Former President Biden’s aggressive prostate cancer diagnosis is raising questions about whether warning signs could have been caught earlier, and if the current screening recommendations should be changed.
Prostate cancer is one of the most common types of cancer in older men. One in every eight men will be diagnosed in his lifetime. According to the American Cancer Society, prostate cancer kills 35,000 a year, meaning a man dies from prostate cancer every 15 minutes.
Biden’s diagnosis is serious, and while treatable, it can’t be cured. Prostate cancer experts said it’s unclear how long Biden has had cancer. Even if he was screened regularly in recent years, they said it’s not uncommon for cancer to develop without notable symptoms.
“Cancer doesn’t necessarily follow a rule book. It’s possible that this came out of the blue, because cancer can do that,” said Alicia Morgans, a prostate cancer specialist at the Dana-Farber Cancer Institute, and board member of the advocacy group ZERO Prostate Cancer.
Doctors diagnosed Biden with a prostate nodule last week after he experienced increasing urinary symptoms. By Friday, he was diagnosed with cancer that had metastasized to his bones. It’s not clear if the symptoms were due to cancer, or if the nodule was found as part of a routine screening.
Morgans said even if Biden had been getting regular screening, it is an imperfect science.
“Sometimes our tests are imperfect. And even if we’re doing perfect blood tests and perfect imaging and perfect everything, we don’t find things,” she said.
Biden left office as the oldest serving president in history, consistently dogged by concerns over his physical health and mental acuity. Prior to the diagnosis last week, his most recent medical update came in February 2024, when he was declared “fit to serve” after a routine physical at Walter Reed National Military Medical Center.
The public summary of his visit listed several tests doctors performed, but not a prostate-specific antigen (PSA) test. That’s not surprising, said Geoffrey Sonn, an associate professor of urology at Stanford University School of Medicine.
“Really, there’s not many people out there that will advocate for continuing aggressive PSA screening for men in their 80s,” he said. “In retrospect, I think that it’s likely that if he had continued screening against pretty much all guidelines, that they probably would have found this earlier.”
Current cancer screening guidelines are complicated, and Biden’s case echoes a tension; it’s best if the cancer is caught early, but there needs to be a balance between early detection and overtreatment.
The American Cancer Society does not recommend routine testing for men at any age. Instead, it recommends men have a conversation with their health provider about the benefits, risks and uncertainties of screening starting at age 40 for those at highest risk, and age 50 for men at average risk.
The U.S. Preventive Services Task Force, an independent panel of experts that makes recommendations on services like screenings, suggests men ages 55 to 69 make an “individual” decision after first discussing it with their provider.
The “shared decisionmaking” recommendation generally stops at age 70 and older, because prostate cancer is slow-growing and physicians don’t see a clinical benefit in doing a screening for people with only 10 to 15 years of life expectancy.
“One of the reasons that you don’t want to screen older men is they’re so likely to have prostate cancer, even though it’s that benign-ish prostate cancer that’s never going to kill them,” said Otis Brawley, a medical oncologist at Johns Hopkins University who treats patients with metastatic prostate cancer.
“I’ve seen an awful lot of guys have a lot of mental torment and a lot of physical torment because they were diagnosed with a prostate cancer that all the doctors knew was a cancer that was never going to bother them if It was left alone,” Brawley said.
President Trump had his PSA levels tested in April, according to the White House. They were normal. Speaking to reporters at the White House on Monday afternoon, Trump questioned whether Biden was tested, and why the cancer wasn’t caught sooner.
Behfar Ehdaie, a urological surgeon at Memorial Sloan Kettering Cancer Center in New York, said while it’s difficult to provide an accurate assessment of Biden’s prognosis, men typically are not screened for prostate cancer after the age of 70, unless they show symptoms.
In Biden’s case, for example, frequent urination prompted a screening.
And while Ehdaie was cautious about discussing Biden’s case specifically, more generally, he said “in many cases, this type of cancer is treatable” even in someone in their 80s, such as the former president, who is 82.
Still Ehdaie added, “the goal is to discover it and detect it early.”
A spokesperson for Biden did not respond to questions about when he was last screened for the cancer.
Politically, the timing of the announcement from Biden’s team raised some eyebrows among Democrats and Republicans.
Democrats have blamed their record-low polling numbers in part on a perception that Biden and his team covered up the former president’s age-related health decline.
A new book on Biden’s decline by CNN’s Jake Tapper and Axios’s Alex Thompson, set for release on Tuesday, is sure to exacerbate the Democratic blame game.
However, even Democrats who had blamed Biden for causing Trump’s victory in November called for a more respectful and muted response.
“Joe Biden has given so much to this country, it’s time for us to give him some time and space to focus on his health,” Democratic strategist Jamal Simmons told The Hill. “This isn’t a time for politics.”
But they were skeptical that Biden’s diagnosis would ultimately change the narrative.
“It is politics, I expect them to use anything they think will keep the base happy and give them an advantage,” one longtime Biden ally said. “I’ve never known that side to think there was much of a line.”
Since the revelation of Biden’s cancer diagnosis on Sunday, Trump and his aides have tried to thread a needle on the delicate issue.
In a statement on Sunday, Trump said that he and first lady Melania Trump were “saddened” to hear about Biden’s diagnosis. “We wish Joe a fast and successful recovery.”
However, in his remarks to reporters Monday, President Trump drew a link between the cancer diagnosis and reports of Biden’s circle hiding his decline. And he asked why it wasn’t caught sooner.
Earlier in the day, Vice President Vance questioned Biden’s overall health during his time as president.
“We can pray for good health but also recognize that if you’re not in good enough health to do the job, you shouldn’t be doing the job.”
Doctors not involved in Biden’s care said they did not see any signs of a missed diagnosis.
“Nothing about his story sounds to me as if there’s been a cover-up or a delay, or anything that is untoward,” said Morgans.
“It really sounds like an unfortunate case of prostate cancer diagnosed just a hair too late to cure in a man who also happened to be the President of the United States very recently, and now has a very real-world problem that he and his family have to tackle.”
