Biden’s Cancer Battle

As a doctor and a specialist in prostate cancer, what was your reaction to the Biden diagnosis? Did you find it surprising?
First, I want to emphasize that I’m not President Biden’s treating physician; that’s an important distinction, both ethically and professionally. I’m speaking here in general terms as an expert in the field, not based on any direct involvement in his medical care.
That said, the public was understandably surprised by the diagnosis, particularly because, according to media reports, the cancer had already spread. While prostate cancer is often detected at earlier, localized stages thanks to routine screenings, there are certainly cases where it’s discovered later, especially if the disease is more aggressive or if there were gaps in monitoring. So from a clinical standpoint, this type of diagnosis is not entirely unexpected.
My initial reaction was one of concern but not shock. In some cases, even when patients are being monitored, the cancer can progress silently or more rapidly than anticipated. However, it’s very important to stress that even when prostate cancer has metastasized, it is by no means a death sentence. Fortunately, even for advanced stages of the disease, we now have a range of treatment options—hormonal therapies, newer-generation medications, and targeted treatments not infrequently combined with targeted radiation treatments—that can often bring about a meaningful remission and help maintain quality of life.

Many find it hard to believe that this diagnosis came as a surprise or that it reached this stage without being detected. Some wonder if the cancer was monitored but not closely enough, or even speculate that there may have been a cover-up.
I think what you’re pointing out is the fear this has generated—specifically, the idea that someone could be under regular surveillance and still end up with metastatic cancer that appears to emerge suddenly. That scenario would be unusual.
Again, I can’t comment on how President Biden was monitored or screened, as I’m not privy to his records. But I can say that in patients who are being regularly monitored—especially when there’s a documented rise in the PSA (prostate-specific antigen) blood test levels—it’s not common for the disease to spread suddenly and dramatically without some signs. That said, it is possible that certain advanced imaging or follow-up tests may reveal a spread that wasn’t initially apparent.
This highlights why several things are crucial—consistent and careful monitoring of PSA levels, and conducting the appropriate diagnostic tests to assess if, and where, the cancer may have spread. With this information, a decision can be made to perform a biopsy to establish the diagnosis, and only then can the disease be treated in a way that’s tailored to the specifics of each case.

Acknowledging that you’re not his physician and can’t speak about his specific prognosis, what is the general outlook for someone with this type of cancer at his age?
According to media reports, President Biden has what’s referred to as a Gleason 9 prostate cancer. The Gleason score is a measure of how aggressive the cancer cells from the biopsy appear under the microscope to the expert eyes of a pathologist.
To simplify it, Gleason 6 represents low-risk disease, less aggressive. Gleason 7 is intermediate risk—moderate aggressiveness. Gleason 8, 9 and 10 indicate high-risk disease. These cancers are the most aggressive type and often have a greater tendency to spread, particularly to lymph nodes and bones.
So a Gleason 9 cancer is categorized as high-risk. The first step in such a case is always to perform imaging—such as a PET scan and an MRI—to determine whether the disease is still contained within the prostate or if it has spread.
If the cancer is still localized, meaning it hasn’t spread to lymph nodes or bones, the five-year survival rate can be as high as 80 percent—and some reports suggest even higher. However, if imaging reveals that it has spread to other areas like the bones, that survival rate may drop to around 30 percent.

In Biden’s case, the reports say the cancer has spread to his bones. What survival rate would he fall under? And does age make a difference in outcomes like this?
That’s an important question. Once the disease has spread to the bones, the higher survival rate no longer applies in the same way. But it’s also worth noting that the presence of bone metastases doesn’t always mean the situation is dire; it depends on how widespread the metastases are. If the spread is limited to a few areas—what we call oligometastatic disease—there are effective treatment strategies that can still have a significant impact and bring about disease remission.
As for age, it’s a common misconception that prostate cancer in older individuals is always slow-growing, or that it’s more aggressive in younger people. The truth is that the cancer’s behavior is more dependent on the biology of the tumor—the Gleason score, the PSA blood test level, whether the cancer is limited to the prostate or has spread, and how the patient responds to treatment—rather than age alone.
That said, the overall health of the patient and his ability to tolerate treatment are important considerations. In general, though, many studies have shown that age is not the main determining factor in treatment success. What matters most is the nature of the disease and whether the appropriate treatments are being used.
If someone has a Gleason 9 cancer with documented bone metastases, one of the most commonly used and effective treatments is hormonal therapy. This approach has been around for many years and is often successful in putting the cancer into remission. It works by essentially shutting down the hormone called testosterone, which fuels the cancer’s growth, and this can lead to significant tumor shrinkage and symptom relief.

