Dem
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The "original" Joe Biden health news was related to his alleged cognitive decline. The "recent" Joe Biden health news is related to his cancer diagnosis.
We want to focus specifically on the cancer diagnosis right now, a diagnosis about which many people who are not Joe Biden or his doctors made many confident pronouncements. This includes a number of people who are not inherently hostile to Biden, like Dr. Ezekiel Emanuel, who is brother to Rahm Emanuel, and who was appointed to several blue-ribbon panels by Biden during his presidency. The general thrust of the comments, including those from Ezekiel Emanuel, was that it's very hard to believe that Biden, with access to the best preventative care in the world, only learned about the cancer after he left office. This, in turn, has caused many people (particularly on the right, but also some on the left) to incorporate the cancer into the broader "Biden cover-up" narrative.
We took great exception to people who have not examined Biden, and who were not part of his care team, and who have not seen his test results, presuming to make an armchair diagnosis, whether they are trained oncologists (like Dr. Emanuel) or not. We had several responses that we wanted to share. The first three are from physicians; the fourth is from a prostate cancer survivor (and then, at the end, we'll have some more comments):
J.E. in Akron, OH: Dr. Ezekiel Emanuel's "surprise" that President Biden's prostate cancer wasn't picked up by "routine" screenings is disingenuous. The United States Preventive Services Task Force recommends AGAINST continuing to screen for prostate cancer beyond age 70.
While this recommendation is controversial, it reflects the considered, evidence-based judgment of the entity tasked by the Affordable Care Act with weighing the risks and benefits of various preventative strategies. To my knowledge, Dr. Emanuel has never criticized this recommendation; if anything, he has been a critic of excessive testing and healthcare spending in the later stages of life. While it is certainly possible that the publicity surrounding Biden's diagnosis will prompt a re-evaluation of current recommendations, nothing publicly known about Biden's diagnosis suggests any deficiency in his preventative care.
H.R. in Pittsburgh, PA: As a physician, I want to commend you on your very insightful and non-hyperventilatory description of the significance of Biden's prostate cancer. I agree 100% with your assessment of the ridiculous and unfounded assertion by Ezekiel Emanuel that Biden had prostate cancer "for years," ergo there must have been a cover-up.
Eminent professor he might be, but Emanuel seems to have forgotten his roots as an oncologist entirely. Even I, who am neither an oncologist nor a urologist, know that cancers are graded as "aggressive" vs. "intermediate risk" vs. "non-aggressive" based on at least two factors. One is "invasive vs. indolent"—phrases that mean exactly what they imply. The other is poorly differentiated (i.e. uncontrolled cell replication) vs. well-differentiated (i.e. partially responsive to growth inhibitory factors).
What distinguishes the two extremes in ALL cancers is called "doubling time." In solid tumors, that means volume, not two-dimensional diameter. In prostate cancer specifically, however, there are two other measures of aggressiveness. One is Prostate-specific antigen (PSA) doubling time, which is traditionally determined as <6 months for the most aggressive, 6-12 months for intermediate, and >12 months for slower-growing prostate cancers. However, there is considerable doubt as to the reliability of doubling time as a measure in the individual patient. That is the unending and unresolvable problem of "intra"-polating (if I may create a word) from population studies to the singular level, as the statistician in [V] will attest. (For those interested in frying their brains with a more detailed explanation of how many ways to Sunday have population studies tried to manipulate doubling time to achieve the Holy Grail of reliability in the clinical context, you can read a summary of those efforts here.)
That said, the PSA-doubling time can potentially be helpful if one has a baseline value within the prior 12 months (as Joe Biden must have as an 80+ year old). If, as I suspect, his PSA had not risen by more than 0.6ng/ml/yr—the generally accepted clinical range for biopsy—then a diagnosis of "highly aggressive" (i.e. PSA doubling time of <6 months) definitively rules out a "cover-up" for three reasons. First, if the PSA had doubled, a biopsy would have been performed earlier. Second, the presence of metastases to bone—something, by the way, any cancer patient will tell you is not asymptomatic for any length of time—indicates a really aggressive form of prostate cancer. Third, many such cancers are so undifferentiated that they cannot even synthesize PSA (so forget PSA doubling time)!
