Understanding Prostate Cancer in Light of President Biden's Diagnosis
What you need to know (and what we don’t know about President Biden’s health) 🇺🇸
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According to a statement from President Joe Biden’s team, last week he was diagnosed with an aggressive form of prostate cancer. Apparently a prostate nodule was discovered after he experienced increasing urinary symptoms. His cancer is characterized by a Gleason score of 9 (Grade Group 5), and, unfortunately, it has spread to the bone. While this represents a more aggressive form of the disease, the cancer appears to be hormone-sensitive, which means he likely will be a candidate for hormone therapy (see below).
Since this news broke, I've received lots of questions from patients and readers about prostate cancer—what it is, who's at risk, and how it's detected and treated. So, today I'll address some of these questions.
What Is Prostate Cancer?
The prostate is a small gland—about the size of a walnut—that sits below the bladder in men and produces fluid that nourishes and transports sperm. Prostate cancer develops when cells in the prostate begin to grow out of control. Unlike some other cancers, prostate cancer often grows slowly and, in many cases, may not cause harm during a man's lifetime. However, some prostate cancers can be aggressive and spread quickly.
What are the Symptoms of Prostate Cancer?
Early-stage disease often causes no symptoms at all. This is why screening can be valuable for detecting cancer before symptoms develop. However, as the disease progresses or when a tumor grows large enough to affect urinary function, men may experience various symptoms.
Common urinary symptoms that may indicate prostate problems include:
Frequent urination, especially at night (nocturia)
Difficulty starting urination or having to strain to empty the bladder
Weak or interrupted urine flow
Feeling that the bladder hasn't completely emptied
Urgency (feeling a compelling need to urinate immediately)
Blood in urine or semen (hematuria or hematospermia)
Painful urination or ejaculation
It's important to note that these urinary symptoms are more commonly caused by benign prostatic hyperplasia (BPH)—a non-cancerous enlargement of the prostate that becomes increasingly common as men age. However, because cancer can cause similar symptoms, any new urinary issues should be evaluated by your doctor.
Symptoms of advanced prostate cancer may include:
Unexplained weight loss
Bone pain, especially in the back, hips, pelvis, or ribs (which may indicate the cancer has spread to the bones)
Weakness or numbness in the legs or feet
Loss of bladder or bowel control (if the cancer is pressing on the spinal cord)
Anemia (low red blood cell count), which can cause fatigue and weakness
Note that if you experience any of these symptoms, it does not necessarily mean you have prostate cancer. Many other conditions can cause similar issues.
Who Is at Risk?
Prostate cancer is the second most common cancer in American men, behind only skin cancer. About 1 in 8 men will be diagnosed with prostate cancer during their lifetime. Several factors influence risk:
Age: Prostate cancer risk increases significantly with age. It's rare before age 40, but the risk increases rapidly after age 50. About 60% of cases are diagnosed in men over 65.
Family history: Having a father or brother with prostate cancer more than doubles a man's risk. The risk increases further with multiple affected relatives, especially if they were diagnosed at a younger age.
Race: African American men have a substantially higher risk of developing prostate cancer compared to men of other racial and ethnic groups. They're also more likely to develop aggressive disease and to be diagnosed at a younger age.
Genetic factors: Certain inherited gene mutations (such as BRCA1, BRCA2, and HOXB13) can increase prostate cancer risk. Men with Lynch syndrome also face an elevated risk.
Geographic factors: Prostate cancer is more common in North America, northwestern Europe, Australia, and the Caribbean islands. It's less common in Asia, Africa, Central America, and South America. I wish I could tell you why this is!
Prevention: What We Know
While no guaranteed prevention method exists, several lifestyle factors may help reduce prostate cancer risk:
Diet: Research suggests that a diet low in animal fats and high in fruits, vegetables, and whole grains may help reduce risk. Specifically, tomatoes (rich in lycopene), cruciferous vegetables (like broccoli and cauliflower), soy, green tea, and pomegranate have shown potential benefits in some studies.
Physical activity: Regular exercise appears to lower the risk of many cancers, including prostate cancer. It also improves outcomes for those diagnosed with the disease.
Maintaining a healthy weight: Obesity is associated with more aggressive prostate cancer and a higher risk of recurrence after treatment.
Consider the evidence on supplements: Despite marketing claims, most supplements have not been proven to reduce prostate cancer risk. In fact, some studies have raised concerns that certain supplements, like vitamin E and selenium, might actually increase risk in some men.
