Hollings Cancer Center urologist on what Biden's cancer diagnosis means

With news that former president Joe Biden, 82, has an aggressive form of prostate cancer that has spread to the bone, Eric Wallen, M.D., chair of the Urology Department at the Medical University of South Carolina, agreed to talk about:

• What that diagnosis means.
• How Biden’s cancer may be treated.
• How research at Hollings is trying to make treatment even better.
• The important message that Wallen hopes Biden’s revelation sends.

Wallen specializes in the care and treatment of patients with prostate and genitourinary cancers at MUSC Hollings Cancer Center.

The diagnosis

Biden revealed late last week that he has cancer, with an announcement from his personal office. It released a statement, saying: “Last week, President Joe Biden was seen for a new finding of a prostate nodule after experiencing increasing urinary symptoms. On Friday, he was diagnosed with prostate cancer, characterized by a Gleason score of 9 (Grade Group 5) with metastasis to the bone.”

 

Apart from the troubling news that a former president has cancer, people were struck by the use of the term “Gleason score.” Wallen said a Gleason score is a way of grading the severity of prostate cancer. “The closer it gets to 10, the higher it is, the worse the prognosis. So he's in the highest risk group. High risk means a high chance of developing metastasis, and a high risk of dying from prostate cancer.”

Metastatic cancer, which Biden has, means that it has spread from where it started to another part of the body – in his case, from the prostate to the bone. It’s also known as Stage 4 cancer.

Somebody Biden’s age wouldn’t normally be screened for prostate cancer. Wallen said men in that age range are usually diagnosed when they have symptoms from problems caused by the cancer, such as bone pain or even bone breaks or sudden urinary symptoms, as Biden apparently did.

But Wallen said metastatic prostate cancer also shows up in people who weren’t screened for prostate cancer when they were middle-aged, the normal time to get checked. That failure to screen for the cancer can allow it to metastasize.

One bit of encouraging news about metastatic prostate cancer is that life expectancy is increasing. “With newer therapies directed at metastatic disease, survival is much longer than it was 20 years ago. Twenty or more years ago, it was two-and-a-half to five years. Now it's five to 10 or even more,” Wallen said.

Treatment

Another encouraging point: Wallen said there are several treatments available for Biden’s type of cancer. “If I were talking to a patient right now in his situation, I would first try to lower the temperature in the room. I would say, ‘Look, nobody in this room is going to die today, tomorrow or even this year from this. Prostate cancer is something that we can manage, and we're going to start managing it once we get a full picture of what's going on. Let’s get some more information about our enemy, then we’ll get after it.’”

Once they have that full picture, androgen deprivation therapy, also called hormone therapy, is a likely next step. Androgens are male sex hormones essential to the function of the prostate. Therapy that lowers androgen levels or blocks the hormone may shrink the cancer and slow its progress.

Wallen said it can be used in combination with other treatments such as radiation. Another possibility, chemotherapy, usually isn’t used for men with prostate cancer – but it sometimes is in advanced cases. 

Whatever the treatment plan, doctors adjust it as needed. “I tell patients there's a plan A. There's a plan for maybe A plus B to start. There's a plan C; there's a plan D. This is going to be going on for many months, more likely many years.”

Unfortunately, those months and years will include side effects from the hormone therapy and other treatments. “When we take away testosterone or block testosterone in a man that way, they tend to get a lot of symptoms. And I think as physicians, we need to be extra sensitive about those, particularly in the elderly because they're already prone to having some of the symptoms. For example, almost half the patients can have cognitive decline from the treatment,” Wallen said.

“They also have menopausal symptoms from androgen blockade: hot flashes, night sweats – and it can be a pretty rough go for some patients. The hormone treatment can last as long as five or 10 years before the cancer becomes what's called castration-resistant metastatic prostate cancer.”

Castration-resistant metastatic prostate cancer is harder to treat, growing even when androgen is low. New types of hormone therapies may help with symptoms and quality of life.

Research at Hollings

Quality of life is important, Wallen said. It’s a key part of his discussions with patients about what treatments they choose to undergo.

But the quest for better treatments is important, too. That’s why scientists at MUSC Hollings Cancer Center, the only National Cancer Institute-designated cancer center in South Carolina, are doing clinical trials on new ways to tackle prostate cancer. 

“Hollings has investigated a number of drugs for advanced prostate cancer, including chemotherapy, immunotherapy, combinations of those and moving drugs earlier into the course of the disease,” Wallen said.

“This one won't apply to Biden, but we're also part of a national trial where, for a patient with metastatic disease, we're treating the disease at its origin in the prostate. That can only be done in a clinical trial space because we don’t know if it makes a difference.”

Message

They aren’t sure about that treatment yet, but Wallen said doctors like him do know that having a public figure such as Biden discuss having cancer can nudge others to sign up for screening. “What we've learned over the years is that men are more reluctant to do screening than women are.”

The American Cancer Society recommends that men talk with their doctors about whether to be screened for prostate cancer. Those discussions should take place:

• At the age of 50, for men at average risk.
• At age 45, for men at high risk, including Black men and men who have a father or brother diagnosed with prostate cancer under the age of 65.
• At the age of 40, for men with more than one close relative who had prostate cancer at an early age.

Wallen said it’s important to keep in mind that when prostate cancer is at its most treatable, patients usually don't have any symptoms. “Screening should happen even in the absence of symptoms. Do it for your family. You’re a vital part of your family. Do it for your community. Do it for yourself.”