What does Joe Biden’s prostate cancer diagnosis mean for older patients?

Prostate cancer affects one in eight men and is the most common cancer among men in the United States.

It's also a leading cause of cancer-related death among men.

On May 18, former President Joseph Biden’s office announced that his prostate cancer had spread to his bones.

The Gleason score, which refers to how aggressive prostate cancer is, usually ranges from 6 to 10.

Biden’s Gleason score was 9, indicating his cancer is aggressive.

However, the diagnosis may not be grim, given recent advances in diagnosing and treating prostate cancer.

Todd M. Morgan, M.D., a urological surgeon and chief of urologic oncology, and Tudor Borza, M.D., M.S., an assistant professor of urology, both at University of Michigan Health and Weiser Center for Prostate Cancer, answer questions about the current screening procedures and survival outlooks.

How unusual is it to get diagnosed with advanced prostate cancer?

Borza: Although many of these cancers are diagnosed at lower stages, about  5 to 7% of men are found to have metastatic disease at diagnosis.

When you factor in the frequency of the cancer, which was 300,000 incident cases in 2024, it turns about that about 18,000 men present with this advanced stage per year in the U.S.

How often do patients over age 70 undergo routine prostate exams and blood tests?

Morgan: Current guidelines advise most men to begin prostate-specific antigen testing—often paired with a digital rectal examination—between ages 45 and 50.

These are usually started earlier for those with a family history or African ancestry.

However, routine PSA screening is usually stopped around 70 to 75 because the harms of detecting indolent cancers outweigh the potential benefits.

For a healthy man in his 80s, continued screening is not routinely recommended.

If President Biden followed guideline-concordant care, he likely discontinued PSA testing several years ago.

What does a Gleason score of 9 mean?

Borza: Two factors help predict the clinical behavior of prostate cancer: how aggressive the cancer appears under the microscope and the extent of the cancer at diagnosis.

The Gleason score is a measure of cancer aggressiveness based on the appearance of the cancer cells under the microscope, with the tissue typically obtained from biopsy of the prostate.

A Gleason score of 9 is considered high-risk cancer with potential for aggressive behavior.

How would a severe prostate cancer case get missed long enough for it to spread to the bones?

Morgan: Without regular PSA testing, even an aggressive prostate cancer can progress without causing symptoms.

Tumors often cause no urinary symptoms while confined to the prostate, and the first sign may be bone pain or unexplained weight loss once the disease has metastasized.

Alternatively, by the time symptoms appear in the prostate, the cancer may have already spread beyond the prostate.

In an octogenarian who is no longer being screened, discovering cancer only after it has spread is, unfortunately, not surprising.

How long does it take for prostate cancer to spread to the bones?

Morgan: The timeline is highly variable and depends on the biology of the tumor.

Some high-grade cancers metastasize within a few years, while others may take a decade or more.

Without prior PSA data, imaging or biopsy results, it is impossible to pinpoint the moment of spread with accuracy.

Are there other conditions common in older men that can mask prostate cancer?

Morgan: Benign prostatic hyperplasia, or non-cancerous enlargement of the prostate, affects the majority of older men and produces many of the same urinary complaints, including weak stream and difficulty starting urination.

However, those symptoms are so prevalent and nonspecific, they are unreliable indicators of cancer.

What treatments are available for advance prostate cancer?

Borza: The majority of prostate cancers, even when advanced, are hormone sensitive.

Blocking the body’s testosterone significantly slows the growth of the cancer and often results in tumor shrinkage.

The most common treatment involves an injection that blocks testosterone production.

This treatment is often referred to as androgen deprivation therapy.

More contemporary treatments can also include oral medications that block the androgen receptor to further deprive the cancer cells of testosterone.

What are Biden's survival chances, and do any of his current medical issues put him at greater risk of complications?

Morgan: With current therapies, most men diagnosed with metastatic prostate cancer respond well to treatment.

While the duration of the response to treatment can be highly variable—and partially depends on the extent of the metastatic spread—it is usually measured in multiple years.

Borza: Even within the category of cancers like that of President Biden’s, the extent of the spread can vary widely from a single metastatic focus to hundreds and this affects the prognosis.

In general, the primary goal of treatment is to slow progression.