Exactly.
It also remains difficult for us to process this properly. Also, we wildly overtreat pCa....as we do almost all other medical conditions.
Screening will always save some lives...at the cost of cost, including toxicity of diagnosis and treatment. Screening in 90 year olds will save the occasional life (for a little bit).
But in populations, it comes out in the wash. In retrospect, I'm sure Biden's family thinking that he should have continued to get PSAs. However, even in his case, it is unclear what the impact of not screening and his diagnosis (including stage and GG) will have on his overall life expectancy. It is very possible (as said above) that this is a cancer that would have emerged aggressively between screenings. This is not that unusual.
It is very possible to get 4+ years out of this situation (although there are rare neuroendocrine type pCa that just crush a patient in a short interval). He is 82 (and frail...conjecture that his frailty is related to a hidden pCa diagnosis is just that and unlikely to be true). His life expectancy without pCa might have been 6 years.
What is indisputable is that he, the current president and many members of congress carry significant daily risks due to age alone.
It is true that current data does not show a mortality benefit in screening above age 70. Unclear if this is because there is no benefit or due to reduced benefit combined with trial issues (over half the patients in the control arm get psa screening, many positive screens not getting biopsies, etc)
The thing about PSA testing, is that it is not a binary, it is a spectrum. Higher numbers portend a higher risk of cancer, and a higher risk of more aggressive cancer.
That means it doesn't have to be a one size fits all approach. If you're 51 years old and have a psa of 3.1 (US guidelines say above 4, interestingly European guidelines use 3 as a cutoff) with me, you're getting an MRI and possibly a biopsy.
If you're 76 and you have a psa of 5 that's gradually risen from 3 over the last 10 years, i;m going to keep watching you. If you're a "good" 82 and your PSA has gone from 1 to 5 to 15 over the last year, you're getting an MRI and likely a biopsy.
Now biopsy is not benign, 1% infection risk, ~.2-.3% sepsis risk in modern TRUS prophylaxis protocols, even lower if done transperineal but potential of more resource utilization as those are often done in ASC.
More importantly, there are benefits to detection that won't translate to mortality. One of the reasons it's hard to show mortality benefit to psa screening, is the average metastatic prostate cancer patient will live for 7 years. That means most patients in their 80s when diagnosed will not die of prostate cancer, even with metastatic disease. that said, metastatic prostate cancer has a very high burden on QOL, including negative effects of ADT, bone pain/fractures, urinary issues, etc.
The data is also tough to parce, as it depends a lot on mortality attribution. If you're on ADT for years you are at significantly higher cardiovascular disease. If you die of a heart attack, was it due to your prostate cancer that you let progress to metastatic disease? Maybe.
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