The final chapter of Joe Biden’s five-decade political career has been mired in questions about his clearly ailing health, and who knew what when. Now, a new puzzle has emerged: why was the president of the United States – one of the most medically scrutinised people on earth – not tested for prostate cancer once in over a decade? Was it, as his team insists, a routine omission for a man of his age, or was it something more calculated?
What we do know is that Biden’s cancer was reportedly detected so late that it is now aggressive. According to medical specialists, the cells have a disordered appearance with a Gleason score (which analyses how likely they are to advance) of nine out of 10. It is also classed as stage four because the cancer has mutated from his prostate to his bones. At this point, it can only be controlled, not cured.
That it is serious is beyond doubt, but what is more complicated is the question of how this happened. On one side, we have Biden’s aides, who told The New York Times that doctors stopped analysing his PSA (prostate-specific antigens) in 2014 in line with US regulations, which suggest that men over 70 do not need routine testing. This is because an elevated PSA is so common that testing can lead to unnecessary treatment, which often causes more damage that it solves.
Still, presidents are subject to more rigorous and more personalised medical care than the rest of us, and Donald Trump (despite having no evidence) has suggested that this was a cover-up. Trump, who is 78 to Biden’s 82, is still being tested for prostate cancer and has released his (relatively low) PSA results numerous times. Barack Obama and George W Bush both regularly published their PSA scores while in office.
There are a number of flaws in Biden’s argument – namely that 71 seems young for a man in high public office to stop all testing. “We do not recommend routine screening for men after age 75 or in men with life expectancy of less than 10 years because the benefits of detecting a prostate cancer and treating it for curative intent are not realised in that short time period,” says Behfar Ehdaie, a urologic specialist at Memorial Sloan Kettering Cancer Centre in New York. “However, patients are still seen regularly and questions are asked about prostate health after age 75.”
Urological surgeon Declan Cahill, who is based at the London Bridge Hospital, believes 70 or even 75 is an increasingly arbitrary age, as men are living longer than ever. “I would have thought it was particularly inappropriate not to test a man as medicalised as Biden, who would also have had a life expectancy beyond the mean – he is lean, he doesn’t smoke, he is fit – and was very well taken care of. There’s never any point in not knowing – knowledge is everything, so long as it is responsibly managed.”
A senior surgeon weighs in, adding, “To take a blood test from a man over 50 and not do a PSA is practically an assault. It is the most male-specific health-related blood test you can do. If you get an abnormal result, then you do a scan (I imagine the White House has an MRI scanner) and then after that you do a biopsy. It is not as if we throw drugs at anyone with a high PSA, but I simply cannot envision a world where nobody at the White House ever ticked yes to a PSA test for him.”
This then raises the question of whether they deliberately failed to screen him – particularly in light of new tests now available that are far more accurate than the PSA. Bartu Ahiska, the senior director at Oxford Bionynamics, explains that one of the problems with the PSA is that it is not accurate enough to distinguish between the prostate cancer that needs urgent treatment and the more indolent versions of the disease that do not. Their Epi Switch PSE blood test cuts false positives from about 75 per cent to under 10 per cent, and has been available in the US and UK for two years.
Then there is the fact that new forms of treatment are far less invasive than they once were, with some carrying almost no side effects – negating the argument that it is not worth testing for. “If it is localised, prostate cancer is curable with a number of approaches which – yes – include surgery and radiotherapy, but there is also an emerging technique called focal therapy,” says Dr Rakesh Heer, the chair of urology at Imperial College London. “High frequency ultrasounds or cryotherapy, or irreversible electroporation, destroy the cancer but leave the prostate intact, so avoid the side effects which include incontinence and erectile dysfunction.”
This only works in cases that are caught early. Hormone treatment is usually the first line of defence for anyone diagnosed with slightly more advanced prostate cancer. Notably, one of the side effects can be cognitive decline. “Androgen deprivation therapy, or ADT, blocks production of testosterone and this causes a number of side effects,” says Cahill. “Cognitive decline is one – it is not usually that common to be glaringly obvious, but a lot of relatives will notice that the man in question’s short term memory is really failing or that he has become really forgetful.”
Biden’s history of covering up health problems means that this most recent revelation has led to a media storm in the US. Many Democrats blame Trump’s 2024 victory on Biden’s lack of transparency around his health, his clear cognitive decline during the second half of his presidency and his late withdrawal from the 2024 election.
This news also comes the same week that Original Sin: President Biden’s Decline, Its Cover-Up, and His Disastrous Choice to Run Again, written by authors and journalists Jake Tapper and Alex Thompson, is released. The book alleges that, “Biden’s physical deterioration – most apparent in his halting walk – had become so severe that there were internal discussions about putting the president in a wheelchair, but they couldn’t do so until after the election.
“Given Biden’s age, [his physician Kevin O’Connor] also privately said that if he had another bad fall, a wheelchair might be necessary for what could be a difficult recovery,” the book adds. According to Tapper and Thompson, aides tried to ensure he never walked long distances and used handrails when climbing stairs.
Biden’s former physician, Kevin O’Connor, is alleged to have said that Biden may need a wheelchair if he suffered ‘another bad fall’ – Shutterstock
At the time, the press were repeatedly told that his altered gait was because of a fracture he suffered in 2020 and the fact he failed to wear his prescribed surgical boot.
His mental decline was arguably more disturbing. According to Tapper and Thompson, Biden failed to recognise George Clooney at a California fundraiser last June, reportedly saying, “Thank you for being there,” to the film star. Not long after, Clooney wrote an opinion piece suggesting he withdraw his candidacy. None of this interaction was made public.
A spokesperson for Biden says, “evidence of ageing is not evidence of mental incapacity”, arguing that he had been a “very effective President”.
However, Thompson and Tapper allege that, as well as taking far too long to come forward with his health problems and thereby possibly costing the Democrats the election, Biden hid information about the cancer diagnosis of his late son, Beau Biden, who was an elected official at the time.
The authors argue that this demonstrates “the Bidens’ capacity for denial and the lengths they would go to avoid transparency about health issues”.
A senior Republican source agrees, saying: “It was clear to anyone who was watching the President that he had declined cognitively and physically. The White House and the media condemned concerns about his health as political attacks, so it would not be surprising if they also lied about more serious health issues he had.”
