Former President Joe Biden’s cancer diagnosis: What we know so far, and treatment options

Former President Joe Biden
_{© joebiden.com}

Daniel Isaac, DO, MS, spoke with Medical Economics to offer his insights about that disease and what has been reported publicly so far. Isaac is an assistant professor of hematology/oncology at the Michigan State University College of Human Medicine and an oncologist/hematologist for the Karmanos Cancer Institute at McLaren Greater Lansing.

This transcript has been edited for length and clarity.

Medical Economics: Can you explain about what we know so far about his diagnosis?

Daniel Isaac, DO, MS: From my understanding, the former president was diagnosed with what we would call high-grade prostate cancer, as you have probably seen pointed out in the news articles, which we grade by Gleason score. And his was a Gleason score nine, which we consider to be a high-grade prostate cancer. And from my understanding through the news outlets, it has been reported that has been metastasized to his bone. And so it seems to be that he has metastatic prostate cancer at this juncture.

Medical Economics: Some of those reports have described it as an aggressive form of cancer, can you talk about what that means?

Daniel Isaac, DO, MS
_{© MSU/Karmanos Cancer Institute}

Daniel Isaac, DO, MS: Aggressive forms of prostate cancer is that very kind of heterogeneous term. We use Gleason score, which is how pathologists grade prostate cancer under the microscope. And aggressive forms of prostate cancer have higher Gleason scores. And so when we look under the microscope, we take the two highest Gleason scores that are present in the biopsy specimen and we grade those. So, for example, higher grade patterns are grade four and five patterns, and so if the two most common patterns are grade four and five, you would end up with a Gleason score of nine. So that's something we would consider a high-grade prostate cancer.

Medical Economics: What are some of the treatment options that former President Biden may have for this form of cancer?

Daniel Isaac, DO, MS: Once prostate cancer is spread to the bone, our mainstay of treatment is to suppress testosterone, because prostate cancer grows off of testosterone. And so much of the initial treatments the president will receive will be treatments aimed at lowering his testosterone levels to what we would call castration levels of testosterone, so, as low as we possibly can make them. But I would highlight that the treatment approach to advanced prostate cancer is highly individualized, and so his physician and his team of physicians will be making decisions about his therapy based upon the extent of disease he has, side effects, his other medical comorbidities, and tailoring his therapy to specifics that fit his disease state and his overall state of health.

Medical Economics: Can you talk more about how treatment options may depend on a patient's age and other pre existing medical conditions?

Daniel Isaac, DO, MS: I would say that individualized care has a lot of components to it. One is personalized components, as you pointed out, that are individual to the patient's health. But other are disease-related factors. And so, for example, genetic factors, how many bone metastases are present, et cetera. So in regards to personal characteristics, you know, suppressing testosterone in men does come with a whole host of quality of life and side effect issues that we need to take into context in terms of comorbidities that people may have. And so we always individualize our concepts of how intensely we treat people based upon what other medical issues they may have. There are many ways to treat prostate cancer from suppressing hormones. In the simplest form, sometimes we give just simple shots to lower testosterone, but we know that enhancing therapy above and beyond that to completely suppress testosterone production by adding other agents can be more efficacious, and so we do that. But there may be some people who have other issues that may preclude our ability to do those things to their fullest extent, and so we really need to take into account both personal factors and patient wishes when we're making decisions about how intensely we treat patients.

Medical Economics: Will a surgical approach be in the armamentarium to treat this cancer?

Daniel Isaac, DO, MS: From what I understand of the former president's diagnosis is spread to the bone, and so generally, we don't offer surgery to the prostate in most cases for those patients. But there is, depending on how many sites of bony metastases he may have, evidence to suggest that treating the prostate perhaps with radiation could add to his improved outcomes in his case and in select cases. So his team of physicians will be looking at his imaging and his diagnostic studies and using that information to help guide their decision-making about any therapy that may or may not be warranted to the prostate itself.

Medical Economics: All of us, as Americans, would understand that the president has very good health care, understandably so, he's the leader of our country. Clearly, President Biden, President Trump now in office, they have physical examinations while they're in office. Why was this not detected sooner?

Daniel Isaac, DO, MS: Well, it's not that uncommon. Honestly, in aggressive forms of prostate cancer, it may be very difficult to detect. We know screening PSA is not perfect. Additionally, you know, his age group, the current guideline recommendations don't blanketly recommend screening all patients for prostate cancer. And so, you know, we consider screening for prostate cancer to be quote, unquote shared decision-making between patients and physicians. And so I'm assuming his doctors and the former president have had conversations surrounding that. As he pointed out, he's had excellent health care. So it's not unheard of, and in his age group, quite honestly, there is no guideline to continually screen for prostate cancer in all patients.

Medical Economics: Can you discuss the importance of primary care physicians and screenings for prostate cancer and other forms of cancer?

Daniel Isaac, DO, MS: The primary care physician plays such an incredible role in screening and talking to patients about screening and ensuring patients get their screening in appropriate intervals. And the primary care physician with regard to prostate cancer screening is vital, because sitting down with a patient and having a discussion about the pros and cons of prostate cancer screening for each patient is important, taking into account their other medical problems, their life expectancy, their particular wishes about treatment of a cancer that may or may not cause life-limiting complications for them. And so those are really difficult conversations to have with patients, but so vitally important, and they happen before they get to my office. And so the primary care physician is just an incredibly vital component of that discussion.

Medical Economics: Based on your own experience and training, can you offer one or two pointers or ideas or tips for primary care physicians to use to encourage patients who may be hesitant or fearful about cancer screenings?

Daniel Isaac, DO, MS: I think that it's important to sit down with patients and discuss with them that all cancers are treated differently, and so early detection is really important for a cure. That's the first thing. And second thing is to start to break down barriers of how patients perceive a cancer diagnosis. I think some patients may perceive a cancer diagnosis as coming automatically with chemotherapy and radiation, which may or may not, in fact, be true. And so I think it's important for physicians to sit down and discuss with patients, if we do get a screening test that shows us an abnormality, what would be the next steps and what would be the appropriate treatment paradigm in basic terms as we approach that diagnosis.