Breaking news: Defense Secretary Austin gets hospitalized secretly twice--for a prostatectomy and complications. Biden kept out of the loop.

But what's the real story? We may never know.

By Howard Wolinsky

When I heard the news on Monday that Defense Secretary Lloyd Austin had been secretly hospitalized, the first thing I thought was: prostate cancer.

Why not? He’s 70 years old—average age for diagnosis is 66. And he’s a Black man, facing a one in six chance of being diagnosed prostate cancer—compared with one in eight in the rest of the population. (See feature below on racism and prostate cancer.)

My kids scoffed. They think I have prostate cancer on the brain. But I suspect you likely had the same thought.

Today, the Pentagon announced that indeed Austin had been diagnosed with early-stage prostate cancer and had secretly had undergone a prostatectomy and was hospitalized at Walter Reed for an infection following a prostatectomy.

Austin first was admitted to Walter Reed National Military Medical Center on December 22 and underwent surgery to treat the cancer. He developed the infection a week later. Senior administration and defense officials were not told for days about his cancer or hospitalizations.

See a timeline from ABC: https://abcnews.go.com/US/wireStory/timeline-defense-secretary-lloyd-austins-hospitalization-lack-white-106240241

Not surprisingly, because it involves policy and the national interest, the media has focused on the secretive aspects of his hospitalization, how Austin did not notify his boss, President Biden, of what was going on. That’s a breach of responsibility. But will that be a fireable offense?

Republic senators, including Tom Cotton (Arkansas) and Roger Wiger (Mississippi, respectively), criticized the Biden administration and called for Austin’s ouster. Many — including some Democrats — criticized the administration for its lack of transparency and the possibility that U.S. defense forces could’ve been put in jeopardy.

On Jan. 4, while Austin was hospitalized, the U.S. military killed a militant and his aide in Baghdad. The Pentagon officials said clearance for military operation had been given in advance of Austin’s hospitalization.

The Pentagon summarized Austin’s surgery as being “elective.” Sounds to me like a strange choice of words. What was the hurry? What was found in an MRI or pathologist’s report? Could he have been on Active Surveillance?

The Pentagon also described the operation as “minimally invasive.” Paul Schellhammer, MD, past president of the American Urological Association and a PCa patient, told me the term minimally invasive surgery (MIST) is used for robotic prostatectomy and a host of other robotic procedures

Another world authority, who asked that his name be withheld, said: “Secretary Auston probably has an abscess in the surgery bed due to urine leak and accumulation, which is a rare but not an unexpected postop complication following robotic RP.” 

These articles raise more questions than they answer.

Inquiring minds want to know. But I am skeptical that the Pentagon and White House press will ask about these issues. Even though Austin is a public figure, he’s entitled to privacy to some degree,

Meanwhile, was Austin ashamed of his illness and feared he would be asked to step down?

Some guys—like about 25% according to my survey— keep their prostate cancer diagnosis—even for low-risk diseases—a secret because of cancer stigma. They fear discrimination and maybe even being fired.

What do you think?

Austin rightly asked his deputy to take over but never informed the deputy about his surgery, let alone the President.

White House Chief of Staff Jeff Zients told cabinet secretaries in a memo to send the WH any existing procedures for delegating authority in the event of incapacitation or loss of communication.

While the review is ongoing, Zients also is requiring agencies to notify his office and the office of cabinet affairs at the White House if an agency experiences or plans to experience a circumstance in which a cabinet head can’t perform their duties

Curiouser and curiouser

There’s a lot that’s fishy about this.

Why the rush to surgery? Did he have a Gleason 5+5? Walter Reed has a rep for being surgery-happy.

Is surgery appropriate in a 70-year-old? Many surgeons are unwilling to operate on men 70 and above because of concerns, such as postoperative heart attacks and issues with anesthesia.

In a statement, the Pentagon said Austin’s surgery was “elective.”

Are prostatectomies ever elective? Maybe they are for men with favorable intermediate-risk prostate cancer that still makes a man a candidate for active surveillance, or close monitoring? What caused Austin to decide to undergo surgery?

What does that mean? Could Austin have been on AS? Or maybe his Gleason score was upgraded to a favorable Gleason 3+4? Is that why it’s an elective procedure, a term more likely to be applied to nose jobs?

Also, Austin had an infection that sent him to the hospital. Could that have been potentially deadly sepsis? We don’t know.

It’s unlikely Pentagon or White House reporters will get down to the nitty-gritty of prostate cancer. They typically don’t know the right questions to ask. And the medical reporters often remain on the sidelines on stories like these.

We see the same thing happen when celebrities, baseball managers, and the like are diagnosed, and the entertainment and sports media have no clue of what’s going on.

I imagine Austin will be learning a lot in the days ahead. Whatever else happens here, Austin can play an outsized role, as did Powell and General “Stormin” Norman Schwarzkopf, in getting the word out on prostate cancer.

Urologist Schellhammer said he read suggestions that Austin kept the cancer secret because this is a deeply personal issue. “So much has been made about prostate cancer and African-American men, that I find this unusual,” he said. “Being forthright, and upfront would have been helpful to the prostate cancer community.”

Here’s some tips for reporters covering Defense Secretary Austin:

Already facing higher PCa stats, Black men encounter racial disparities in secondary tests, MRIs, guidelines, more

By Howard Wolinsky

Black men like Defense Secretary Lloyd Austin and the late Secretary of State Colin Powell already are more impacted by prostate cancer (PCa) than their white counterparts.

