Ok so I can't be the only one wondering this, and I'm sure we're never going to get all the information, but why the heck was former President Biden not getting screening PSAs??!! I have so many questions.
screening PSAs
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I'm not sure my first assumption would be that Biden wasn't getting PSAs. He's been a senator, vice president, and president for decades. He's gone through the era of PSA screening, the backlash against PSA screening, and the backlash against the backlash while serving at the highest levels of government. I think there's approximately 0% chance that Biden hasn't gotten a PSA in the past 10-15 years.
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The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older [Recommendation: Prostate Cancer: Screening | United States Preventive Services Taskforce]
Case closed. End thread.
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Pretty good chance you can have a “normal” PSA with a Gleason 9. Although the news did say it was hormone sensitive. And also a pretty good chance you can have a normal PSA a year ago with Gleason 9 (fast growing etc).
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Wouldn't this just be included as part of labs, warranted or not, given that he's president? This was likely found a while ago.
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I'm not sure we'll ever know for sure.
I've never been the PCP to a POTUS, so maybe normal screening doesn't apply...
But if I'm 80 and have neurocognitive issues *ducks head*, I don't want screened either.
It's just impossible to speculate what all has gone on. We just don't have enough info and never will. In my Overton Window I think it is possible they knew he had cancer but it is also possible his PSA was "high normal" say a year ago then bumped pretty high over 12 months. I've seen patients like this.
I've never been the PCP to a POTUS, so maybe normal screening doesn't apply...
But if I'm 80 and have neurocognitive issues *ducks head*, I don't want screened either.
It's just impossible to speculate what all has gone on. We just don't have enough info and never will. In my Overton Window I think it is possible they knew he had cancer but it is also possible his PSA was "high normal" say a year ago then bumped pretty high over 12 months. I've seen patients like this.
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All that bike riding and wrecking he did had to make psa interpretation tough.
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Not sure if it tells you much, but an article I read said Bush, Obama, and Trump routinely reported PSA's as part of their publicized check ups. I don't believe Biden ever reported a PSA.
So either wasn't checked or they chose not release the values.
This is the dirt I was looking for!
And I know this is wild speculation, but I mean curiosity is part of how we got on the path to be a doctor, so whatevs.
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Interesting. Maybe diagnosed and treated prior to office, and then recurred during presidency in a bone. Maybe the covid vaccine did this...hopefully it's still sensitive to ivermectin. maybe we'll see a bump in LR prostate referrals.
alwaysbeIMRTing
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ASTRO also recommended against using IMRT and the necessary image guidance for breast cancer gaslighting an entire generation of rad oncs that it was "unwise" to use advanced technology. Yeah, and advanced auto tech can sometimes directly contribute to traffic fatalities. I remember riding on the front bench in my grandparent's Buick without a seatbelt as a child. Worked great.
If you take health-guideline and pharmaceutical propaganda biased with obvious financial motives with good faith at this point and believe these task forces and committees are really just benevolent regulatory referees looking out for you, then you kind of deserve the consequences.
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LOL, he's running for the President of the f*cking country. I think some due diligence was in order.
But, to be fair, it seems like Presidential PCPs are more performative than clinical in our era.
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May also be true.
Though they're calling it "hormone sensitive" in some of the reports which suggests... how would they know it's hormone sensitive this quickly except the PSA went up then down after starting therapy?
Who knows.
As GFunk mentions, PCP's are performative it seems for these Presidents...and a lot of trust (for both candidates) has been lost over fabrications and cover ups of a number of issues, including denying health issues/cognitive decline....so everyone is skeptical.
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I've seen a lot of cognitive decline with ADT plus abi. Just sayin...
Yup, this is the conspiracy theory I'm thinking of as well. No release of prior PSAs, worsening neurocognitive issues in the past few years, ADT side effects...
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Maybe God really does want DT to be prez. In other new, after hearing it remains hormone sensitive, DJT called JB a "very low PSA individual."
The other thing about this recommendation is like I'm pretty sure at least half of new prostate cancer diagnoses are in men over the age of 70 so....yeah....
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One simple question that I doubt will ever be answered.
When was the diagnosis of prostate cancer first made?
Added context-I have been involved with three negligence cases where delay in diagnosis was the primary claim.
When was the diagnosis of prostate cancer first made?
Added context-I have been involved with three negligence cases where delay in diagnosis was the primary claim.
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Can’t wait to see this forum when it is announced he is getting experimental cutting edge whole body proton therapy
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A few possibilities
1. It truly is an extremely fast mover. I had a patient go from PSA 1 and normal DRE to PSA 90 with urinary retention in 1 year. GG5 in every core and metastatic disease. Rare but it happens.
