Research & Discovery

Q&A: How Did President Biden’s Prostate Cancer Advance Without Detection?

Former President Joe Biden was diagnosed last week with an aggressive form of prostate cancer that has spread to his bones.

The news has raised lots of questions about the typically slow-growing disease, including why it was detected in the president at such an advanced stage.

UVA Health’s Dr. Kirsten Greene, chair of the UVA Department of Urology and a specialist in caring for patients with prostate and related cancers, answered UVA Today’s questions.

Portrait of Dr. Kirsten Green, Chair of the UVA Department of Urology

Dr. Kirsten Greene is the chair of the UVA Department of Urology. (Contributed photo)

Q. What is prostate cancer?

A. The prostate is an organ that is only found in biological men. It’s a little organ that wraps around the urethra, right at the base of the bladder, and its function is to make the fluid that sperm travels in. It makes ejaculate. It produces a chemical called PSA, prostate-specific antigen. When the levels are high in the blood, that can indicate cancer.

Q. Can you describe a prostate exam? What happens?

A. Nowadays, it’s a PSA blood test. You can also do a rectal exam. The purpose of the rectal exam is to feel the prostate, which you can feel through the rectum. Sometimes, people don’t even do the rectal exam anymore and just do the blood test.

Q. Can you describe Biden’s diagnosis?

A. I don’t treat President Biden, so I’m just going by what I’ve read in the media. It sounds like his cancer was detected because of a rectal exam and they felt a nodule. That’s very uncommon nowadays because most prostate cancer is detected with the PSA test. And a PSA blood test can usually diagnose you with prostate cancer 10 to 15 years before you’d ever have a symptom. He has … the most aggressive grade of prostate cancer.

Q. When you say aggressive, what does that mean?

A. Aggressive in the prostate cancer world essentially means cancer that can spread. And we know, unfortunately, that President Biden’s cancer has spread because we’ve seen reports that it spread to the bone.

Q. How is it that Biden’s cancer was detected at such an advanced stage?

A. Everyone is asking me that same question. I have two speculations. One is that prostate cancer screening guidelines in the United States recommend stopping prostate cancer screening after age 75. It’s uncommon to continue to check a PSA every year beyond the age of 75 if your PSA has been fine prior to that.

The other possibility could be that his prostate cancer is so aggressive or de-differentiated that it actually stopped making PSA. It’s an unusual situation. Now, another (possibility) is … maybe he’d had biopsies in the past that didn’t show cancer, and the biopsy just happened to miss it.

Q. What is Biden’s prognosis?

A. This is not curable. But with prostate cancer, this can be controlled for many years. This is not the type of thing where he only has months to live. If he accepts treatment, he has many, many years ahead of him.

One thing that I read is that he has hormone-sensitive prostate cancer. The treatment is to administer a drug that tricks a man’s body into halting testosterone production. Prostate cancer likes to have testosterone. It helps it grow. Then he’d be monitored, and depending upon how widespread it is, he could get radiation to the prostate.

Q. Does stopping testosterone kill the cancer?

A. At some point in time, the prostate cancer regains the ability to grow, even in the absence of testosterone. And in that case, that’s called castrate-resistant prostate cancer. In that case, there’s a whole different set of drugs that can be given.

Q. What are the current guidelines for prostate cancer screening?

A. Generally speaking, people are advised to start at around age 40 with PSA blood tests if you’re at high risk. High risk … could be Black or African American individuals; the gene that causes breast cancer, believe it or not … and people who have a strong family history (of prostate cancer). Everybody else, if you’re not high-risk, start (testing) at age 45.