There is, however, a second and even more troubling fact that shows how aggressive Biden's cancer is—even if one ignores the presence of mets to bone. ABC News was among the first to report that Biden was given a Gleason score of 9. It means the diagnosis was confirmed by a prostate biopsy (the old adage that you never sign a death warrant without conclusive proof holds in medicine as much as in justice). If true, then a score of 9 might be the scariest fact of all. On a scale of 1-10, a 9 means a highly anaplastic (undifferentiated) form of cancer. It explains not only how rapidly his cancer grew (i.e., there was, tragically, no "need" for a cover up), but also why it had already metastasized to bone by the time the diagnosis was made.
While great advances have been made in the treatment of advanced cancer, it is still the case that two-thirds of men with a Gleason score of 9-10 will not live five years—a prognosis that gets even worse when the cancer has already metastasized.
Needless to say, I am heartbroken by this news. I still believe, despite all the bad press and executive pullback by TCF, that Biden was the most consequential president of my time since I emigrated to the U.S. in the 80s. It has taken a great effort and considerable emotional distress for me to write this, but I did it so my fellow Electoral-Vote.com acolytes might understand the reason why (V) and (Z)'s resounding rebuttal of Emanuel is so on point. He seems to have gone over to the dark side (at least by my reckoning), so yesterday's post only closed the circle on my decision to write in.
I will close with my wish for President Biden's survival despite this dread disease. And to all my fellow 70-year-olds, please make sure you get an annual PSA and (ideally) a prostate exam, as well. Because the small nodule felt in Biden's prostate, and not his PSA, was, to my reckoning, the reason he got a biopsy.
B.B. in Toronto, ON, Canada: I'm am a retired family physician and professor in the University of Toronto's Department of Family and Community Medicine.
As you know, Joe Biden has been diagnosed with an aggressive prostate cancer, and some (J.D. Vance perhaps) believe he has known for a long time and there is some sort of cover-up.
Here's my take. I suspect even though PSA screening is often stopped in elderly men, that the president was getting it done anyway. The problem with any screening is that it tends to detect less aggressive forms of disease. Screening is conducted at intervals, yearly... or longer. So how could his cancer have been "missed"?
The answer is that it wasn't. He has what is known as an "interval cancer." Aggressive forms of cancers come up quickly between the screening intervals, and it is entirely possible that he had a normal screening test a year ago, or even 6 months ago, and an aggressive form of cancer now.
This is true of all cancer screening—mammography and the various tests for colon cancer, for examples. By nature, screening tends to miss rapidly growing cancers, but does find slower cancers, and may detect cancers earlier in their natural course. Sometimes with routine screening you find an aggressive cancer early, but it's just luck.
So how CAN we screen for these rapid cancers? Shorten the interval? That's costly, and don't forget that screening detects all kinds of issues that aren't cancer, but have to be investigated to be certain... so called false positives. Eliminating the false positives is also costly and may do actual harm. For example a certain proportion of colonoscopies lead to bowel perforation, which is VERY serious. The interval for screening is chosen based on the best combination on sensitivity (the ability of the test to find cancers that are actually there, implying a low false negative rate) and specificity (the ability of the test to detect ONLY cancers and not other things, implying a low false positive rate). I know of no general screening test where the interval is shorter than a year. In some high-risk individuals, screening may be as short as every 6 months, but these are special cases, not good practice for screening everybody regardless of risk.
In short, Biden almost certainly didn't have this prostate cancer a year ago, and it would have taken some luck to have found it early.
Meantime, your sense that Gleason 9 with metastases to bone is not early detection is correct. His cancer is not curable, and it remains to be seen if it is controllable in any meaningful way. None of the treatments he faces are a walk in the park. They all have significant and life-altering side effects. He has my utmost sympathy.
B.C. in Phoenix, AZ: I'm a prostate cancer survivor. It took the Mayo Clinic three biopsies to actually confirm I had cancer, and a HoLEP laser surgical procedure plus two dozen sessions of proton radiation therapy to defeat it.
The problem with many types of cancer is that they are very difficult to diagnose, even with all the modern technology. I was at Mayo because my former urologist had diagnosed a spot on another part of my urological system as a potential cancerous lesion and had recommended a pretty serious, invasive surgical procedure to remove it. Mayo determined it was nothing more than a benign spot, but was concerned about a high PSA level. PSA is a protein which, if detected at elevated levels in the blood, suggests cancer. Some urologists have recently called its accuracy into question.
