Former President Joe Biden’s recent prostate cancer diagnosis has brought renewed attention to this common but serious disease. As a primary care physician who has cared for many patients with prostate cancer, I’d like to address some key questions many Americans may have — including how this cancer might have developed without earlier detection.
Biden has been diagnosed with an aggressive form of prostate cancer that has spread to his bones, characterized by a Gleason score of 9. The Gleason score rates prostate cancer cells from 6 to 10 based on how abnormal they appear under a microscope, with higher numbers indicating more aggressive cancer likely to grow and spread quickly. A score of 9 indicates a highly aggressive cancer requiring more urgent treatment.
The PSA test, though valuable, has significant limitations as a screening tool.
Many have wondered how this cancer could progress to this extent without being found earlier. We know that before his presidency, Biden had been treated for an enlarged prostate, and before the diagnosis, he had urinary complaints that can be seen with more advanced prostate cancers. While the exact timeline of his prostate screenings remains unclear, medical records do not mention a PSA (prostate-specific antigen) test during his final presidential physical in February 2024. Standard practice is to generally stop such screenings at the age of 70, but exceptions exist for older patients with longer life expectancies such as Biden.
While most prostate cancers grow slowly, aggressive varieties like Biden’s can progress and spread much more rapidly. And the PSA test, though valuable, has significant limitations as a screening tool. About 15% of men with prostate cancer will have normal PSA results (false negatives). Conversely, elevated PSA levels don’t always indicate cancer. In fact, normal PSA ranges increase with age — what’s concerning at 50 might be acceptable at 80. These complexities explain why universal PSA screening and the interpretation of PSA test results for older men both remain controversial among medical experts.
Now that the former president has been diagnosed, he faces a long road of treatment. The bones, where Biden’s cancer has already metastasized, are among the most common sites for prostate cancer spread (other potential sites include lymph nodes, liver and lungs). Aggressive prostate cancers like Biden’s, if left untreated, typically continue to grow and spread. Without treatment, metastatic prostate cancer progressively affects bone health, potentially leading to pain, fractures and other complications. It would be hard to imagine enduring those symptoms without treatment for a long period of time.
What will that treatment look like? Advanced, metastatic prostate cancer is generally not considered curable. But it can often be effectively managed, particularly when it’s hormone-sensitive, as Biden’s appears to be. For advanced prostate cancer like Biden’s, doctors first use hormone treatments to block testosterone (the fuel that helps cancer grow). These hormone therapies often get paired with special drugs like abiraterone that make them work even better.
When the cancer stops responding to hormones, treatments shift to chemotherapy (strong medicines that attack fast-growing cells) or targeted therapies that exploit the cancer’s weak spots, such as PARP inhibitors, which kill cancer cells while preserving healthy cells. While these treatments can’t cure advanced prostate cancer, they help slow its spread, ease symptoms like bone pain, and give patients more time — often using a mix of approaches tailored to each patient.
Biden’s diagnosis highlights the importance of prompt evaluation of new urinary symptoms in older men, even when routine screening isn’t recommended. It also reminds us that cancer doesn’t discriminate — it affects people of all backgrounds, no matter how excellent their health care.