To put it in layman’s terms, it all depends on the details of a particular person’s disease in terms of longevity and survival.
Yes, exactly. In other words, just because someone has aggressive prostate cancer doesn’t mean it’s the end. Nobody should give up or feel that it’s hopeless—that’s simply not the case. As you correctly pointed out, outcomes depend on many factors: Is the cancer localized or contained, or has it spread? If it has spread, how diffuse and widespread is that spread?
Fortunately, hormonal therapy as a treatment for prostate cancer was discovered nearly a century ago. Since then, and especially in recent years, we’ve seen significant advancements in both the effectiveness and administration of these therapies. Many are now available in oral form—just one pill a day—and have been shown to improve longevity, induce remission and slow cancer growth. So yes, it is still very often a highly treatable disease.

Over the decades you have been involved in prostate cancer treatment, have you seen an increase in survival rates?
Yes, absolutely. We’ve seen improvements on multiple fronts. The delivery and types of hormonal therapy have become more effective, and that’s been confirmed in many studies. Surgical techniques for treating earlier stages of tumors have also advanced dramatically.
And radiation therapy—well, that has seen revolutionary improvements. It’s now much more precise and targeted, resulting in significantly fewer side effects. In fact, we are now utilizing it for situations where the cancer has not spread. MRI-guided and targeted radiation treatments allow for delivery of the radiation beams with exquisite precision, providing the necessary accuracy but with fewer side effects—something we haven’t been able to accomplish before.
So not only have survival and response rates improved, but the treatments themselves are now better tolerated. I remember 30 years ago, the side effects of treatment were quite difficult to tolerate and had a major impact on patients’ quality of life. Today we see improvements in longevity, in the range and effectiveness of therapies, and in the tools we use every day.

So it’s not so much that new therapies have been invented, but that existing therapies have improved and are administered more effectively.
Correct. The general concept of hormonal therapy has been around for a long time, but the drugs have been greatly improved. These newer drugs have been shown to increase longevity and improve response rates. So while the basic treatment strategies—hormonal therapy for advanced cancers, surgery and radiation for earlier-stage cancers—remain the same, outcomes, even for people with advanced disease, have improved because of significant improvements in the way we deliver these therapies.

Is there anything in the pipeline—some kind of “magic bullet”? Any hope for a breakthrough?
A magic bullet at this time—unfortunately not. But more recently, we’ve seen the development of therapies that can specifically target areas where the cancer has spread—especially the bones. This new field is called theranostics, where an injectable agent seeks out cancerous areas in the body and delivers targeted radiation directly to those sites.

Are these in clinical trials?
They are. There are many ongoing trials being conducted to test the effectiveness and safety of these approaches. But some of these newer treatments have already been tested in large studies and are now available in practice.
For example, Pluvicto is one such treatment that can deliver radiation to specific areas where prostate cancer has spread to the bones, after hormonal therapy is no longer working. These therapies are still evolving and being improved. Additionally, while not quite ready for widespread use, immunotherapies are being explored for advanced prostate cancers that no longer respond to hormonal therapy.
So yes, there are several emerging treatments on the horizon that show a lot of promise. I personally believe that using some of these therapies earlier in the disease course may have an even greater impact in preventing progression, but that would need to be carefully tested in future trials.

Are you involved in this kind of research?
Yes, I’m very involved in clinical research. I see and treat a large number of patients and serve as a professor of radiation oncology and a leader of the Prostate Disease Management Group here at NYU. A big part of my role includes researching new and better ways to treat this disease.

There are reports suggesting that prostate cancer is on the rise. Would you say that’s accurate, or is it more of a media overreaction?
There is evidence of a modest increase over the years. According to the American Cancer Society, about 300,000 men are now diagnosed with prostate cancer annually in the US. That number was closer to 200,000 about 10 or 15 years ago. So yes, there appears to be an increase.

