Biden confirms advanced PCa that has spread. Situation raises many questions.
But a Gleason 9 doesn't come out of nowhere for an 82-year-old like Biden
By Howard Wolinsky
Former President Joe Biden, 82, has been diagnosed with advanced Gleason 9 prostate cancer, with the tumor metastasizing into his bones, his office confirmed on Sunday.
Sources say the frail Biden, who was pushed out of the 2024 Presidential campaign. because of growing concerns about his health, say he will likely undergo androgen deprivation therapy (ADT) and other drug therapy to suppress his testosterone levels to starve the cancer and possibly chemotherapy.
Sources said he probably is not a candidate for surgery or radiation therapy—though some patients qualify for targeted radiation for limited metastases and some undergo combination radiation therapy and ADT.
The story began to unfold on May 9 when Biden was diagnosed with a prostate nodule, probably from a DRE (digital rectal exam) at a Philadelphia hospital. Experts told The Active Surveillor that it was unusual for a man of Biden’s age to be undergoing prostate screening—unless he was very healthy or very ill.
Kevin Shee, MD, The Urology Report column for the Active Surveillor, told me Sunday: “So many questions about Biden’s new diagnosis of metastatic prostate cancer. I wonder if Biden was screened with PSA testing when he was younger.”
Let me add: We assume President’s have platinum medical care, with their own White House medical staff. Did Biden get PSAs or even DREs during his annual physicals?
Shee, a urologic oncologist and prostate cancer researcher at the University of California, San Francisco, said: “There’s no way this disease [Gleason 9] comes out of nowhere.”
He added: “Treatment with ONLY surgery or radiation is off the table. RT has a role in some cases.”
The question arises about whether Biden actually had been followed for prostate cancer before the nodule was diagnosed. But what did he know and when did he know it?
Is it possible that he knew something before he started to launch a presidential re-election campaign that ultimately would be derailed by health and aging concerns?
Rick Davis, a survivor of advanced prostate cancer and founder of the AnCan platform of support groups, said the Biden case is “fishy. I'd bet $$$ to donuts there may have been a reason to continue screening Biden at age 75. How can an 82-yr old man who has had close medical supervision suddenly be found to have de novo metastatic with Gleason 9 and bone mets. This after they found a nodule with a DRE??? PSA history??Prior scans if any??
“Sounds like someone was sleeping at the switch. G9 doesn't creep up on you at age 82.”
How will Biden be treated?
Uropathologist Ming Zhou, MD, who writes The Pathology Report column for this newsletter, and Director of the Urological Pathology Service Mount Sinai Hospital and Icahn School of Medicine in New York City, said, “The management [of the prostate cancer] should focus on palliation of symptoms such as pain control and bone protection.”
Brian Helfand, MD, PhD, chief of urology at Endeavor Health in Chicago, said, “[Biden] will likely have hormone therapy (combination of androgen production blockade and receptor blocker) and then depending on how many metastases there are— maybe radiation.
“This is a funny thing because it was all found during a prostate exam— technically according to guidelines shouldn’t be done.”
Shee said: “What's next depends on his life expectancy (5 years is usually the cutoff for this), but if more than 5 years he should be treated with some form of combination medical therapy. Androgen deprivation therapy, or ADT, is the base of treatment. This is used in combination with usually an anti-androgen therapy (e.g. abiraterone, apalutamide, enzalutamide), and sometimes with a chemotherapeutic agent called docetaxel. If there's little spread of disease (e.g. in only a few bone areas or lymph nodes), then there may be a benefit to the addition of radiation therapy to this treatment.
“If his life expectancy is less than 5 years, then the number of treatment agents will decrease (e.g. ADT alone) or he will be observed instead.”
Common side effects from ADT include sexual dysfunction, hot flashes, osteoporosis, breast enlargement, fatigue, mood changes, and weight gain.
Then, as part of what is known as doublet therapy, patients like Biden are given other androgen receptor pathway inhibitors (ARPI) to quell male hormones: enzalutamide, an antiandrogen, specifically a nonsteroidal antiandrogen, or abiraterone, an androgen biosynthesis inhibitor. They carry similar side effects like fatigue and also diarrhea.
Sometimes, chemotherapy is added for triplet therapy.
Alternative history?
It didn’t happen this way. I suspect some paranoid press will see some sort of conspiracy here. And alternative history buffs probably see all kinds of possibilities.
But if Biden ran and was elected to the very stressful job as “leader of the free world? Could he manage Gleason 9 and a presidency?
Opinions vary.
Davis said, “Had Biden known he was a candidate for hormone therapy, most likely doublet therapy [would have been recommended], it would have been medically responsible for him to stand down during his presidency, and certainly to discount any thought of running again.”
