Former President Joe Biden’s diagnosis with aggressive, metastatic prostate cancer has set off a wave of questions: Did he have cancer while in office? How was this missed? And, why had Biden not had a standard prostate screening test since 2014?
Since word of Biden’s diagnosis came Sunday, news reports have focused on the prostate specific antigen (PSA) test, which measures the level of this protein in the blood, and the fact that Biden had not had this test since 2014. There is alarm that Biden’s cancer was not found until it had spread to his bones. But there’s also reality: the PSA test has limitations, and guidelines do not recommend it for a man of 82.
Former President Joe Biden | Image credit: The White House
Biden reached that age November 20, 2024, making him the oldest sitting president. Questions about Biden’s age and health had played a role in his decision to drop his re-election bid, and now Republicans from the House Oversight Committee have renewed efforts to force Biden’s close aides and physician to testify about his health.
QUESTION 1: Did Biden Have Cancer While He Was President?
Ezekiel Emanuel, MD, PhD, an oncologist and ethics expert from the University of Pennsylvania, set off a firestorm early Monday when he told viewers of MSNBC’s “Morning Joe,” that Biden undoubtedly had cancer “for years,” and “probably” had it as he took the oath as president. Cancers like Biden’s do not erupt overnight, said Emanuel, who served in the Obama administraton while Biden wasa vice president.
“He did not develop it in the last 100, 200 days,” Emanuel said. “He had it while he was president. He probably had it at the start of his presidency in 2021. Yes, I don’t think there’s any disagreement about that.”
A spokesperson for Biden told news outlets that the former president was diagnosed May 16, and that prior to that had not been diagnosed with prostate cancer.
QUESTION 2: How was this missed?
Emanuel and MSNBC host Joe Scarborough had an animated discussion about Biden’s lack of either a PSA test or a digital rectal exam. Scarborough made the case that unlike an typical man in his 80s, Biden was president of the United States. In February 2024, he had his final presidential physical, the last medical information voters would likely see before he stood for re-election.
The New York Times reported that Biden spokespeople deflected questions of why he was not screened more rigorously. It was also noted that a 2019 medical report showed he had benign prostatic hyperphasia, or BPH, a condition in which the prostate is enlarged.
Emanuel’s comments highlight the conundrum of following guidelines that are written for the general population when treating the president of the United States. Although Emanuel said he was not particular fan of the PSA test, when one is dealing with the leader of the country, more testing is preferred.
“We have to have confidence that their health condition is not intervening,” Emanuel told The Times later in the week. “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.”
However, Toni Choueiri, MD, director of the Lank Center for Genitourinary Oncology at Dana-Farber Cancer Institute, took a different view during an interview on MSNBC. Such matters are handled on a case by case basis. “Even if you are the president, the president is a human being [and] you want also to care about their health.”
QUESTION 3: Why Didn’t Biden Take a PSA Test?
Until the public hears from Biden or his physician, it’s impossible to say why the former president stopped PSA screening. However, Choueiri offered some possibilities.
“Unlike a mammogram for breast cancer in women and colonoscopy for colorectal cancer, the PSA for prostate cancer is perhaps one of the most imperfect tests,” Choueiri explained. He noted that the US Preventive Services Task Force (USPSTF) currently grades the test as a “C,” meaning the decision on testing is made jointly with a patient and his physician. Once a man turns 70, USPSTF gives the test a “D” rating—meaning it is not recommended. However, other experts say PSA testing can continue if a man is healthy and has a life expectancy of 10 years.
Choueiri said the presence of BPH could factor into decision-making because this might distort the PSA results. “The PSA could be higher than expected [while] still being benign and not related to prostate cancer,” he said.
He emphasized that with a Gleason score of 9 out 10, this cancer could be progressing very quickly. Biden’s office stated that the cancer is hormone responsive, meaning new therapies that block testosterone offer options.
Celine Gounder, MD, a medical expert for CBS News, noted Biden’s cancer was discovered after he had urinary symptoms. She emphasized the need for personalized approaches when deciding whether to test for prostate cancer.
“Doctors will stop screening for prostate cancer at 75 or so, because after that, the prostate cancers you typically pick up are very slow growing, and so the harms of all of the testing and treatment for something that may not kill you — you’re talking about risk versus benefit. It may not be worth the risk,” Gounder said.
The usefulness of the PSA test has been debated for more than a decade. In 2013, USPSTF gave all PSA testing a D rating, due to the potential for overtreatment and potential harm. The recommendation was updated after screening plummeted. But confusion lingers.
Andrew Vickers, PhD, of Memorial Sloan Kettering Cancer Center, said in an interview for the cancer center that while PSA myths are often overblown, the truth is that prostate cancer is simply very common in older men.
“Almost all men will get prostate cancer if they live long enough,” he said in an April 2024 interview. “So we aren’t at all interested in prostate cancer as an end point. What we want to know is whether PSA can predict who gets the sort of prostate cancer that can cause symptoms and threaten a patient’s life. It turns out that PSA is very good at doing that.”