But have those statistics taken population growth into account?
To some degree, yes. But what’s more important to emphasize is that not all prostate cancers need to be treated. Early-stage cancers—those with Gleason scores of 6 and low PSA levels—are associated with a very low risk of spreading. In many of those cases, we actually recommend not treating them, instead monitoring them carefully with blood tests and, when appropriate, imaging studies such as MRIs.

Why is that?
Because those cancers tend to be very slow-growing.

What’s the disadvantage of treating them right away?
Any treatment carries some risk of side effects. These treatments can have an impact on the quality of life of the individual. So for prostate cancer that is early, localized and unlikely to spread—as indicated by a low Gleason score—it’s entirely appropriate in select cases to monitor it closely without immediate treatment, provided that appropriate tests confirm it hasn’t spread.

In terms of the rise in prostate cancer, is there any information about whether the increase is among younger, middle-aged or older men?
It’s not entirely clear. The rise doesn’t appear to be isolated to any one age group. In the past, blood tests were more routinely performed across the board, but now we’re seeing a slight uptick overall. However, it’s not specifically concentrated in younger or older populations—at least, not based on the current data.

What should men be doing to protect themselves?
The best advice I can give is that this is an area of ongoing debate, particularly around screening and the routine use of PSA blood tests. There’s a lot of controversy in the field about whether everyone should take a PSA test at a certain age. However, for those with a family history of prostate cancer or those who are getting older, having a baseline PSA blood test is probably a reasonable and proactive step.

At what age should men start PSA testing?
If there’s a family history, it’s advisable to start earlier—perhaps in the early 50s. There’s no universally agreed-upon age, though. In general, maintaining a healthy diet, especially reducing red meat intake, watching your weight and being overall health-conscious are important factors, too.

You mentioned that using the PSA blood test to screen the general population is controversial. Why?
The controversy lies in the fact that PSA testing can detect cancer at such an early stage that it sometimes leads to additional testing and a diagnosis of very indolent, non-aggressive cancers that might never cause harm or spread. This raises the question of whether we are overdiagnosing and overtreating conditions that don’t require intervention.

Is the controversy more from a medical and insurance standpoint—because it can lead to more tests and potentially unnecessary treatments? Or is it also about the emotional toll on the patient? Even if it’s indolent, the word “cancer” can really shake someone up. Would you agree?
That’s true to an extent. But I also see many people who, once they understand the situation, prefer just to monitor it. If they’re told it’s a very low-risk cancer with a very low likelihood of spreading, and that treatment could come with significant side effects, many choose to keep an eye on it rather than rush into action.
It’s important to have an open, honest discussion with your doctor. Just because we label it “the C word” or “yene machlah” doesn’t mean it behaves like other, more dangerous cancers. Many of these early-stage prostate cancers are biologically very different; they may never spread or cause harm. So before subjecting someone to major surgery or radiation with possible side effects, the risk–benefit balance really needs to be carefully considered.
I see both types of patients. Some are deeply anxious at the mere suggestion of cancer, no matter how low-risk, and they feel compelled to act. These are people who, emotionally and psychologically, need treatment for peace of mind. Then there are others who place a high value on maintaining quality of life. If we as doctors determine that the cancer is unlikely to spread for many years—and especially if the patient is dealing with other health issues—then it may be wiser not to expose them to aggressive treatment that could make them more frail or compromise their well-being. That all has to be part of the cheshbon we make together with our patients.
When people think about prostate cancer, they often think of it as an “old man’s disease.” Is that true?
Not necessarily. Unfortunately, we do see people in their 40s and 50s being diagnosed. It’s true that it’s more commonly found in men in their late 60s and 70s, but it can certainly be diagnosed in younger individuals as well.

You mentioned earlier the importance of staying healthy and maintaining a trim figure; those are general health guidelines. But is there anything more specific? Have doctors or researchers found any particular risk factors that make someone more vulnerable to prostate cancer?
Yes, there are a few known risk factors. Genetics and family history certainly play a role; there are familial genes associated with increased risk. Obesity has also been linked to a higher risk of developing prostate cancer. Diet plays a part as well—higher consumption of red meat has been associated with increased risk, whereas a diet richer in fish, fruits and vegetables may be more protective. Lycopene, for instance, which is found in cooked tomatoes, has been thought to have a protective effect.
There are also some supplements that may help lower risk. But overall, maintaining a healthy lifestyle—eating well and exercising—helps reduce the risk of many health conditions, including prostate cancer.