2. He had a PCP who was a strict guideline follower. USPSTF says no PSA over age 70. BS in my opinion as a psa is just a data point and is not harmful in and of itself, it's what you do with that information that can cause harm. very reasonable to watch a PSA of 5 in an 80 year old, but it's still helpful to see if it goes from 5 to 15 to 30 over a year.
3. He has known about this for a while and has been on ADT/abi and is now allowing the news to come out. As others have said could explain some of the cognitive changes, though could just be getting old.
1. It truly is an extremely fast mover. I had a patient go from PSA 1 and normal DRE to PSA 90 with urinary retention in 1 year. GG5 in every core and metastatic disease. Rare but it happens.
2. He had a PCP who was a strict guideline follower. USPSTF says no PSA over age 70. BS in my opinion as a psa is just a data point and is not harmful in and of itself, it's what you do with that information that can cause harm. very reasonable to watch a PSA of 5 in an 80 year old, but it's still helpful to see if it goes from 5 to 15 to 30 over a year.
3. He has known about this for a while and has been on ADT/abi and is now allowing the news to come out. As others have said could explain some of the cognitive changes, though could just be getting old.
His office put out a press release today that said he hasn’t had a psa done since 2014. The White House physical report on Biden in 2024 is available online via the Wayback Machine and no mention of PSA testing is made. If these statements are true I would tend to think #2 is the most likely, although it really is surprising for any VIP type patient to not have the full battery of cancer screening regardless of age. I guess another possibility is that he was offered screening and declined.
Amazing that your common sense take on “it’s what you do with the [psa screening] information that can cause harm” is the one with the least traction in all the online discussion I’ve seen on this, most of which is just circling the wagons on the idea that old men shouldn’t be screened.
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News outlets saying Biden/team declined PSA since the chance of having a slightly elevated PSA was high and that would be negative publicity-- so they made a publicity/political decision, not a medical decision here. I find this believable- that he was told there's a small risk of missing a prostate cancer ("which can be easily treated later if we find it") to avoid the politics of having a possible cancer diagnosis all over the news in an election cycle. I would have bet he had a PSA more recent than 2014 (despite press release) but it is plausible that he hasn't in the last 3-4 years since he was planning re-election.
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“it’s what you do with the result that matter” is easy to say when you’re talking theoretically and don’t actually work in this part of medicine. The issue is finding cancers that never would have killed the patient. There’s quite good evidence that screening in this age group doesn’t affect mortality.
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There are methodological issues with the trials that were conducted. Adherence to tests, "contamination" of the control group with PSA screenings outside of the trial, overestimation of the potential benefit.
We have all seen patients that came in the hospital with a PSA >1000 ng/ml and many of us likely wondered, why it was not picked up earlier. Patients who had been treated for months for "back pain", when it was full blown out M1 PCA.
One could suggest that outcomes of these patients (perhaps not only mortality counts, but maybe QoL as well or burden of necessary treatment if picked up later?) would have been better if that cancer was diagnosed at a PSA level of 15, 30, 60 or even 120 ng/ml?
On the other hand, I fully understand the burden PSA screening will put on these individuals.
My mother is 84 now, and was shocked to find out a few years ago, that mammography screening is no longer recommended.
She went for screening anually over decades, never had a finding. She declined to not hane any more screening and still goes yearly, pays for it out of the pocket.
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Here is the meat of it. Population vs individual. Could Biden have otherwise lived to his mid 90s? Maybe (though based on public appearances maybe not). Chances now are much lower. Maybe he and Jill still like to get freaky deaky on the reg (as do many older men) and ADT is taking that away. No question that thousands of older men will suffer consequences of not screening.
I personally don’t agree with a set age limit but do agree indefinitely screening for all also causes harm as well. To me, the real question is will the patient live long enough to suffer any consequences of progression and would they care? The reality is that the worst case for most men is not dying from PCa but getting put on ADT. If they don’t care, screening probably would cause more issues than help. But if they are like my grandpa was at 80, still fully independent at home with his wife with literally no comirbidities, one could argue screening is appropriate. FYI, he died a at 96. And she made it to 93. Both living at home until the very end. Missing a bad actor in his early 80s absolutely would have negatively affected him.
And that’s understandable because that’s the group of patients that you are exposed to through your specialty and therefore where your focus is going to be.
I could equally hit you with the anecdote, as an intensivist, of the patient who developed renal failure from septic shock from the TRUS biopsy which ultimately turned out to be negative, which was ordered because of a high PSA.
I don’t mean to come in and hijack this thread as an outsider, but I think it’s an interesting discussion. I think it’s easy to get stuck viewing things just from the lens of your own specialty (I certainly do that too).
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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.
