Joe Biden's prostate nodule: Could it be PCa? Or something else? Yes and yes.
But the real question is: Why are Biden's docs screening their 82-year-old patient for prostate cancer even though he has no known history of PCa and has frail health?
By Howard Wolinsky
A “small nodule” was found last Friday in the prostate of former President Joe Biden, and he is undergoing “further evaluation,” a Biden spokesman has said.
ABC said the spokesman indicated "a small nodule can mean a wide range of things and will require further testing to understand the underlying cause. It is too early to say if it is a benign lump caused by inflammation or something more serious.”
The report also raises more questions about Biden’s health.
Could Biden, 82, have prostate cancer?
My panel of experts said he may, but he could have something else, like hyperplastic tissue.
Prostate cancer is quite common in men between 80 and 85. Approximately 80% of men who reach 80 years old already have prostate cancer. This, after all, is a disease of aging, Most of us can live with prostate cancer and die from something else.
Let’s find out more about the Biden basics.
What are nodules?
Ming Zhou, MD, PhD, Vice Chair for Oncological Pathology, Director of Urological Pathology Service, Mount Sinai Hospital and Icahn School of Medicine in New York City, said, “A prostate nodule is an abnormal growth or firm area in the prostate gland. The primary concern is cancer, but other possibilities include BPH, prostatitis, stones, etc.”
How common are nodules in men who have routine care at this age--80+85?
Zhou: Not uncommon. Seen in probably approximately 10% of patients in this age group upon DRE..
Are nodules usually found with DRE?
Zhou, who writes The Pathology Report column for The Active Surveillor: “Yes. They also an also be found on imaging such as ultrasound and MRI.”
The billion dollar question: Should Biden’s doctors have been screening for prostate cancer in an 82-year-old man in ill health? Thumbs down from the experts.
Zhou: “No for Mr. Biden. But a very healthy man may still be screened.”
What do urologists think? I asked a couple.
Urologic oncologist Brian Helfand, MD, PhD, associate chief scientific officer at Endeavor Health in Chicago, said: “The bigger question is why are they still screening him for prostate cancer given that he has many other medical co-morbidities (disclosed or undisclosed) and is far older than age 75 (when guidelines say screening should stop). He is very unlikely to die from prostate cancer and our guidelines would suggest refraining from screening as there is little to no benefit.”
Kevin Shee, MD, PhD, who writes The Urology Report column for The Active Surveillor told me:“Traditionally, in a younger patient, assuming that his PSA is elevated, this would be further worked up with an MRI +/- additional biomarker testing, followed by prostate biopsy. However, in an 80-85 year old man, [doctors] honestly should not be screening for prostate cancer if there has been no prior diagnosis. All of our available guidelines say that screening should stop at 75 because at that point the workup and management risks outweigh the benefits.” (Emphasis added.) (Shee is a resident urologic pathologist at UCSF.)”
DREs: Finding nodules
The Biden case opened another can of worms—digital rectal exams (DREs), which have been declining in recent years because multi-parametric MRIs are detecting so many cancers early.
Will Biden get a biopsy?
Zhou: In my opinion, no. But he may still get a tissue diagnosis if he has significant urinary obstruction and undergoes TURP for symptomatic relief. [TURP is short for transurethral resection of the prostate, a surgical procedure to treat symptoms of an enlarged prostate (benign prostatic hyperplasia or BPH).
What are the odds for cancer vs. hyperplastic tissue?
Zhou: It really depends on where the nodule is. If it is found on the surface of the prostate gland, chances are it is cancer. If it is found on the prostate base protruding into the bladder, or around the prostatic urethra, it is more likely to be BPH.
We don’t know if Biden has cancer. If he does, isn't it likely he'll have low-grade cancer?
Zhou: We do not know. Even if he is diagnosed with high-grade cancer, he is not likely be treated definitively for his general health condition, and probably will be followed and closely monitored.
What options might Biden have?
Zhou: If the cancer is diagnosed, treatment depends on: 1. Aggressiveness of the cancer. 2. Overall health status and life expectancy.
For Mr Biden, it is probably appropriate to follow and watch, and treat symptoms that may develop. Any treatment should be more palliative, symptomatic relief, such relief of urinary obstruction, pain control, treatment of symptoms associated with mets.
What are the odds of metastases?
Zhou: We even do not know if he has cancer. If he does have cancer, the risk of mets at his age depends on the risk category of the cancer, 10-20% over 10 years for localized, low-risk PCa, significantly higher for high risk cancer.
What are the odds for cancer vs. hyperplastic tissue?
Zhou: It really depends on where the nodule is. If it is found on the surface of the prostate gland, chances are it is cancer. If it is found on the prostate base protruding into the bladder, or around the prostatic urethra, it is more likely to be BPH..
Shee said: “It's too early in the work-up to even consider treatment, and would certainly need to be discussed through shared decision-making with the patient. Odds of prostate cancer death and metastasis are unknown until a biopsy is performed, but most likely at this point he is more likely to die of other age-related issues than possible prostate cancer.” (Emphasis added.)