Zhou noted that some of our top leaders in government held down jobs while dealing with prostate cancer.
BREAKING News: Top doc Francis Collins, former NIH director, shares his advanced PCa journey
(Francis Collins, MD, from AS to radical prostatectomy.)
Francis Collins, MD, PhD, ran the National Institutes of Health while on Active Surveillance, which he kept from the public, missing a real educational opportunity. Seemingly overnight, he was diagnosed with a Gleason 9 and was able to undergo a radical prostatectomy at age 73.
And then, there was the case of General Lloyd Austin, Biden’s Secretary of Defense, who got into hot water last year for withholding his prostate cancer diagnosis from his boss and the American public.
President Trump said in a post on Truth Social that he and First Lady Melania Trump are "saddened to hear about Joe Biden's recent medical diagnosis…We extend our warmest and best wishes to Jill and the family, and we wish Joe a fast and successful recovery,”
Harris said in a post on X that she and her husband, Doug Emhoff, were saddened to hear of Biden's diagnosis and were keeping his family in their hearts and prayers.
"Joe is a fighter — and I know he will face this challenge with the same strength, resilience, and optimism that have always defined his life and leadership," Harris wrote. "We are hopeful for a full and speedy recovery."
Amen.
Active Surveillance Patients International and AnCan were co-sponsors.
News on Dr. Jonathan Epstein’s webinar on what’s news in uropathology—and news on Dr. E.
By Howard Wolinsky
The video of Dr. Jonathan Epstein’s webinar for The Active Surveillor on May 17 has posted in the Surveillor’s YouTube channel:
Many kudos came in on the program, where Dr. Epstein, one of the top urologists in the world, told us Active Surveillance, cribriform and loads more. You can view the recording here
While you’re there, check out other videos in The Active Surveillor’s YouTube Channel. Please subscribe.
Dr. Epstein’s slides are available here: https://docs.google.com/presentation/d/1OPXmN-m1R31spW-22s1rL_C0DSMX92tW/edit?usp=sharing&ouid=103480725196523876180&rtpof=true&sd=true
Unfortunately, not everyone was able to get in because of a glitch with Zoom. No worries. Dr. E. has agreed to come back in June for round 2. Details soon.
More meetings, including a new one in the Windy City only for AS patients
—Chicago Area Active Surveillors meet in person 11:30. a.m.-1 p.m. Wednesday, May 21,
Be there or be square. But you gotta’ be there in person.
The newly formed Chicago Area Active Surveillors is meeting at
Seasons 52 in the Napa Room
3 Oakbrook Center
Oak Brook, IL 6052
If you want to join us, let me know at howard.wolinsky@gmail.com, and I’ll share details.
We have drawn members from as far away as Columbia, Missouri, for the meeting of what we believe is the largest in-person AS-only support group on the planet—certainly in the Chicago area. Maybe in the multi-verse.
—ZERO’s town hall meeting on ZOOM. Prostate cancer research—along with research on other diseases—has taken a body blow.
Attend a ZERO Prostate Cancer town hall at 7 p.m. Eastern Tuesday May 20 by ZERO to discuss the status of funding cuts under the proposed federal budget and what can be done about it. Register for the session here. More background on the cuts proposed for CDC here.
—UMiami’s Sanoj Punnen takes on the debate over transperineal vs. transrectal biopsies. Active Surveillance Patients International (ASPI)’s monthly webinar will focus on these issues in a program entitled, “The great biopsy debate: Where do we stand on transperineal vs. transrectal?”
The program will be Saturday, May 24 from noon to 1:30 pm Eastern.
Register here:
https://zoom.us/meeting/register/UZVDHmq9Rlyw6y_mqmK0hg#/registration
Check out Punnen’s presentation of the MAST AS study at the recent meeting of the American Urological Association: https://news.med.miami.edu/improving-prostate-cancer-prediction-during-active-surveillance/
Please send questions in advance to: contactus@aspatients.org
I cannot believe these doctors are claim this. My husband was 58 when he was diagnosed after two high PSA test. He was a Gleason 10 in all 12 samples, and it had already metastasized to the bones. He underwent RT and several rounds of chemo, but passed away 18 months after first PSA. It came out of nowhere and had no symptoms. It's rare, but becoming more common. They should know better.
Another good one Howie!
What I want to know is what Biden's baseline T is. At his age, it has to be extremely low already. Frankly, he's a candidate for bilateral orchiectomy (he really doesn't need them anymore), but the surgery would be intense and given his health status, probably too extreme. ADT, however, messes with so many pathways it will probably accelerate his degradation. Since they are going palliative for the mets, that may be all that they do.