Lawrence K. Altman , 2025-05-19 19:15:00
News of former President Biden’s aggressive and incurable prostate cancer has surprised the public (and presumably him).
Based on the public record of Biden’s medical care and standard medical recommendations, as recently as a year ago there was no reason to perform screening tests for the disease, despite his age, 81 at the time. The diagnosis underscores the fact that cancers can sometimes pop up suddenly, even among recipients of the most sophisticated care doctors can offer.
Biden’s health was widely discussed when he was the oldest serving president. When he ran for reelection in 2024, many observers, including his doctors, raised questions about what might have caused his shuffling gait, whispered voice, and mental lapses. Among the many possibilities considered was Parkinson’s disease. (There has been no further news on Parkinson’s at this time. STAT requested information on it from the Biden White House near the end of his term.) A team of doctors from 11 specialties — not an unusual number — examined Biden at the Bethesda, Md., military medical facility and determined that he was being treated for sleep disorder, a heart rhythm disorder (atrial fibrillation), abnormal lipid levels, gastroesophageal reflux, pain from damage to nerves in his legs, and seasonal allergies, according to a detailed public summary released in February 2024.
Biden’s cancer diagnosis came after he experienced unspecified urinary symptoms. According to a statement his spokesman issued Sunday, the examination detected a “small nodule” in his prostate and an elevated prostate-specific antigen (PSA) blood test.
Pathologists at a hospital in Philadelphia examined the prostate tissue removed in a needle biopsy, graded the two most common patterns they observed 1 to 5, and then combined the numbers to create the score — 9 out of a possible 10 on the Gleason scale, a troubling number. Additional tests showed the cancer had metastasized to bone, though the statement did not specify which bone. (Prostate cancer often spreads to the spine but also other bones.)
The February 2024 medical report from Biden’s physician, Kevin C. O’Connor, listed several tests performed on Biden that were also reviewed by other doctors in the White House medical office and experts from George Washington University Hospital in Washington. But the list of results did not include a PSA test. Monday morning quarterbacks, including at the New York Post, are already questioning why Biden’s doctors did not order a PSA test to screen for cancer. (Donald Trump Jr. has wondered if there was a cover-up here.)
However, those concerns do not consider the publicly reported facts. The test is controversial because it can lead to both false positive and false negative results. A false positive declares the presence of a condition when it is not, while a false negative says a condition is not present when it is.
For example, the U.S. Preventive Services Task Force recommends against PSA-based screening for prostate cancer in men 70 years and older. The task force recommends that doctors should discuss use of the PSA test with each patient. The website says the group is currently updating the recommendations, which were made in 2018.
President Trump, who will become the oldest serving president if he fulfills his four-year term, has had very low PSA test results reported on his check-ups in 2016 and 2025. In 2017, his then-personal physician, Harold Bornstein, said that Trump had never had treatment for prostate cancer and attributed the low value to Trump’s use of a drug, finasteride, to help his hair grow.
Pleas from experts for researchers to develop a more accurate PSA test highlight the reality that detecting cancer is not always easy.
Questions about whether Biden’s prostate cancer might have been detected earlier also reflect disputes among doctors over how extensively they should examine presidents and other political leaders. Should they do every test imaginable because the patient is a national leader whose decisions affect hundreds of millions of people? Or should such doctors follow expert committee recommendations like the U.S. Preventive Services Task Force in ordering such tests?
Most doctors I’ve spoken to who have cared for political leaders have said that they favor following recommendations because ordering tests when they are not advised often leads to unnecessary procedures, some of which can pose significant risks to the patient. These doctors favor a time-honored medical practice of exercising their judgment in determining which tests to order when and for which patient. When events go sour, the doctors must withstand the criticism. For example, President George H.W. Bush’s doctors did not order a screening test for thyroid disorders that might have detected his overactive gland and prevented a heart rhythm abnormality that caused a complication that led to his hospitalization in 1991. In defending their decision, the doctors cited the lack of a standard for ordering a thyroid screening test. Critics said Bush’s unusually high level of activity should have been a clue to his hyperthyroidism and so a reason for doing the test.
