH). Other tests help rule out benign elevations. The ExoDx Prostate Test is a non-invasive, urine-based test that assesses a man's risk of having high-grade prostate cancer. It's used in conjunction with PSA tests and other clinical factors to help determine if a prostate biopsy is necessary and most importantly an MRI OF THE PROSTATE. The recommendations not to screen are out of fear of biopsy morbity and complications of intervention.

Today’s evaluation is definitely more benign and we have discretion on whom to proceed with biopsy.

None of this makes sense for such poor screening for the former president, if a pt has an elevated psa and psa velocity >0.5 per yr we do Exodx on the urine and an MRI for further evaluation.

Warren Buffet had Intensity Modulated Radiation Therapy (IMRT) which is a sophisticated radiation therapy technique that precisely shapes and delivers radiation beams to a tumor, minimizing damage to surrounding healthy tissue.xrt (IMRT) prostate at age 82. That is appropropriate medical care and screening