News broke today that President Joe Biden has been diagnosed with stage IV (metastatic) prostate cancer. As an oncologist, this is not just a headline—it becomes an important teaching moment for how we evaluate and manage newly diagnosed metastatic prostate cancer. With the public eye now focused, many are likely wondering: what does this diagnosis mean, and how do oncologists think through next steps?
Understanding the Diagnosis
Metastatic prostate cancer means the cancer that started in the prostate has spread beyond its original site. Most commonly, it spreads to bones, lymph nodes, and occasionally to other organs like the lungs or liver. In President Biden’s case, though details remain limited, it appears the diagnosis is new and reportedly involves bone metastases.
The First Steps in Evaluation
When a patient is newly diagnosed with metastatic prostate cancer, a few key assessments are crucial:
- Imaging: CT scans and bone scans help determine the extent of spread. Increasingly, PSMA PET scans are used for their higher sensitivity in detecting metastatic disease.
- Molecular Profiling: Blood or tissue samples are tested to identify molecular markers that may guide treatment, including targeted therapies or immunotherapy.
- Spinal and Skeletal Concerns: If metastases involve the spine or weight-bearing bones, there is heightened concern for spinal cord compression or pathologic fractures. MRI of the spine may be warranted for midline back pain or neurological symptoms.
Treatment Strategies
While a stage IV diagnosis sounds daunting, prostate cancer is uniquely responsive to hormonal manipulation. First-line treatment typically involves androgen deprivation therapy (ADT) to block testosterone, which fuels prostate cancer growth. ADT is usually administered as an injection every 1 to 6 months and may be combined with an oral anti-androgen.
Though President Biden has often been described as healthy, his recent clinical appearance and reported frailty may suggest the gradual toll of undiagnosed metastatic cancer—especially with extensive bone involvement? This is conjecture on my part. For patients presenting with similar signs of frailty, oncologists may favor less aggressive options. In these cases, the preferred initial treatment may include androgen deprivation therapy (ADT) combined with agents like abiraterone or apalutamide, which offer effective disease control without the toxicity of chemotherapy. These regimens aim to balance efficacy with tolerability, especially for older or more vulnerable individuals.
In many patients—particularly those with high-risk or extensive disease—treatment intensification with androgen receptor pathway inhibitors (such as abiraterone or apalutamide) can significantly improve outcomes beyond ADT alone. Other considerations:
- Addition of chemotherapy in high-volume disease in chemo-eligible patients
- Bone health agents like bisphosphonates or denosumab to prevent fractures
In addition to bone-protective agents, patients on ADT should undergo periodic DEXA scans to monitor for bone loss, as hormonal therapy is known to weaken bones over time. If significant deterioration is observed, additional medications—such as bisphosphonates or denosumab—may be required to help maintain bone integrity.
Special attention is paid to the spine, as spinal metastases can pose a risk of spinal cord compression—a true medical emergency. Early symptoms like persistent midline back pain or leg weakness should trigger prompt MRI imaging. If caught early, interventions like radiation or surgery can preserve function and avoid permanent complications.
Similarly, weight-bearing bones such as the hips and femurs are monitored closely. Large metastatic lesions in these areas can predispose patients to pathologic fractures. Prophylactic orthopedic stabilization and localized radiation can reduce this risk, allowing patients to maintain mobility and independence.
Monitoring Response
Treatment success is monitored through three lenses:
- Clinical: Improvements in symptoms, appetite, weight, and energy
- Biochemical: Reduction in PSA (prostate-specific antigen)
- Radiographic: Imaging studies to follow any visceral or bone lesions
Prognosis and Perspective
While metastatic prostate cancer is not curable, it is highly treatable. Many patients can live for years with good quality of life, particularly when their tumors are sensitive to first-line therapies such as ADT combined with newer hormonal agents. Outcomes depend on multiple factors, including disease burden, molecular profile, and overall health status.
Additionally, if a patient’s cancer is found to be microsatellite instability-high (MSI-H) or have a high tumor mutational burden (TMB), this may open the door for immunotherapy options. Likewise, patients with BRCA mutations or other HRD-positive findings may benefit from targeted therapies such as PARP inhibitors, which interfere with cancer cells’ ability to repair DNA damage. Each of these insights helps to inform second-line or future treatment strategies tailored to the individual. Clinical trials also play a critical role in exploring these targeted approaches, offering patients access to promising new therapies not yet widely available.
A Broader Message
This diagnosis, especially in someone as prominent as the President, underscores the importance of awareness, routine screening, and proactive management. For oncologists, it is also a reminder of how far we have come in treating this disease. New therapies, many developed through the tireless efforts of researchers and brave patients participating in clinical trials, continue to transform outcomes.
While the spotlight may be on one patient, this is a story shared by thousands every year—a journey from diagnosis to treatment to hope. Our role as oncologists is to guide, inform, and support at every step. And for patients and families, understanding the landscape can make all the difference.
Our thoughts are with President Biden and his family, as they begin this journey that so many others have walked. It is my greatest hope—for him and for all patients like him—that with effective therapy, improvements in strength, appetite, and quality of life are possible. And if he does regain his stride, well… don’t be too surprised if he’s back on the campaign trail in 2028. To all patients out there: you are not alone.
About the author
Dr. Sajeve Thomas is a distinguished medical professional and a compassionate guide in the field of oncology. With over a decade of dedicated experience as a board-certified medical oncologist/internal medicine specialist, Dr. Thomas has become a trusted expert in the treatment of melanoma, sarcoma, and gastrointestinal conditions. He brings a wealth of expertise to the complex and challenging world of oncology.
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