Helfand said in the pre-MRI, PSA screening era, approximately 10-15% of men were diagnosed by feeling a nodule on the prostate. The use of MRIs is making earlier detection possible so not as many nodules are being found.
He noted: “However, some skill may be lost in this art as primary-care physicians often do not include [DREs] as part of their exams because they found that it didn’t offer increased utility. “
He said in his own practice he still includes DREs to estimate the size of the prostate and to rule out nodules.
Shee noted that DREs are less popular among urologists these days because they’re not a good test with low sensitivity, but can be performed in the setting of elevated PSA as an additional test.
“Usually the presence of a nodule in tandem with an elevated PSA is concerning for a diagnosis of prostate cancer warranting further evaluation. So for him if he has a prostate nodule and an elevated PSA he probably has prostate cancer. There's not really other cancers that would manifest with that on clinical exam,” he said.
For more on the DRE debate, read “Up Yours” here. Christian Pavlovich, MD, head of the Active Surveillance program at Johns Hopkin University, explains in a bylined article why Hopkins favors DREs.
I urge reporters covering the Biden to find out: Why were Biden’s physicians screening him for prostate cancer since treatment is unlikely in a patient in his condition at his age.
Biden’s medical history
Biden had a basal skin cell cancer removed from his chest during a routine physical in 2023.
The just-released book, "Original Sin: President Biden's Decline, Its Cover-Up, and His Disastrous Choice to Run Again," by CNN's Jake Tapper and Axios' Alex Thompsonc overs Biden’s detoriorating health in 2023-2024.
Biden's physical deterioration was so severe in 2023 and 2024 that advisers privately discussed the possibility he'd need to use a wheelchair if he won re-election.
Biden's physical deterioration — most apparent in his halting walk — had become so severe that there were internal discussions about putting the president in a wheelchair, but they couldn't do so until after the election, the authors wrote.
Advisors felt that running a presidential campaign from a wheelchair was not tenable.
Sometimes news bumps news: Sorry, Dr. Zhou
By Howard Wolinsky
Tuesday, I posted star uropathologist Dr. Ming Zhou’s column on the most common questions he is asked and gave his responses.
This was an outstanding column but I bumped it to cover the Biden news. But you can still read it.
The Zhou piece got kudos from Dan Dressen: “For 7+ years, but at different times, I've been a regular at 3 different PC support groups, plus have heard hundreds of hours of "Men's Health" online. This article is the largest plethora of useful information I've seen or heard to date. Much of it I've heard before, yet much of it is new to me. Wow!”
Also, blogger Anthony Feig of the Substack Have You Seen My Prostate? said:“This is all the information I wish I’d thought to ask. Cancer diagnosis results are typically presented as if we know the nomenclature already, or that we’ll look it up and get accurate, non-fiction search results. Thank you both,”
You’re welcome Dan and Anthony.And thanks to Dr. Zhou for contributing to the Biden article.
The Active Surveillor calendar
—Dr. Jonathan Epstein talks in a free webinar. Epstein is presenting a program entitled, “What you need to know about your prostate biopsy—the new news.”
The Active Surveillor newsletter is hosting the event. Co-sponsors are Active Surveillance Patients International and AnCan, key organizations in prostate cancer support and education.
The program will be on from noon to 1:30 p.m. Eastern on Saturday, May 17. Register for the meeting: https://us02web.zoom.us/meeting/register/JwtdomJnT3mJttTI8urvuQ
Please send questions in advance to: Howard.wolinsky@gmail.com.
—Chicago Area Active Surveillors meet in person 11:30. a.m.-1 p.m. 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.
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.
—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 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 on 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
Mr. Biden left office as the oldest serving president in American history. He was dogged throughout his presidency by concerns about his age and his health, which ultimately led him to abandon his re-election campaign.
In February 2024, when Mr. Biden was still president, his longtime doctor declared him “fit to serve” after he underwent a routine physical at Walter Reed National Military Medical Center.
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Mr. Biden has kept a relatively low profile since leaving office in January, but he sat for two interviews last week after Mr. Trump’s first 100 days in office. The day before Mr. Biden was at the hospital in Philadelphia, he and the former first lady, Jill Biden, were in Manhattan for a joint interview on “The View.” Mr. Biden defended his record as president and his mental acuity.
“They are wrong,” Mr. Biden said of reports that he had declined in his final year in office. “There’s nothing to sustain that.”
"But the real question is: Why are Biden's docs screening their 82-year-old patient for prostate cancer even though he has no known history of PCa and has frail health?"
That's easy. They're Republicans! That party has been giving the poor guy DRE's forever.
Dr Helfand, in my opinion is dead wrong about DRE estimating size of the prostate, It really takes an transrectal ultrasound, or an MRI or a CT scan to accurately measure the gland. I believe from early reports that the new ultrasound will make the MRI less necessary Spend that $$ on a PSMA PET Ct scan.....