Worlds colliding: PSAs, conspiracies, pushback, and the future of presidential politics

(Note: President’s Bident’s Gleason 9 (out 10) diagnosis has medical, cultural and historical aspects. I am a one-man show that used to cover medicine for one of the nation’s largest newspapers. So I enjoy dusting off my old skills and reporting on this case that raises so many issues. If you are disinterested, I figure there’s a couple more days of reporting on Biden and then I’ll return to my mission of covering Active Surveillance for low-risk prostate cancer. I do feel that we are a “brotherhood” from low-risk to high-risk cancers. Stay tuned.)

By Howard Wolinsky

Gradually, the bigger picture of President Biden’s prostate cancer is being filled in. At the same time, in the face of claims about a cover-up of his cancer, questions are being raised about how future presidential candidacies and presidencies should be handled in terms of releasing personal medical information,

On Tuesday, Biden spokesman, Chris Meagher, apparently responding to conspiracy theorists, said Biden was first diagnosed with Gleason 9 (Grade Group 5) cancer last week and was not part of a cover-up.

He said Biden’s last-known prostate-specific antigen test (PSA) was in 2014 when Biden would have been 71 or 72 years old.

Still MIA: Biden’s PSA level and his PSA history. In fact, Biden never took a PSA during his presidency. Still, many men who previously have not been diagnosed with prostate cancer stop screening with PSA at age 70 or 75.

“The new details help provide some clarity about Mr. Biden’s health records, but they still do not directly give an answer on why Mr. Biden was not regularly screened for prostate cancer throughout his presidency,” New York Times White House reporter Tyler Pager said.

(Kudos to the political and non-medical reporters who are starting to ask the right questions and slinging the lingo, like PSAs and Gleason scores after years of not asking politicians these questions. This is a moment of learning in a national crash course on PCa. Biden’s spokesmen are on a steep PCa learning curve as well. This all ifor the good because it ncreases public awareness of a disease, according to the American Cancer Sociey, will be diagnosed in 315,000 men this year and will kill about 35,000.)

Meagher did not respond to Pager’s question about why Biden was not regularly screened for prostate cancer throughout his presidency. And Kevin O’Connor, Biden’s White House doctor, did not respond to inquirie,s Pager said. “But allies of Mr. Biden, 82, and medical experts point to guidelines that advise against PSA screening for men over the age of 70. The guidelines vary slightly across different medical organizations, but doctors generally agree that men of an advanced age should not automatically be screened for prostate cancer,” Pager wrote.

Larry Altman, MD, the former medical columnist for the New York Times and an expert on presidential health for more than a half century, concluded that Biden’s care was on target.

He wrote in a STAT News op-ed that despite all the Monday morning quarterbacking: “Based on the public record of Biden’s medical care and standard medical recommendations, as recently as a year ago there was no reason to perform screening tests for the disease, despite his age, 81 at the time. The diagnosis underscores the fact that cancers can sometimes pop up suddenly, even among recipients of the most sophisticated care doctors can offer.”

Altman noted: “Biden’s health was widely discussed when he was the oldest serving president. … A team of doctors from 11 specialties — not an unusual number — examined Biden at the Bethesda, Md., military medical facility and determined that he was being treated for sleep disorder, a heart rhythm disorder (atrial fibrillation), abnormal lipid levels, gastroesophageal reflux, pain from damage to nerves in his legs, and seasonal allergies, according to a detailed public summary released in February 2024.”

Still questions are being raised about Biden’s cancer and how his case was handled—medically and politically.

A liberal medical politician told me: “Howard, I suspect there was a cover up re Biden's diagnosis. An active duty physician at Walter Reed would have had details of Biden's physical exam just as we had all the information about Trump's recent physical. The situation is similar to FDR and Ross McIntyre [President Roosevelt’s White House physician] and how they concealed FDR’s illnesses when he was running for his fourth term.”

Pager brought up an important question: “Mr. Biden was not just the average American man, and his diagnosis of stage 4 prostate cancer has raised the question: Should the oldest president in American history have gone beyond those guidelines? Mr. Biden, until July, was also running for a second term in office, and had he won, he would have been 86 at the end of his second term.”

President Trump shared his PSA—an incredible 0.1— and other medical data. Biden didn’t have a PSA to share. (Fun fact: Trump’s self-reported golf handicap is 2.8.)

I asked Paul Schellhammer, MD, a urologic oncology professor at Eastern Virginia Medical School and a prostate cancer patient, about Trump’s low PSA: “A PSA of 0.1 (Trump‘s) in a 78-year-old is probably in the 1 – 2%, if that, range. Will need to check if any of his meds affect PSA level – do not think so If I were given that PSA level on a pop quiz, I would automatically assume post RP [radical prostatectomy] or post-XRT [X-ray therapy]plus ADT [Androgen Deprivation Therapy]. Presidential anomalies ??”

Schellhammer is past president of the American Urological Association but doesn’t speak for AUA,

Do medical guidelines not apply to holders of the highest level political jobs since they involve national security. Should male candidates be sharing publicly their PSAs and female candidates their mammograms and both their colonoscopy results?

Peter Carroll, MD, a urologic oncologist at UCSF, told me candidates for high office can’t be compelled to undergo screening tests. But the public may come to expect such information from their leaders, including youthful candidates— as a reassurance that the leaders are fit and can make it through their terms.

