Why Biden may not have known about his ‘aggressive’ prostate cancer until recently

Former President Joe Biden’s office announced on Sunday that he was diagnosed with an “aggressive” form of prostate cancer.

Biden’s office also said the cancer had metastasized, spreading to his bones.

Although some people were left wondering why the cancer was caught only after reaching a Gleason score of 9, oncology experts told ABC News that it’s not uncommon for older prostate cancer patients to receive a diagnosis after the disease has advanced or spread.

“Prostate cancer is something that we always hope screening will identify early, when the cancer is all still inside the prostate,” Dr. Alicia Morgans, a genitourinary medical oncologist at Dana-Farber Cancer Institute in Boston and a member of the board of directors of the no-profit Zero Prostate Cancer, told ABC News.

“Even if we screen everybody perfectly, there will never be 100% detection of prostate cancer because, in truth, cancer does not follow a rule book,” Morgans continued. “And just because we are trying to catch it early doesn’t mean it necessarily is present when we screen.”

PSA levels may not have been checked

One screening test for prostate cancer involves a blood test that measures the level of prostate-specific antigens, which are proteins made by cells in the prostate gland.

Although there is no cutoff level that clearly indicates the presence of cancer, many doctors use a cutoff of 4 nanograms per milliliter to recommend further tests with a urologist, according to the American Cancer Society.

For an advanced form of cancer like Biden’s, a recent PSA test would have likely shown elevated levels.

However, the U.S. Preventive Services Task Force recommends against PSA-based screening for men age 70 and older due to harms such as false positives leading to more tests or a diagnosis of problems that would not have caused symptoms or death.

Morgans said it’s unclear what the former president and his doctor discussed regarding screening, but it’s plausible that he did not undergo PSA screening.

“It is absolutely possible that President Biden, like so many men over that age, have decided to stop doing PSA screening because they’ve decided that it is not consistent with their overall health goals and wishes, and that is completely reasonable,” Morgans said.

Cancer could have grown rapidly

Morgans said some men in their 70s and 80s do still undergo PSA screening for prostate cancer based on conversations with their primary care physicians and what’s right for them.

Even so, it’s possible that the results were normal — either due to a false negative or because their cancer was not present at the time, she said.

“Prostate cancer can develop between screening tests,” Morgans said. “It doesn’t necessarily grow super slowly. It can develop between screenings, and it can be aggressive when it does develop; that doesn’t mean it’s not treatable.”

Screening results could have been borderline

Dr. Alan Bryce, chief clinical officer for City of Hope Cancer Center Phoenix, said there may be some patients who receive PSA screening results showing borderline-high results who decide not to pursue further testing.

“There are absolutely scenarios where that conversation happens with a patient or their family member,” Bryce told ABC News. “All of them might say, ‘You know what? Given where we’re at in life, we’re not that worried about this. Let’s go ahead and wait another year.'”

Bryce, a medical oncologist specializing in prostate and testicular cancers, added that shared decision-making is important when it comes to deciding if a patient wants to pursue prostate cancer screening — and if they want to test further following test results that are abnormal.

“As physicians, we present patients with options and recommendations but, at the end of the day, it’s still the patient’s decision,” he said. “So, it’s entirely possible that a conversation happens and the patient decides they don’t want to proceed with further workup. Maybe they don’t want to do a scan, maybe they don’t want to do a biopsy.”

No symptoms present

Advanced prostate cancer can present symptoms such as a weak urination stream; needing to urinate more often; erectile dysfunction; fatigue; weight loss; loss of bladder or bowel control; and pain in the ribs, hips and spine when the cancer had spread to the bones, according to the ACS.

Morgans said just because a patient has advanced prostate cancer, it doesn’t necessarily mean that they will exhibit symptoms.

“I would say that it’s more common than not that people sit in my office and tell me, ‘You know, I don’t have any symptoms. I don’t understand how I have this cancer. I certainly don’t understand how it could have spread outside of my prostate,'” Morgans said. “It is very common for people to be completely asymptomatic.”

Bryce added that some symptoms, such as difficulty urinating or a weak urination stream, may be due to an enlarged prostate, which is common in older men.

“It is entirely normal that in older men, there is a degree of urinary obstruction that just happens with age,” he said. “It’s entirely possible that a man just has normal symptoms associated with aging and nothing about it stands out as being related to a cancerous process.”