The incidence of PCa is 70% higher in Blacks, and the mortality is twice that of whites.

“Prostate cancer has the widest racial disparities of any cancer, and these disparities appear at every stage of the cancer continuum,” according to a report last September by Ilkania M. Chowdhury-Paulino, of the Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, and colleagues in Prostate Cancer and Prostatic Diseases, published by Nature.

To add insult to injury, widely used Postate-Specific Antigen (PSA) blood levels in men with Gleason Grades 2-5 already are not great in detecting clinically significant cancers in all patients, leading to unnecessary negative biopsies, over-detection of indolent (non-aggressive) cancers, and over-treatment, especially in Black men.

Jamila Sweis and Bernice Ofori led by senior author Adam B. Murphy of Northwestern University Feinberg School of Medicine and Jesse Brown VA Medical Center in Chicago, report in an editorial in the current issue of Prostate Cancer and Prostatic Diseases.

(Dr. Adam Murphy of Northwestern U.)

The low specificity for clinically significant Gleason Grade Group 2–5 prostate cancer (PCa) leads to unnecessary negative biopsies, over-detection of indolent cancers, and over-treatment, especially in Black men with favorable risk, reported senior author y, MD, and his colleagues.

“Urologists rely on the negative predictive value (NPV) of the secondary screening tools for GG2-5 (Grade Group 2-5) PCa to defer biopsies for men with elevated PSA. However, the NPV of any threshold chosen decreases in populations with a high prevalence of GG2-5 PCa. For most of these popular secondary biomarkers, specificity and NPV have not been assessed in Black men despite their known high risk,” the researchers said.

This poses problems also in Asian men with both high and low PCa risk.

The National Comprehensive Cancer Network (NCCN) Early Detection guidelines specifically call for biomarkers and MRI tests to improve the specificity of PSA.

The new standard of care in the NCCN guidelines recommends PSA testing using thresholds of PSA equal to and more than 3.0 ng/ml as opposed to 4.0 ng/ml equal to or more than used by most clinicians.

This new standard in effect leads to biopsies for virtually all black men, the researchers said.

Sweis et al, cited a new study from across town at the University of Chicago that appeared in the Journal of Urology finding that the specificity of PSA drops by 45% with the lower threshold (4.7%), leading to an increased number of healthy Black men qualifying for urologic referral for biopsy evaluation. This is essentially a biopsy all strategy for Black men, and it subjects many Black men to unnecessary biopsies,” the NU team said.

“Data on the monitoring intensity for active surveillance in Black men or in safety net hospitals suggests that lost to follow-up is high and repeat surveillance biopsies are not done frequently enough to ensure the safety of a lowered PSA threshold at this point in time,” researchers said.

Screening with secondary urine- and blood-based biomarkers generally has not been validated in previously unbiopsied (“naive”) Black men—yet another form of discrimination.

These include biomarkers for biopsy-naive patients, including blood tests, such as Prostate Health Index (PHI) and 4Kscore, and urine tests such as ExoDx, PCA3, and Select MDx. For prior negative biopsy, 4Kscore, PCA3, ExoDx and the biopsy tissue-based Confirm MDx can help avoid unnecessary biopsies—at least in white men.

“By our understanding of the literature and two reviews on the topic, current screening biomarkers are mainly validated only for discrimination with no assessment of the specificity or the concordance between predicted and observed risk, i.e., calibration, in Black men,” researchers observed.

Beyond the biomarkers, Magnetic Resonance Imaging, recommended where available, also falls short of the mark in Black men.

Risk calculators might offer a solution, because they are flexible, and clinical and imaging data, including racial stratification, can be incorporated in models and electronic medical records systems. UChicago researchers said this should be a priority.

Register for an ASPI program on genetics and prostate cancer

January

27

12:00 - 1:30 PM EDT

REGISTER FOR ZOOM

SAVE THE DATE!

Join us for a free & informative webinar on SATURDAY, JANUARY 27th, from 12:00 - 1:30pm EST as Christina Nakamoto, Medical Science Liaison for Urology at Myriad Genetics, discusses the benefits of medical grade, genetic tests and how testing can provide personalized information about a patient's prostate cancer in facilitating an informed shared decision-making process between the patient and his medical team on Active Surveillance and/or other treatment options.  Michael Glode, MD, who serves on ASPI's Medical Advisory committee will join the discussion and field questions during the subsquent Q &A session. 

The session includes a live Q&A. Send your questions in advance to contactus@aspatients.org.

CLICK HERE TO REGISTER

* PLEASE NOTE WHEN REGISTERING FOR THIS ZOOM MEETING 

YOU WILL RECEIVE A ZOOM CONFIRMATION BY EMAIL. PLEASE USE THE "JOIN" LINK IN THAT EMAIL TO ATTEND THE MEETING

C’mon, join the ZERO support group on AS in March

By Howard Wolinsky

For the past three years, I have run a special Active Surveillance support group for ZERO. Last year, our virtual support meeting drew 60 patients to talk about AS. It was by far the biggest session of any at the annual ZERO Summit.

So sign up now and join us at 11 a.m. Eastern March 12, 2024.

Register in advance for this meeting:
https://us02web.zoom.us/meeting/register/tZUsfuqgrjIoG9AWf7voMhzT_UjdqbQQbQPA

An unsolicited endorsement of TAS

“You’re a good man. Thank you for being there for all the people you help. I know that your thoughts are extremely valuable to many more than you can imagine. I recommend people everywhere to look into AnCan, or other cancer support groups, and that you are a great resource.”

Steven B. Mael, Wisconsin