Biden’s prostate cancer: Key takeaways

How common is prostate cancer?

Prostate cancer is the most common cancer among men. About 1 in 8 men are diagnosed with prostate cancer during their lifetime, so 300,000-plus patients per year are affected in the U.S. Another way to look at it, about 13 out of every 100 American men will get prostate cancer during their lifetime, and about 2 to 3 men will die from prostate cancer. Black men are more likely to get prostate cancer than the overall male population.

How do doctors usually screen for prostate cancer?

The most common way we screen for it is getting your prostate-specific antigen (PSA) checked. If you’re male, this is often included in the annual bloodwork you do with your primary care doctor or provider starting around age 55.

There are some subtleties to PSA tests — about age, when to check it, how to follow it — so have a conversation with your primary care doctor about how you should screen for prostate cancer. It’s not just a one-time test; we follow it over time. Often the screening does stop as you get up to certain ages.

A PSA, or symptoms, are the main way we find it.

What are the symptoms of prostate cancer that men should be concerned about?

Urinary troubles: increasing frequency at night, blood in urine, pain when urinating, difficulty with stream, slower flow or any other urinary changes, which are quite common as men age. Many things that can cause these are not prostate cancer, but it is one thing that can contribute.

Why are there “subtleties” about screening for prostate cancer, and why would screening stop at certain ages? Don’t we want to find every single cancer?

We want to find those cancers that are going to be aggressive — like what’s reported with former President Biden.

A lot of prostate cancers are what we would consider low-risk prostate cancers that are unlikely to cause problems for men. We want to be careful not to overdiagnosis those and overtreat those because the treatment — surgery and radiation — can come with side effects.

But unfortunately, there are aggressive high-risk prostate cancers out there that can cause all sorts of medical problems, and those are the kind we most want to screen for.

Former President Biden’s cancer was a “Gleason score 9.” What does that mean?

The Gleason score is a pathologist’s way of looking at the cancer biopsy and saying, “What kind of features does it have that might make it a more aggressive cancer?” The higher the score, the more aggressive it can be, with 10 being the highest. We use a Gleason score to say, “Is this prostate cancer one that we think is unlikely to cause any major problems and grow very slowly, or is it one that’s likely to grow quicker, and spread more and be more aggressive?”

What is the treatment protocol for someone facing this type of aggressive prostate cancer?

It's important to ask, “Has it started to spread?” Most men when it’s “Gleason score 9, but just in the prostate” would consider things like surgery or radiation, sometimes paired with some medical treatments such as hormone blockers.

What has been reported about former President Biden is that there has been some spread of his cancer, which puts him in a different category. Since it has spread outside of the prostate, it is considered a Stage 4 cancer. It’s important to note: Contrary to what many once thought, Stage 4 cancer does not necessarily mean a patient’s condition is dire.

What are the treatment goals for Stage 4 prostate cancer — a cure? Reducing symptoms? Give them some extra years to live?

Those kinds of decisions can get very patient-to-patient dependent, but for most men who do have Stage 4 prostate cancer, yes, it is an incurable cancer. But incurable does not mean it doesn’t respond to treatment. The goals become both quality and length of life.

There are patients who can live for years, in some cases decades, with control of their cancer through certain drugs and treatments, sometimes incorporating things like radiation to help them.

So, goals are to extend life — and in some cases, very long stretches of life — as well as some control of symptoms, because the cancer can cause pain or other symptoms as it spreads. And so you're trying to keep those symptoms at bay so men can live their lives.

When you diagnose patients at that stage, what are some of the things they’re considering as they wonder: Do I treat this? Do I not treat this?

There’s always some shock with a cancer diagnosis. Almost everybody has known someone or is aware of someone who has gone through a cancer journey. Whenever it happens to them, it takes a lot of processing and trying to figure out how to handle it.

As far as choosing to treat cancer at this particular stage, most men are pretty open to treatment because the treatment is fairly well tolerated.

There are a few men who decide ultimately that they've lived a long and fruitful life, and they’re just interested in comfort measures. That does happen, but it's not very common with this diagnosis.

What are the treatments available for a Stage 4 prostate cancer?

The first treatment is often hormone blockade, which can come with some side effects — things like fatigue and hot flashes, which most of the patients’ wives enjoy because they feel like their husbands will get to experience what they have been through.

There are some real side effects, but there are plenty of men on those types of medications who do exceedingly well, and you can see them go from suffering a great deal from the cancer that they didn't know they had to returning to activities they thought they couldn't do anymore.

There are other cancers where our treatments are much more difficult to handle. But I’ve had some individuals in their 80s and even 90s get started on these types of treatments and actually look better to their family three months after they've started the treatments than they did before, performing and functioning at excellent levels. So you can always be hopeful for that.

Any closing thoughts?

I don't want anyone thinking that it's not worth diagnosing because “There's nothing you can do about it” or anything like that. Actually, there's a lot you can do. So if you have any symptoms that are of concern, it is worth getting it checked out with a urologist — it’s better to know.

I focus on treating men with advanced prostate cancer. In the last 15 to 20 years, we have gotten six-plus new FDA-approved drugs that each work separately and independently of each other, as well as multiple other drugs that are similar and can be used sometimes in conjunction with different side effect profiles. All those drugs can now be used to help men with advanced prostate cancer live longer, function better and have less side effects.