What led you to specialize in prostate cancer?
What really drew me in were the dramatic advancements in treatment. As I mentioned earlier, the innovations in this field have had an incredible impact. I’ve seen it firsthand—baruch Hashem, the ability to help people in such a meaningful way is extraordinary. If I can be a shaliach to bring refuah to people through these treatments, it’s both a tremendous opportunity and a zechus.
Through the research I’ve been involved in and the treatments I’ve had the chance to offer, I have personally witnessed the siyata dishmaya in how these treatments were able to change people’s lives in so many positive ways.

I understand that you’ve treated many rabbanim and roshei yeshivah. Can you share your background?
I studied at Yeshiva University and received semichah from Rav Moshe Feinstein, zt”l. After that, I attended Albert Einstein College of Medicine and then went on to Memorial Sloan Kettering, where I spent many years and led the program. More recently I’ve been at NYU, involved in the most cutting-edge, innovative treatment programs. So I have had a great deal of personal satisfaction being able to help many people and providing guidance. That’s my journey.

Did you have a personal relationship with Rav Moshe?
Yes. My father had a very close relationship with Rav Moshe, and I believe there have been articles written about that. Baruch Hashem, I also have close relationships with many roshei yeshivah, rebbes and poskim in our generation. I consider myself most fortunate to have developed strong ties to our poskim and rabbanim, who provide me the opportunity to ask them complex medical halachic shailos, and also to get chizzuk and inspiration from them.

Did Rav Moshe ever guide you directly about being a doctor? Did you discuss your work with him?
I’ve had many such conversations, though more so with his son, Rav Dovid, zt”l, because Rav Moshe was already quite elderly at the time. I also consult regularly with many other rabbinic leaders, some in Eretz Yisrael, such as Rav Yitzchak Zilberstein, Rav Asher Weiss and the Amshinover Rebbe, among others. Their guidance has been invaluable in navigating complex cases. I work closely with gedolei haposkim to seek halachic direction, especially when dealing with nuanced or sensitive medical issues.

Rav Dovid was known as someone people turned to for medical halachah. Do you have any stories you could share? It’s always fascinating to hear how halachah and medicine intersect.
Absolutely. One case that stands out involved a very complicated situation. The patient was emotionally exhausted and refused to continue treatment. Unfortunately, his disease progressed to a point that it was life-threatening. I called Rav Dovid to ask whether we should encourage him to go on. Rav Dovid spoke directly with the patient and advised him to proceed with treatment, and the man agreed to listen to him.
But then Rav Dovid called me back and said, “I didn’t finish.” I asked, “Rosh Yeshivah, what do you mean?” He said, “I want to tell him one more thing.” He got back on the phone and told the patient, “I want to wish you a refuah shleimah and hatzlachah in all of your treatments.”
It wasn’t just the psak—it was the chizzuk that meant so much. The gedolei haposkim don’t just provide answers; they provide menuchas hanefesh and yishuv hadaas, which is incredibly meaningful to our patients.
The man’s condition had been potentially life-threatening. This brachah from Rav Dovid was fulfilled despite the fact that the disease was so advanced. Baruch Hashem, the patient is alive today, many years later—and completely free of disease!

Since the news about President Biden’s diagnosis, have you seen a spike in phone calls, appointments or people seeking testing?
There have been a lot of questions about the diagnosis of this condition at a late stage. And the message I have been conveying to people is that while it is not common at all for the disease to suddenly become aggressive and widespread, it still remains highly treatable, even in advanced forms. And I think it’s important for people to be proactive, as well as never giving up hope.
Chazal teach us that even in dire situations, one must strengthen his emunah and bitachon in Hashem. I have had many conversations with Rav Yitzchak Zilberstein about how much to divulge to patients about the prognosis of their disease. Rav Zilberstein has always emphasized that, depending on the individual, the physician should be cautious not to paint too gloomy a picture, which can cause the patient to become depressed. The responsibility of the physician is to provide chizzuk, support and hope, because the Ribbono Shel Olam can turn things around at a moment’s notice—yeshuas Hashem k’heref ayin.
So yes, the news about President Biden has certainly raised awareness. And with that awareness, more people are asking questions, wanting to educate themselves and seeking testing—which is a positive thing. ●