Carroll said: “I don't think it can be a requirement due to individual rights, but appropriate cancer screening should be done for important offices. While you can't force it, it can be strongly advised that candidates seek expert medical review in all domains. Prostate cancer is a common cancer, and knowing a candidate's overall health in detail for common cancers, like colon cancer (colonoscopy) and breast cancer (mammography), is important. It would be interesting to know which presidents haven't been screened.”

Schellhammer saidL “When one decides to run for president of the USA, and /or hold the office of the president of the USA you are protected from external dangers by Secret Service, (you can’t walk to the grocery store on your own to buy a quart of milk.), you fly on Air Force One (you can’t get on the United Airlines commuter jet)

“The candidate for and the occupier of the presidential office agrees to the fact that their external environment will be planned and protected to the last detail for their safety which translates to the safety of the country-therefore it would seem to stand to reason that such an individual's internal environment (bodily organs and their health status) needs precise and careful monitoring and care above and beyond what might be appropriate/recommended for the everyday citizen -It goes with the territory that they have signed up to occupy

Dr. Ezekiel J. Emanuel, an oncologist who served as an adviser on the coronavirus pandemic for the Biden administration, told the NYT that presidents should be held to a higher standard than the average American. He emphasized that should especially be the case for presidents when they are above the age of 70, and he suggested changing the way the president’s health is assessed.

“We have to have confidence that their health condition is not intervening,” Emanuel said. “We need a committee of doctors who are not chosen in a political manner who are making an independent evaluation of the president and making it public.

On Monday, Trump wished Biden well, seem to suggest Mr. Biden’s cancer diagnosis was hidden from the public and questioned why it took so long for doctors to discover it.

“It can take years to get to this level of danger,” he said. “So it’s a — look, it’s a very, very sad situation, and I feel very badly about it, and I think people should try and find out what happened.”

“It doesn’t surprise me that he wasn’t being screened because honestly the data don’t really support screening in someone that age,” Dr. David Penson, the chair of urologic oncology at Vanderbilt University Medical Center and the secretary of the American Urological Association, said about Mr. Biden.

It is unclear how much, if any, discussion Mr. Biden had with his doctors when his P.S.A. screening stopped in 2014.

‘Dilbert’ creator Scott Adams and Gleason 9

By Howard Wolinsky

Reacting the the recent announcement of former President Biden’s Gleason 9 prostate cancer, cartoonist Scott Adams, 67, creator of the cartoon “Dilbert” that lampooned cubicle life starting in the late 1980s, has gone public with his diagnosis with the same disease.

“My life expectancy is maybe this summer,” he said on his podcast.

A supporter of President Trump and a critic of Biden, Adams said: “I’d like to extend my respect and compassion and sympathy for the ex-president and his family because they’re going to be going through an especially tough time … It’s a terrible disease — it’s going to get very painful for the president.”

He has kept his own diagnosis under wraps but decided to show solidarity with Biden. ““Once you go public, you’re just the dying cancer guy,” he said.

He said he has been disturbed by the way Biden’s situation has been treated in certain corners: “One of the things I’ve been watching is how terrible the public is. There’s no sympathy for Joe Biden for a lot of people. It’s hard to watch.”

Personally, I was a fan of Dilbert, though I could never distinguish my mission statement from my vision statement.

In recent years, Adams has faced criticism for his non-politically correct language.In 2023, hundreds of newspapers dropped his cartoon because he made what was construed as racist comments on his podcast. Adams denied this.

Adams said he had been using a walker for months and is in a constant pain. He has said that under California law he plans to use g aid-in-dying drugs, available to the terminally ill in the state.

“I don’t have good days,” he said. “Every day is a nightmare. And evening is even worse.”

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Q&A with Dr. E. May 31. Be there. Or be square.

By Howard Wolinsky

Dr. Jonathan Epstein, the noted uropathologist, is coming back to The Active Surveillor audience for a Q&A at noon Eastern May 31.

Here’s your invitation:

When: May 31, 2025 noon Easterm (US and Canada)

Register in advance for this meeting:

https://us02web.zoom.us/meeting/register/sazI-npeR3OdGWyRIrVRYg

After registering, you will receive a confirmation email containing information about joining the meeting.

The sessxion is co-sponsored by ASPI and AnCan.

Here’s the scoop: Only 100 people at a time could get in to see his first lecture and Q&A last Saturday because of a glitch with Zoom.

So I invited him back. And Dr. Epstein graciously accepted.

If you want to send question in advance, write to me at howard.wolinsky@gmail.com

Please get down to your essential question and limit the back story to help get your questions answered. We can’t dispense medical advice.

Meanwhile, The Active Surveillor YouTube Channel is getting a lot of traffic. More than 1,000 people have viewed the Epstein video. It would be worth checking out for background to hear Dr E.’s talk and response to questions.

While you’re there, view the other videos in my new The Active Surveillor’s YouTube Channel. Please like and 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

I’m giving valuable prizes to the first registrants and the 100th: the much-coveted The Active Surveillor T-shirt or a plush prostate doll. Maybe I’ll add the 200th and 300th registrants?

ASPI webinar on the Great Biopsy Debate this Saturday

UMiami’s Sanoj Punnen, MD, 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

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