Nonetheless, in Biden’s case, those Monday morning quarterbacks may question whether his doctors seriously overlooked the possibility of prostate cancer in seeking causes for his shuffling, spinal degeneration, and arthritis.
The public record shows that the specialists known to have consulted in his case included optometry, dentistry, orthopedics (foot and ankle), orthopedics (spine), physical therapy, neurology, sleep medicine, cardiology, radiology, and dermatology. O’Connor is a family medicine specialist. A urologist was not listed. However, it would be standard practice for radiologists and orthopedic specialists who examined Biden’s X-rays and other imaging bone scans to rule out evidence of metastatic cancer. But imaging tests may not detect the earliest stages of spread.
When presidents leave the White House, they become private citizens, and the public has less reason to know their health status unless they continue to play an active role in politics or something new sheds light on what they disclosed about their health in office. Though public interest in their health may continue, the retired leaders may choose not to disclose new health developments. In Biden’s case, the disclosure is pertinent because of publication of new books — most notably “Original Sin” by Jake Tapper and Alex Thompson — reporting that aides withheld information about Biden’s cognitive and physical health. Among other things, they limited his working hours and were reportedly concerned that if in a second term, Biden might require the use of a wheelchair.
Many recent presidents have had skin cancers, including Biden, Ronald Reagan, and Lyndon Johnson, but of types that usually do not spread and cause serious illness. George H.W. Bush had skin cancers removed as vice president, while Bill Clinton had some removed after his presidency concluded. Only two presidents, Reagan and Grover Cleveland, had serious cancers in office. In 1985, Reagan’s doctors detected a cancer while performing a colonoscopy. Reagan underwent colon surgery (a right hemicolectomy) at Bethesda Naval Hospital, did not receive chemotherapy, and did not experience a recurrence. In 1893, doctors removed a cancer from the roof of Cleveland’s mouth. The surgery, which also involved a dentist removing two teeth, was performed secretly in a makeshift operating room on a yacht in New York Harbor.
However, a number of unsuccessful candidates and nominees for the presidency have had cancer. Two, Sen. Bob Dole of Kansas and Sen. John Kerry of Massachusetts, had treatment for prostate cancer in 1991 and 2003, respectively. Their cancers were detected in part by PSA tests. Dole was the Republican presidential nominee in 1996, and Kerry was the Democratic presidential nominee in 2004. Sen. John McCain of Arizona had at least three surgeries for melanoma, a serious form of skin cancer. He was the Republican presidential nominee in 2008. In 1993, a melanoma was removed from his left shoulder; in 2000, an invasive melanoma was removed from his left temple, along with the removal and examination of lymph nodes; and in 2002 another melanoma was removed from his nose. McCain died of a brain cancer in 2018.
While Sen. Paul E. Tsongas of Massachusetts ran for the Democratic presidential nomination in 1992 he and his doctors said he was cancer-free of non-Hodgkin lymphoma after undergoing an experimental bone marrow transplant. However, he had experienced a relapse before he ran for president. He experienced further relapses, dying of the disease a few days short of what would have been his four-year term if he had been elected president. Sen. Edward M. Kennedy of Massachusetts died of brain cancer in 2009, 29 years after his unsuccessful bid to oppose Jimmy Carter’s nomination for re-election in 1980. In 1976, Sen. Frank Church of Idaho ran for president after surviving testicular cancer.
Aggressive prostate cancer can be fatal in months depending on its state at time of detection, but many affected men survive for many years. Biden’s spokesman said his cancer seemed sensitive to hormone treatment and he would discuss treatment options with his physicians.
On Monday morning, Biden posted on X, writing, “Cancer touches us all. Like so many of you, Jill and I have learned that we are strongest in the broken places. Thank you for lifting us up with love and support.” As he alludes to, this is not the first time cancer has touched his family: His son Beau died of brain cancer in 2015, inspiring the Obama-Biden administration to launch the Cancer Moonshot.
Lawrence K. Altman is a physician and former reporter and “The Doctor’s World” columnist for the New York Times. He is researching and writing a book on the health of political leaders.