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All fair points. And certainly, I do not want to see people getting biopsies when they 85 years of age, because of an elevated PSA.
But perhaps, just perhaps, looking for PSA every couple of years after the age of normal screening, will suffice?
I don't want to overdiagnose PCA, but I would like to avoid any disasters from happening.
On the other hand, nowadays, we have MRI. We are no longer supposed to be doing blind biopsies. MRI is quite good at telling us if there's "bad" cancer in the prostate or not. This should dramatically decrease the number of biopsies we are doing, showing harmless cancer.
I mean, look at what the haematologists are doing with MGUS.
One percent of all people with MGUS develop myeloma per year. So after 10 years, it's 10%.
Still, haematologists recommend following up MGUS, regardless of age.
Do you think, it's wise to follow up MGUS in a patient who is 75 years old? What will you "miss" if you don't diagnose that patient the instant that MGUS turns into myeloma and not when he/she develops symptomatic myeloma? The haematologists are likely doing that to prevent "disasters" from happening. And with a quite rigorous follow-up (electrophoresis and even some BM-biopsies).
And what's the evidence for that? Likely, not a lot...
But perhaps, just perhaps, looking for PSA every couple of years after the age of normal screening, will suffice?
I don't want to overdiagnose PCA, but I would like to avoid any disasters from happening.
On the other hand, nowadays, we have MRI. We are no longer supposed to be doing blind biopsies. MRI is quite good at telling us if there's "bad" cancer in the prostate or not. This should dramatically decrease the number of biopsies we are doing, showing harmless cancer.
I mean, look at what the haematologists are doing with MGUS.
One percent of all people with MGUS develop myeloma per year. So after 10 years, it's 10%.
Still, haematologists recommend following up MGUS, regardless of age.
Do you think, it's wise to follow up MGUS in a patient who is 75 years old? What will you "miss" if you don't diagnose that patient the instant that MGUS turns into myeloma and not when he/she develops symptomatic myeloma? The haematologists are likely doing that to prevent "disasters" from happening. And with a quite rigorous follow-up (electrophoresis and even some BM-biopsies).
And what's the evidence for that? Likely, not a lot...
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WRT biopsy timing/necessity, as we all know, it's not necessarily step 2 with elevated PSA, it just happens that way in the community
A sitting US prez, however old, should probably think about getting a PSA and mpMRI if there's a concern. Could then just not biopsy if not PI-Rads 4/5.
A sitting US prez, however old, should probably think about getting a PSA and mpMRI if there's a concern. Could then just not biopsy if not PI-Rads 4/5.
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Wish this was true (maybe it is)?
Agree that the biopsies are better, but I'm not seeing benign appearing MRIs discouraging biopsies for men with elevated PSA (finding low grade Ca in this circumstance is common).
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I discouraged a biopsy in my father-in-law who had a PSA of like 4.5, but fractionated PSA concerning for hi grade disease. MRI showed nothing, but urology wanted to biopsy. He's dead now from prostate cancer. jk. continues living sans biopsy. For the most part, MRI is just done to inform biopsy it seems, not discourage biopsy.
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From a CBS article:
"Back in 2019, Biden was diagnosed with benign enlargement of the prostate, or BPH. That December, his campaign released his medical evaluation, which noted: "This patient has been treated for Benign Prostatic Hyperplasia (BPH). This was initially treated with medication and was then definitively treated with surgery. He has never had prostate cancer."
I am fine with not screening for a normal 70 year old male. But how many dudes undergo treatment, medical vs. ?TURP? for BPH and don't have a PSA checked?
www.cbsnews.com
"Back in 2019, Biden was diagnosed with benign enlargement of the prostate, or BPH. That December, his campaign released his medical evaluation, which noted: "This patient has been treated for Benign Prostatic Hyperplasia (BPH). This was initially treated with medication and was then definitively treated with surgery. He has never had prostate cancer."
I am fine with not screening for a normal 70 year old male. But how many dudes undergo treatment, medical vs. ?TURP? for BPH and don't have a PSA checked?
Biden's prostate cancer diagnosis raises questions about screening and how the disease spreads
Former President Joe Biden has been diagnosed with an advanced stage of prostate cancer that has metastasized, or spread, to his bones.
www.cbsnews.com
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I do think there is a general shift away from doing low cost, persistent f/u, which will prevent rare disasters but takes some clinical time. (I would say this is the entire paradigm behind most of peds, where the vast majority of pts derive no benefit from their doctor visits but rare conditions are detected and disasters averted).
I have no problem with a judicious PCP adding a PSA to annual labs until a patient can no longer independently get around or suffers major cognitive decline (this could include folks into their early 90s and rarely later).
