With President Biden’s recent diagnosis of prostate cancer, many people are encountering terms that might be unfamiliar. Key indicators like Stage, Grade, and Gleason score can be confusing. Staging indicates how far the cancer has spread, classified as Stage I-IV (sometimes with additional letters), where higher numbers generally mean a worse prognosis. Each type of cancer has specific criteria for staging, considering tumor size, lymph node involvement, and whether it has spread to distant organs—Stage IV often indicates that cancer has reached organs like the liver or bones, with Stage IVb being the most advanced for prostate cancer.
Grade refers to how abnormal the cancer cells appear under a microscope. The more irregular they look, the more likely the cancer is to progress quickly. Think of it like a car headed toward a cliff: the Stage shows how far the car has gone, while the Grade indicates its speed. A cancer might be far from a critical stage, but if it’s growing rapidly, it can become problematic sooner. However, different cancer types can have varying rates of spread, even at the same Grade.
The Gleason Score is a specific system for prostate cancer assessment. During a prostate biopsy, samples are taken from various locations suspected of harboring cancer. The most common grades from these samples are added together to create a score between 1 and 10, where a higher score indicates a more aggressive cancer. While Mr. Biden couldn’t have Stage 9 cancer, having a Gleason score of 9 is possible.
PSA, or prostate-specific antigen, is often elevated in cases of prostate cancer, but its use in asymptomatic men has sparked debate. This is mainly because PSA can be elevated even when no cancer is present, leading to many false positives and, conversely, some false negatives. Additionally, many prostate cancers grow so slowly that they may never affect the patient in their lifetime. The United States Preventive Services Task Force has shifted its recommendations over time. Initially, it was advised for almost all men over 50, but later findings suggested that in many cases, the risks outweighed the benefits. Presently, the task force recommends that the decision to test should involve discussions about personal risk factors and preferences for men aged 50-69.
For men over 70, routine PSA testing is generally not recommended. Most men will likely develop small areas of prostate cancer by that age, but because these tend to grow slowly, they probably won’t cause problems during the patient’s lifetime.
While there are additional considerations for evaluating PSA results beyond the total PSA, these haven’t been widely discussed in the media yet. Digital rectal exams were once common, but they are less effective than PSA tests. If a rectal exam is performed, it’s typically accompanied by a PSA test.
The aforementioned guidelines regarding PSA and digital rectal exams apply mainly to asymptomatic men without specific risk factors. If symptoms suggesting prostate cancer or higher-than-average risk factors are present, testing is usually recommended.
Even though prostate cancers typically grow slowly, that isn’t the case for all instances. Given Mr. Biden’s age—82—he wouldn’t have been screened for prostate cancer in over a decade according to USPSTF guidelines. This might mean he had undergone screening before 70, but then developed cancer after regular screenings were no longer recommended. It’s also plausible that his cancer falls into the 5-15% category of prostate cancers that do not show elevated PSA levels.
This overview is meant to provide some context for those without a medical background to better understand the media coverage surrounding this topic. I’m a family medicine physician, and I recognize that urologists and oncologists could offer more in-depth information.
