Joe Biden has prostate cancer

So do I

Joe Biden has prostate cancer, and it seems that everyone has jumped to various conclusions about this unfortunate event. It is already being seen as a conspiracy and a cover-up by many on the right. After they send their well-wishes, they go online to criticize the former President, his staff, his supporters and his doctors for failing to find the cancer, and for failing to tell the world about his failing mental status.

I don’t blame anyone for being surprised. I was surprised. To suddenly pop up with stage 4 Gleason 9 advanced prostate cancer is indeed shocking.

Unfortunately, the answer to preventing such problems is not as simple as doing a PSA and rectal exam on every male patient every year forever. Such a course of action would lead to a great many complications, cost and suffering. I know of a 90-year-old man who died after a lung biopsy for a lung nodule that turned out to be benign. One of my patients almost died from sepsis after a prostate biopsy. That was also shocking. Who knew that a simple biopsy procedure could be life threatening? Infectious complications from prostate biopsy are about 2.5%. Other complications are similar in incidence.

Once certain tests are done, the medical care machine tends to move relentlessly forward towards more testing, biopsies and treatment. It picks up speed like the Amtrak train I was on last week, and it is very difficult to stop.

Here is the flow of care: If the PSA is a little high (3.5 to 10 ng/ml), let’s repeat it in a few months and if it is rising, let’s do an MRI and if that is suspicious, let’s get a biopsy. If that biopsy is inconclusive, let’s wait a while and do it all again. The rectal exam is just not accurate enough to be recommended, except, perhaps, in the hands of an experienced urologist. Your PCP is unlikely to find a nodule and save your life. Mine didn’t.

The United States Preventive Services Task Force (USPSTF) and the Canadian Task Force on Preventive Health Care (CTF) did the calculations about lives saved, lives lost, cost and risk and concluded that the PSA should not be routinely done after age 70. The rectal exam is not recommended at all for screening. Even for men between ages 55 to 69, they suggest that the patient and doctor decide whether to have the test. It is possible that Joe Biden declined the PSA after being apprised of the risk and benefit.

The Canadian Task Force looked at the data going back to 1969, before there was a PSA test. In 1991, as the test became widely used, there was a spike in prostate cancer diagnoses, but no consistent decrease in death from prostate cancer. In other words, the PSA test may be working to find examples of mild and early prostate cancer that would never become active or metastatic. Although there is a slight decrease in prostate cancer mortality after introduction of the PSA in the chart below, experts can show that the decrease started too soon to be caused by screening. Overall deaths did not change.

Like many other issues in medical care, sometimes the results of studies contradict common sense. Studies are repeated with ever larger cohorts of patients to confirm initial observations, and as I said in my discussion of physician assisted suicide, it’s complicated.

When I was diagnosed with prostate cancer in 2017, I was 68 years old. My cancer was Gleason 9 Stage 2 with spread beyond the prostate. My PSA had gone from 3.5 up to 7 in a year. That got things started. I have had wonderful and aggressive care including surgery and radiation. The cancer was gone for 4 years, PSA below measurement levels, until last June. I am working with 2 oncologists to determine next steps, but what I have heard about Joe Biden gives me hope. Even at Stage 4, they believe that he may have a normal life expectancy.

When I told my good friend at UCSF Medical Center about my recent diagnosis at our 50^th High School Reunion in 2017, he scoffed. He would never have even had a PSA. This is an Internist who teaches at one of the best teaching hospitals in the country. It was his opinion that the PSA did not save lives – it only contributed to risky medical care. In my case he was wrong, but it is a commonly held opinion among academic Internists and Family doctors.

Remember the doctor’s credo, “do no harm.”

There is another consideration. Guidelines like those from the US and Canadian Task Forces on Preventive Care are designed to guide public health decisions for large groups of healthy people. When I worked for an HMO, we made sure that our staff was familiar with the guidelines and used them to guide preventive care decisions. We had 100,000 lives to manage. The focus was on making sure that all the appropriate tests and immunizations got done. Our goal was quality preventive care – making sure the right tests got done at the right time – and efficiency – not doing unnecessary tests.

The doctor for the President of the United States has one patient to consider, not a population. Are the guidelines for healthy populations appropriate for that one precious patient? We know that corporate executives and many others have been getting “Executive Physicals” at the Greenbriar Clinic and other places for years. Stress EKGs, chest X-rays, total body CT scans or even total body MRIs are routinely being done on rich people even though those tests are not recommended for the general population. Such tests are not cost effective for populations, but individuals, including today’s tech bros, put great faith in technology, scans and blood tests, regardless of the evidence. To them, more is better. For populations, we strive to find a balance between preventing disease and causing harm.

If I had been Joe Biden’s doctor, I would have discussed doing a PSA with him. I would have considered a total body CT or MRI. Treating my one special patient, I would use the guidelines as starting points, not commandments.

Another consideration: If the prostate cancer had been found earlier, say in 2020, would we have wanted our president to be on testosterone blockers, the first line of treatment for prostate cancer? Lower testosterone would mean less aggressiveness and less energy managing domestic and foreign affairs. (DJT seems to have plenty of testosterone for all of us, and his doctors seem to have done a thorough job with his exams.)

For those men over age 70, currently considering a visit to their doctor’s office for a PSA and a rectal exam, be careful what you wish for. Listen carefully to your doctor and the specialists you consult with. Try to make up your mind based on the facts, not fear, or even hope.

1. March 10, 2025. Prostate Cancer, A Review. Ruben Raychaudhuri, MD1,3; Daniel W. Lin, MD2,3; R. Bruce Montgomery, MD1,3,4 JAMA. 2025;333(16):1433-1446. doi:10.1001/jama.2025.0228

2. Going the Distance: One Man's Journey to the End of His Life
by George Sheehan