When I saw my phone blowing up on Sunday afternoon with word that former President Biden had been diagnosed with an aggressive form of prostate cancer that had spread to his bones, I immediately reached out to my friend Bill Nelson, MD, PhD, DSc, the chair of Stand Up To Cancer’s Scientific Advisory Council and an expert on prostate cancer. He’s the director of the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, where he’s also a professor of urology, medicine, pathology, and radiation oncology and molecular radiation sciences. In other words, Bill knows what he’s talking about. We agreed there’s much we don’t know about the situation, but here are his initial insights about the former president’s diagnosis and prognosis.
Katie Couric: What was your reaction when you heard about President Biden’s situation?
Dr. Nelson: I feel for anyone who hears the three terrible words “you have cancer.” Their world, and all of their plans, are turned upside down as they worry instead about what may be in store for them, wondering how the cancer can be treated, how well treatment might work, and what side effects they might confront.
It’s being reported that the cancer is aggressive, is hormone-sensitive, and has spread to his bones. It sounds serious. Knowing that you are not his doctor, what would you say are his treatment options?
The reports do suggest that he has metastatic prostate cancer, which is a life-threatening condition capable of causing significant bone pain. His doctors may make use of several treatment approaches, particularly lowering the male hormone testosterone and interfering with its propensity to fuel cancer growth and progression, and radiation therapy aimed at sites of disease. Several other treatments can also be used if necessary.
Many people are wondering, why didn’t a Prostate-Specific Antigen (PSA) test detect this earlier?
Screening for prostate cancer using blood tests for prostate-specific antigen can save lives, allowing prostate cancer to be diagnosed at an early stage when surgery or radiation therapy are most effective. Most recommendations are that PSA screening be considered only after consultation with a physician about risks and benefits, and if elected, start at age 50 years (or earlier for Black men or men with a family history of prostate cancer).
When to stop screening can be a vexing question. The US Preventive Services Task Force recommends against routine screening of men after age 70 years, but many men and their doctors continue to pursue PSA screening through the 70s and beyond, taking into consideration other health problems, life expectancy, etc.
Finally, even despite a routine screening regimen, particularly aggressive cancers can arise in between planned screening tests.
Is a Gleason score of 9 serious? And what exactly is a Gleason score?
The Gleason score is assigned by a pathologist who diagnoses prostate cancer by examining prostate biopsy specimens under a microscope. The score (named for a pathologist named Donald Gleason, who worked at the Minneapolis VA Medical Center in the 1960s) ranges from 6 to 10 and reflects the pattern of growth seen by the pathologist, with higher scores indicative of more aggressive cancer behavior.
What are some of the side effects of prostate cancer treatment?
The side effects associated with antagonizing the actions of the male hormone testosterone include hot flashes, loss of libido, fatigue, diminished muscle mass and strength, osteoporosis, and increased risk of cardiovascular disease.
The major side effects associated with prostate radiation therapy are a result of damage to nerves that run along the prostate and are responsible for erections, and of damage to the rectum. Prostate surgery, when appropriate, also risks damage to nerves needed for erections, along with risks of urinary incontinence.
Can President Biden’s prostate cancer be managed, and if so, for how long?
From what has been reported, President Biden’s prostate cancer can definitely be treated, with the promise of keeping his prostate cancer under control for many months, or hopefully even longer.
So many men get prostate cancer. How common is it when you age?
Autopsy studies conducted on men dying from other causes suggest that more than half of men harbor cancers in their prostates by the time they get into their 80s. These days, 1 in 8 men receive a diagnosis at some point in their lives, while about 1 in 44 die of the disease.
One of my old mentors, the late Donald Coffey, used to argue that the key screening and diagnosis challenge is to find the aggressively behaving disease, which he called the “tigers,” early enough to allow treatment for cure, while leaving what he called the “pussycats” alone. This has been slowly improving: Prostate MRI is now more frequently used to ensure that prostate biopsies are aimed at the more aggressive lesions in the prostate so that they aren’t missed.
