Joe Biden had unrivalled medical care: how did his prostate cancer go undetected?

Joe Biden has been diagnosed with advanced prostate cancer. Picture; AP.

How was Joe Biden’s cancer not caught earlier?

The news that the former president is battling an aggressive, stage-4 prostate cancer that has spread to the bone ignited a public debate about why a person with peerless access to medical care was diagnosed at such an advanced stage with a disease that is quite common in men his age.

Many prostate cancers in the U.S. are detected with a blood test that measures prostate-specific antigen, or PSA. The test is cheap and can help find potential cancer before symptoms appear. There are some particularly aggressive prostate cancers that don’t secrete enough PSA to be flagged on the test. But those are rare, doctors said.

Whether Biden, 82, had been getting regular PSA screening before his diagnosis isn’t publicly known, and prostate cancer screening for men in their 80s isn’t considered standard care. The U.S. Preventive Services Task Force, a government-backed volunteer panel of experts that makes preventive health recommendations, advises against PSA screening for men ages 70 and above, based on concerns about false positives and overtreating low-risk forms of the disease. Other groups advise older men to make the decision about whether to continue screening in consultation with their doctors.

“It’s in many ways unsettling that someone who has what is undoubtedly fantastic medical care could suddenly be diagnosed with aggressive, metastatic prostate cancer,” said Dr. Todd Morgan, co-director of the Weiser Center for Prostate Cancer at Michigan Medicine.

“On the other hand, this is often how prostate cancer presents. We typically don’t do PSA screening beyond 75 or late 70s.”

Joe Bide’s health was under scrutiny by voters. Picture: AP.

Biden, however, wasn’t a typical patient. As the oldest president in U.S. history to seek re-election, his health was under considerable scrutiny by voters. His eldest son died of brain cancer at age 46, prompting Biden, then vice president, to launch his “cancer moonshot” initiative to accelerate the fight against the disease. His poor performance in last year’s presidential debate forced him out of the 2024 race, and new attention on his acuity while in office is amplifying concerns that his aides concealed his decline.

Donald Trump – the second oldest president at age 78 – does get screened. He released the results of his prostate cancer screening last month, showing a normal score. Barack Obama released his PSA score when he was president, as did George W. Bush.

Speaking to reporters in the Oval Office on Monday evening, Trump said he is “very sad” to hear about Biden’s diagnosis and raised questions about why it wasn’t discovered earlier.

“Someone is going to have to speak to his doctor,” Trump said. “I feel badly about it, and I think people should try and find out what happened.” The Republican-led House Oversight and Government Reform Committee is currently probing whether top White House officials concealed negative information about Biden’s decline. The probe began last Congress and included a request for an interview with Dr. Kevin O’Connor, Biden’s physician as president, and testimony from former Biden aides – but those asks would need to be renewed.

Chris Meagher, a spokesman for Biden, didn’t respond to questions about whether Biden was screened for prostate cancer as president. O’Connor didn’t respond to requests for comment.

Biden’s cancer appears to be hormone-sensitive and could therefore be receptive to hormone-reducing drugs, and cancer doctors have said that even patients with metastatic disease can live for years, thanks to newer therapies. But the disease probably isn’t curable at this stage, and Biden will likely be grappling with it for the rest of his life.

Around 10% of prostate cancers are already metastatic by the time they are diagnosed, prostate cancer specialists said. Symptoms including difficulty urinating or blood in the urine often don’t appear until the disease is advanced. Biden’s prostate cancer is one of the most aggressive kinds, implying that it is relatively fast-spreading, though it could have gone undetected for years, specialists said.

“It’s possible that he could have had it growing in him for years, or it could be possible that this had a shorter time course,” said Dr. Phillip Koo, chief medical officer at the Prostate Cancer Foundation. “If someone were to get PSA screening annually after age 70, I’d imagine something like this would have been picked up earlier.”

Doctors have debated for decades how often to screen men for prostate cancer, and when to stop. The test can pick up cancers early while they are more treatable, but it can also flag false positives and pick up slow-growing cancers that would never have become life-threatening, particularly in older men, leading to overtreatment and corresponding harms.

“In the majority of cases, our guidelines really maximise their quality of life and reduce the harms associated with overdetection and aggressive screening,” said Dr. Behfar Ehdaie, a urologic surgeon at Memorial Sloan Kettering Cancer Center, which says on its website that PSA testing after age 75 is “rarely helpful.” Many men stop screening at age 75 because doctors think men with a low or normal PSA value at that age have a low risk of developing life-threatening prostate cancer, said Dr. Jonathan Shoag, a urologist who specialises in oncology at University Hospitals and Case Comprehensive Cancer Center.

But the number of later-stage, life-threatening diagnoses in the U.S. has increased in recent years, after medical groups started to advise less screening overall, Shoag and others said.

There is no public battery of medical tests required for all presidents and no standard release forms showing results. O’Connor said in February 2024 that Biden was “fit for duty” after a comprehensive assessment by a team of doctors.

“I would say it’s surprising he did not get this test, given the fact that the proclivity of presidential physicians is to test more rather than less,” said Dr. Ezekiel J. Emanuel, a physician and vice provost for global initiatives at the University of Pennsylvania, speaking Monday on MSNBC’s “Morning Joe.” “Either they didn’t test for it, or they did test for it, they didn’t report it, and we didn’t get the information as a public,” said Emanuel, a former White House health adviser.

Trump has at times failed to be transparent about his health. But he made a point of bragging about his prostate screening results when he was running for president. “My PSA has been very good,” Trump said in a September 2016 interview with Mehmet Oz, who is now his Centers for Medicare and Medicaid Services administrator. “It’s always the first number I ask for. I say, ‘Give me that number.’” Trump was 70 years old at the time and a candidate for president.

Dow Jones