However, do you want to be following these patients? I have a few patients that anxious urologists don't want to follow because they have biochemical failures (but are old with very low PSA kinetics and I don't think they need treatment). Still, they are a tiny fraction of my practice.
Urology definitely can't have these guys on their docket too much. It would be overwhelming.
...and it is one more data point (out a a gagillion) that the PCP has to look at.
None of this applies to the Biden situation however.
From a CBS article:
"Back in 2019, Biden was diagnosed with benign enlargement of the prostate, or BPH. That December, his campaign released his medical evaluation, which noted: "This patient has been treated for Benign Prostatic Hyperplasia (BPH). This was initially treated with medication and was then definitively treated with surgery. He has never had prostate cancer."
I am fine with not screening for a normal 70 year old male. But how many dudes undergo treatment, medical vs. ?TURP? for BPH and don't have a PSA checked?
Biden's prostate cancer diagnosis raises questions about screening and how the disease spreads
Former President Joe Biden has been diagnosed with an advanced stage of prostate cancer that has metastasized, or spread, to his bones.
There is zero chance (0%, empty set, null) that this is a new prostate cancer diagnosis. Any oncologist suggesting it is has political motivations for doing so.
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Hitting on the key point again my friend! It doesn't have to be a full court press. We are only trying to catch the bad players. Mildly elevated PSA without a high velocity can probably just be watched. Not everyone with an "elevated" PSA needs biopsy or a definitive diagnosis. Would this still miss the rare super aggressive tumors? Sure. But there is no perfect solution and something like this will probably strike a better balance. You will notice, it can avoid telling someone they actually have cancer and the anxiety that goes with it (even though we will know they probably do) while still monitoring until it looks like there is actually a problem.
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Just wrong.
Not sure why you would post this. Reasonable possibilities addressed above in @DoctwoB post. The easiest way to be wrong is to assert things like 0% or 100% chance.
There is a zero chance that Trump has 7% body fat...and there is a political motivation for me pointing this out.
alwaysbeIMRTing
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The obvious textbook case of Parkinson's disease that no one talks about is a much bigger deal in terms of the fitness-for-duty scandal, I agree.
Still, anyone who has been through the absurdities of an aviation medical exam, even to ensure you are safe to fly a plane without passengers, will immediately appreciate how nonsensical the idea is that the president was not regularly checked for the most common form of cancer in men. Additionally, the behavioral analysis a normal person must go through for a DoD top secret clearance.
It would be way better to just to come out and say that he prefers to keep his medical record private now that he is no longer a sitting president instead of trying to release all these details that really just don't make much sense.
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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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Not nonsensical at all. The vast majority of pCa is indolent. I know physicians over 70 who are not getting screened. Most board certified family docs do not screen for pCa.
Now, this is not to say that we should trust the Biden media team. Obviously not, and IMO there was a breach of trust regarding disclosure of his fitness while in office.
But all of this is conspiratorial thinking and more than that misses the biggest lesson.
Which is....old people get sick, die often (and often without much warning) and decline rapidly without this necessarily being anticipated.
There is a reason that there is an age limit on commercial aviation. I will try my damndest to remain cognizant of my age, my limitations and my responsibility to "step back" as I get older. I believe this is a cultural failure on our part.
Three congressman have died this term alone from natural causes. Some with major leadership responsibilities.
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Which is bad, because the trials showed that you could ommit biopsy if MRI looks good.
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@DoctwoB
Just curious. Have you ever done a TURP or Urolift on a guy and not had a PSA within say 24 months of that procedure?
I'm biased because all my prostate patients are cancer patients (the same way all my "started with a sore throat" patients have oropharynx cancer, not strep throat), so I don't know how often you'd just do that procedure without knowing PSA trends. Maybe it's not too big of deal.
Just curious. Have you ever done a TURP or Urolift on a guy and not had a PSA within say 24 months of that procedure?
I'm biased because all my prostate patients are cancer patients (the same way all my "started with a sore throat" patients have oropharynx cancer, not strep throat), so I don't know how often you'd just do that procedure without knowing PSA trends. Maybe it's not too big of deal.
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If i have it was a screw up on my part. Ideally i want it within a year. it can be annoying, since patients who come in with acute retention and/or infection will get falsely elevated psas, which then you have to wait a few weeks to repeat it and ensure it's normalized (or evaluated). Even in the elderly, it's no longer prostate cancer screening at that point, it is workup of the cause of their symptoms which may direct their treatment.
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Biden’s drop in performance status last year is consistent with metastatic cancer.
He should perk up now on ADT
He should perk up now on ADT
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Alright, I’ll be the shameless person who asks.
Should I buy more Novartis stock???
Should I buy more Novartis stock???