My treatment has resulted in a PSA level which has remained at an undetectable level for the last two years. But the HoLEP procedure was necessary to address my symptoms of BPH (enlarged prostate) and an elevated PSA level also usually presents with BPH. The doctors cannot tell me how much my high PSA level was due to cancer and how much was caused by BPH.
A funny aside: as I was going through treatment, I was contacted by the company I had retired from just a year earlier. As the IT director and I were having lunch, he explained that his crew knew the Microsoft Windows environment very well, but were clueless about the various modern FreeBSD and Linux systems which were in place. He wondered if I could come in and, on a contract basis, school his people on those systems. Knowing about my cancer diagnosis, he asked "Do you feel up to it?"
"Sh**, yes," I laughed, "I've got cancer, not dementia!"
Thanks to all of you for sharing your expertise.
We imagine our purpose in passing these letters along is evident, but just in case: Quite a few people, including virtually the entire Trump administration, but also people like Emanuel, have behaved as if it is a certainty that Biden knew, before he left the White House, that he had been stricken. As the reports above make clear, the available evidence suggests the exact opposite. What it does not do is support the conclusion that there must have been a cover-up.
And that brings us back to Biden's alleged dementia. More specifically, it brings us back to Jake Tapper, Alex Thompson and their book. Original Sin is an important part of this story, because Tapper and Thompson are ostensibly "on the left," and so give credence to right-wing claims of a cover-up. We've mentioned this a couple of times before, but in historical analysis, and in particular in Biblical analysis, this is known as the "criterion of embarrassment." If someone says something they would presumably prefer not to say (for example, if one of the four gospel authors reports something embarrassing or negative about Jesus), it's likelier to be true, since there would be no good reason to tell that lie.
We're not so sure that Tapper and Thompson are actually "on the left," but that's the assumption that gives their book credence. And their book is built on certainty, because that is what sells, and that is what makes for a compelling argument, and compelling op-eds, and compelling TV interviews, etc. They are certain Biden was incapacitated to the point of dysfunction. They are certain that his underlings and family members knew it. They are certain that those underlings and family members, aided by others, took steps to cover the whole thing up.
But here is the thing. So many people, including trained oncologists, are certain (or nearly so) about Joe Biden's cancer. And, as we lay out above, that certainty is simply not warranted. Now consider that the Biden book (and all the other reports) are based on second- and third- and fourth-hand reports, from people who are not experts. Also consider that dementia and other mental conditions are considerably harder to isolate than something like, say, cancer. In part, that is because diseases of the brain often fade in and out, such that a person is fine sometimes, compromised at other times. That is somewhat less true with something like cancer, which tends to follow a relatively straight trajectory. And in part, it is because it can be hard to separate the symptoms of actual cognitive dysfunction from things like normal aging, normal tiredness after a long day and, in the case of Biden, a lifelong stuttering problem.
It is certainly possible that the story that Tapper, Thompson and others are telling is 100% on the mark, or nearly so. It's also possible that they have completely missed the boat, and none of it is correct. What is most likely, however, is that the truth is somewhere between those two extremes. We would guess that there was/is something amiss, and that the people around Biden slowly developed an awareness of that, but didn't quite know how serious it was, or quite what to do. Eventually, he blew the debate, some conversations were had behind the scenes, a few high-profile people went public, and he withdrew from the race. If we basically have the gist of it, then it's not nearly as conspiratorial or as nefarious as the "Biden cover-up" narrative suggests. But that version of the story also wouldn't sell as many books, and wouldn't do nearly as much to get the blood of Fox viewers boiling, as the Watergate-esque version.
Tomorrow, we will talk about whether or not the Biden dementia/cancer coverage has a purpose, and what that purpose might be. We have a few ideas on that subject, and readers have submitted some other thoughts.
Also, we did not forget about the next set of reports on gubernatorial candidates, nor the item on Gov. Ron DeSantis (R-FL). But the above item on the trade war is over 3,000 words and took a long time to get to a point we deemed satisfactory (whether readers deem it satisfactory is a different matter, of course). We don't want to overtax people (this posting, in whole, is nearly 7,000 words), and we don't want to post TOO late. So, we'll try very hard to get to those pieces, plus one on Harvard, tomorrow. That's in addition to Part III of this series. Fingers crossed. (Z)