| Prostate cancer has shifted significantly since 2011, when I first reported on the growing controversy surrounding its diagnosis. At the time, middle-aged men were routinely tested for prostate-specific antigen (PSA). A result above 4.0 nanograms per milliliter often led to a biopsy — a procedure involving a dozen needles passed through the rectal wall into the prostate to extract tissue samples. The problem was twofold. First, biopsies increasingly led to serious infections, driven by the rise of antibiotic-resistant bacteria. Second, many men were undergoing aggressive treatment for slow-growing tumors that would likely never have caused harm. Concerns about over-diagnosis and overtreatment led to a shift in clinical guidance. PSA testing and biopsies fell sharply during the 2010s as public health authorities tried to minimize unnecessary interventions. But prostate cancer never went away. Today, with incidence rates rising again — and with better tools for diagnosis and risk stratification — doctors and health agencies are rethinking their approach. The goal now: target high-risk tumors early, while sparing men with indolent disease from overtreatment. (Here in Australia, draft guidelines are under public consultation.) What makes former US President Joe Biden’s diagnosis more than a personal health story is what it reveals about prostate cancer more broadly: it’s extremely common, especially in older men — but often far from harmless. “This is clearly aggressive by virtue of the fact that it’s already spread,” Melbourne urologist Jeremy Grummet told me. Grummet pointed out that many men in their 80s have prostate cancer, but most cases are slow-growing and clinically insignificant. Biden’s isn’t. His Gleason score of 9 places the tumor in the most aggressive category. And with bone metastases, treatment is far less likely to be curative — the focus shifts to controlling the disease and prolonging quality of life. That said, androgen deprivation therapy — the standard for metastatic prostate cancer — can control the disease for years. “He can expect years of life ahead of him with hormone therapy to slow it right down,” Grummet said. “But there’s a whole bunch of side effects.” Those side effects include loss of libido, erectile dysfunction, bone thinning, and muscle weakness. In younger men, the impact can be devastating. “If you catch it early, you can prevent this,” Grummet added. The case highlights a persistent tension in prostate cancer care. After years of caution around over-diagnosis, screening was scaled back. But now, as more men are being diagnosed at later stages, the pendulum may be swinging back toward earlier, risk-adapted detection. Biden’s diagnosis is a reminder that aggressive prostate cancer can still catch people off guard, and that the balance between detection and overtreatment remains an evolving challenge. Or, as Grummet put it: “If the president of the United States can get metastatic prostate cancer, then it shows that we really need to get better at early detection and PSA testing.” — Jason Gale | 