Screening and Early Detection
Prostate cancer screening remains one of the most nuanced areas in preventive medicine, with evolving guidelines and ongoing debates about benefits versus potential harms.
The primary screening tools include:
PSA (Prostate-Specific Antigen) blood test: This measures a protein produced by both cancerous and non-cancerous prostate tissue. Elevated levels can indicate cancer, but also benign conditions like prostate enlargement or inflammation. As an example, I recently saw a patient whose PSA was elevated due to riding his bicycle more regularly, causing mechanical irritation of the prostate gland.
Digital rectal examination (DRE): A doctor can check the prostate for abnormal size, shape, or texture with a good old fashioned rectal exam, however this exam is not thought to provide much utility in men without symptoms.
Current guidelines generally recommend:
For men ages 55-69, discussing the potential benefits and harms of screening with their doctor before deciding whether to be screened
For men ages 70+, discussing the U.S. Preventative Services Task Force (USPSTF) recommendation not to pursue screening
For men with higher risk (African American men or those with a family history), considering screening discussions earlier, typically at age 45
For men with multiple first-degree relatives diagnosed with prostate cancer at an early age, screening discussions might start as early as age 40
Why the debate on screening? Prostate cancer screening has both pros and cons. Screening may help find aggressive cancers early when they're more treatable, potentially reducing deaths from prostate cancer. However, screening can lead to false positives, unnecessary biopsies, and overdiagnosis of slow-growing cancers that would never have caused symptoms or death. This overdiagnosis can lead to unnecessary treatment with significant side effects affecting urinary function, bowel function, and sexual health.
Diagnosis and Early Evaluation
If screening suggests possible prostate cancer, the next step is typically a prostate biopsy where small samples of prostate tissue are removed and examined under a microscope to check for cancer cells.
If cancer is found, understanding the behavior of an individual's prostate cancer is crucial for making appropriate treatment decisions. This is where classification systems like the Gleason score come in. The Gleason score (ranging from 6-10) or Grade Group (1-5) helps determine how aggressive the cancer appears under the microscope. Higher numbers indicate more aggressive disease.
The next step? Additional tests help determine whether the cancer has spread beyond the prostate:
Imaging studies: MRI, CT scans, bone scans, or newer PET scans can help identify whether cancer has spread to nearby tissues, lymph nodes, bones, or other organs.
Genomic testing: These newer tests analyze the genetic makeup of the cancer cells to help predict how aggressive the cancer might be, which can guide treatment decisions.
Based on these evaluations, prostate cancer is assigned a stage (how far it has spread) and a grade (how aggressive it appears). Together, these factors help determine the most appropriate treatment approach.
Treatment Options
Treatment for prostate cancer varies widely depending on the cancer's aggressiveness, its stage, and the patient's age, overall health, and personal tolerance for risk and treatment side effects.
Main options include:
Active surveillance: For low-risk, slow-growing cancers, closely monitoring with regular PSA tests, DREs, and periodic biopsies—without immediate treatment—may be appropriate. This approach aims to avoid unnecessary treatment while remaining vigilant for any signs that the cancer is becoming more aggressive.
Surgery (radical prostatectomy): Surgical removal of the entire prostate gland and some surrounding tissue. This can be performed through traditional open surgery, laparoscopic surgery, or robot-assisted surgery.
Radiation therapy: Using high-energy rays to kill cancer cells. This can be delivered externally (external beam radiation) or internally by placing radioactive seeds directly into the prostate (brachytherapy).
Hormone therapy: Also called androgen deprivation therapy (ADT), this reduces levels of male hormones (androgens) that stimulate prostate cancer growth. This is often used when cancer has spread beyond the prostate or when it returns after initial treatment. When a prostate cancer is described as "hormone-sensitive" (as in President Biden's case), it means the cancer is likely to respond well to hormone therapy.
Chemotherapy: Using drugs to kill cancer cells, typically reserved for cancers that have spread beyond the prostate and aren't responding to hormone therapy.
Immunotherapy: Treatments that help the immune system recognize and attack cancer cells.
Targeted therapy: Newer drugs that target specific abnormalities in cancer cells.
For advanced cases like President Biden's (with a high Gleason score and bone metastasis), treatment typically involves a multi-faceted approach, often combining hormone therapy with other treatments like radiation, chemotherapy, or newer targeted therapies.
