One of the surprises for men turning 70 is that the annual physical exam no longer includes rectal examination of the prostate. Similarly, American medicine has abandoned routine prostate-specific antigen (PSA) testing for men over 70. The U.S. Preventive Services Task Force concluded that PSA testing is an unreliable screening tool, producing false positives and false negatives that led to overdiagnosis, unnecessary MRIs, and biopsies whose risks outweighed their benefits. At present, no diagnostic test reliably predicts which prostate cancers are life-threatening at a stage when cure is possible. That is why President Biden’s last PSA test was in 2014.
The consequence is tragic. On May 18, 2025, the New York Times reported that President Biden now suffers from stage IV prostate cancer with painful malignant bone metastases. Undetected for years, his disease progressed silently. Unlike mechanical back pain, which may ease with rest, bone cancer pain never subsides. It often intensifies at night, producing stabbing jolts that radiate down the legs and groin. Painkillers may not be effective. Muscle weakness, unstable walking, bladder or bowel incontinence, and profound fatigue can follow, amplifying suffering. Median survival with skeletal metastases is two to four years, usually with terrible pain. Some patients survive longer, but many do not.
Ordinarily, prostate cancer first manifests in the prostate gland before spreading to lymph nodes or bone. If detected early, it can be treated and often cured. In President Biden’s case, PSA levels were not monitored as he passed silently through stages I, II, and III before stage IV cancer was finally recognized.
- Stage I: cancer confined to one organ, readily treatable with excellent outcomes.
- Stage II: cancer extends to adjacent tissue and may involve lymph nodes.
- Stage III: regional spread to lymph nodes but not distant organs.
- Stage IV: spread to distant organs, commonly bone, liver, or lungs; treatment is palliative, not curative.
The tragedy is that Biden’s cancer could have been identified and controlled years earlier.
PSA Testing: Modest Cost, Significant Value
PSA testing is inexpensive. LabCorp charges $69; Quest Diagnostics $28–59. Medicare Part B policies pay labs about $18 for a PSA test, with no cost to the patient.
Traditionally, a PSA of 4.0 triggered biopsy referrals, but this often led to overtreatment of benign, slow-growing cancers that are rarely lethal. Only 3 in 1,000 progress. In 2016, leading prostate specialists suggested a lower threshold of 2.5–3.0. More importantly, an acceleration of 1.5 points should prompt an MRI, which helps distinguish lesions worth investigating from those that can be safely monitored. Medicare pays $320–495 for prostate MRIs, again with no patient cost.
For men over 70, especially with a family history of prostate cancer, annual PSA tests remain prudent. Like breast cancer, prostate cancer can be hereditary, and genetic testing can identify risk markers. In these men, ignoring PSA scores is risky.
A Preventable Oversight
Every man over 70 who wants to avoid Biden’s fate should tell his physician to include PSA in the annual blood panel. Physicians should explain PSA’s limitations but also compare results year-to-year for significant changes. The National Cancer Institute advises repeating a test within 6–8 weeks if elevated, followed by MRI if levels remain high.
Had Biden’s doctors followed this approach, aggressive tumors could have been detected and treated before metastasis. His cancer—a Gleason 9, nearly the most aggressive form—is unusual but not unprecedented. The official announcement may be incomplete, but what is clear is that a window for prevention was missed.
Understanding the Gleason Score
The Gleason system grades prostate cancer on a 6–10 scale:
- 6 (3+3): low-grade, slow growing.
- 7 (3+4 or 4+3): intermediate-grade, variable risk.
- 8–10: high-grade, aggressive, prone to spread.
Biden’s Gleason score of 9 means his cancer is aggressive and dangerous.
Pathway of Care
- Elevated PSA → repeat test, then MRI if confirmed.
- MRI → distinguishes benign from suspicious lesions.
- Fusion biopsy → combines MRI and ultrasound for 3D targeting, vastly safer than older rectal methods.
- Genomic testing → labs such as Decipher or Tempus analyze whether the cancer is aggressive.
- Radiation or surgery → depending on stage and location.
For localized cancer, outcomes are excellent: over 90% survive 10 years cancer-free. But once metastasized, treatment shifts from cure to control.
Treatment Options
- Radiation: external beam (IMRT, IGRT), stereotactic (CyberKnife), proton beam, or brachytherapy. Risks include bladder, ureter, and rectal damage.
- Radiopharmaceuticals: radium-223 (Xofigo) or lutetium-177 PSMA (Pluvicto) target bone metastases.
- Hormone therapy: blocks testosterone, controlling disease in up to 90% of advanced cases but with side effects akin to male menopause.
- Surgery: robotic-assisted prostatectomy (RALP) is the gold standard for localized cancer, offering high cure rates with faster recovery.
- Emerging therapies: HIFU and cryotherapy aim to ablate tumors with minimal collateral damage.
Leading U.S. centers for care include University of California San Francisco, Johns Hopkins, Mayo Clinic, MD Anderson, Memorial Sloan Kettering, UCLA, City of Hope, and others.
A Systemic Failure
President Biden’s ordeal is more than personal misfortune. It exposes a system overly reliant on population statistics that dismiss rare but devastating cases. While most prostate cancers are indolent, the 6% that progress cause immense suffering. For these men, routine PSA monitoring can make the difference between cure and catastrophe.
The PSA test is imperfect, but it is inexpensive, widely available, and potentially lifesaving. Dismissing it outright for older men is misguided.
Conclusion
President Biden’s cancer illustrates the cost of inaction. What could have been a treatable disease is now incurable, leaving him to endure bone metastases, extreme pain, and shortened survival.
The tools exist: PSA testing, MRI, fusion biopsy, genomic analysis, and world-class cancer centers. They should be used. Every man over 70 deserves proactive care. Ask your physician to include PSA testing, track changes, and follow up promptly.
The cost of prevention is measured in dollars. The cost of neglect is measured in suffering.