Living With and Beyond Prostate Cancer
Many men live long, full lives after a prostate cancer diagnosis. The five-year relative survival rate for all stages of prostate cancer combined is about 98%. Even for men with advanced disease, newer treatments continue to extend survival and improve quality of life.
However, treatments can have significant side effects, including urinary incontinence, erectile dysfunction, bowel problems, changes in body composition, hot flashes and breast enlargement (from hormone therapy), and fatigue. Fortunately, many effective interventions exist to address side effects from treatment and the cancer itself, from pelvic floor physical therapy for incontinence to various medications and non pharmacologic interventions for erectile dysfunction.
Working closely with your primary care doctor, urologist, and oncologist to manage these side effects is an important part of prostate cancer care.
Do I think President Biden’s Prostate Cancer isn’t Actually New?
I have no idea. The hot takes online are wild! Is it possible that his cancer flew under the radar and was only just detected a week ago? Yes—it just seems unlikely. While it is true that the USPSTF recommends against screening men over age 70 for prostate cancer, it is difficult to imagine that President Biden didn’t get aggressive screening tests and extra-careful medical monitoring while in the White House.
Is it possible that he had an indolent, slow-growing cancer that had been known for years and that only became aggressive more recently? Yes, that is possible, too. Regardless of the timeline, I hope he is taking good care of himself, and I wish him well. 🙏
Looking Forward
President Biden's diagnosis highlights the importance of maintaining regular check-ups as we age. For men approaching or past middle age, it’s important to understand your prostate cancer risk and screening options. Whether or not to pursue screening is a personal decision, but it should be an informed one.
For those already diagnosed with prostate cancer, remember that treatment options continue to improve, and research is constantly advancing our understanding of this disease. Many resources exist to support patients and their families through this process, including the Prostate Cancer Foundation, Us TOO International, and the American Cancer Society.
As with all aspects of your health, understanding your options, asking questions, and making decisions aligned with your values is the path to reclaiming agency.
Until next week,
Lucy
P.S. If you have specific questions about prostate cancer or screening that I haven't addressed here, please don't hesitate to reach out. While I can't provide individualized medical advice through this newsletter, I'm always looking for topics that matter to my readers!
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Disclaimer: The views expressed here are entirely my own. They are not a substitute for advice from your personal physician.
Excellent article. I can add nothing to the medical angle, but there are other angles to consider too.
Let’s use President Biden as an example. I believe he’s 82. If he were totally cured of his cancer, that doesn’t really solve the problem given his age. If he was totally cured of one thing, that’s really just setting the stage for the next problem.
My Dad died of prostrate cancer, but he went pretty quick, so there was no hospital horror show. My Mom died of Parkinsons, which can be brutal over an extended period of time, 15 years in her case.
What I’m trying to get at here is that it seems difficult to analyze the desired course of action in these cases unless we have some basis of comparison. Where does President Biden think he’s going after this life? He seems to be a serious Catholic, so that gives us a clue, but perhaps none of us REALLY know what we believe until the end?
Many seniors suffer enormously as they reach the end of their lives. Some giant percent of all health care spending occurs in the last year of life.
Assuming a person is 80+ years of age, I would propose that serious illness at that age is not really a medical issue, but a philosophical one. How one would approach treatment would seem to depend a lot on what one considers the alternative to treatment to be.
The medical community has the best of intentions. But to the degree they push advanced treatments which may come with many ugly side effects, they are unintentionally sending a dark philosophical message.
“As bad as your current situation is, the alternative is even worse”
While that may indeed be true, it seems important to make clear that this is not a science based assumption, because there is no proof of that statement’s validity.
We might be wary of looking to the medical community for advice on matters which, so far at least, really have nothing to do with science.
Harvard researchers followed 1000+ men with early-stage prostate cancer for several years. Compared with men who rarely ate eggs, men who ate even less than a single egg a day appeared to have twice the risk of prostate cancer progression. The only thing worse for prostate cancer than eggs was poultry: Men with more aggressive cancer who regularly ate chicken had up to four times the progression risk. A single daily serving of cruciferous vegetables such as broccoli, brussels sprouts, cabbage, cauliflower, or kale may cut the risk of cancer progression by more than half.
A 2015 meta-analysis found that high intakes of dairy products—milk, low-fat milk, and cheese, but not nondairy sources of calcium—appear to increase total prostate cancer risk.