The recent announcement of former US President Joe Biden's diagnosis with Gleason grade 9 advanced prostate cancer has drawn global attention to a disease that affects millions of men worldwide.
Prostate cancer is the most commonly diagnosed cancer among men in the United States, with over 288,300 new cases and approximately 34,700 deaths annually.
In Malaysia, prostate cancer ranks as the third most common cancer among men, but late presentation remains a significant concern.
Globally, around 10–20% of men present with advanced-stage prostate cancer at diagnosis.
In Malaysia, this percentage is notably higher, with many men first seeking care when the disease has already spread.
Advanced prostate cancer frequently metastasises (spreads) to the bones.
Some men with advanced disease may have no symptoms until the cancer burden becomes substantial, often presenting as bone pain in the lower back or hips.
For many, the first signs prompting evaluation are urinary difficulties, including frequency (urinating more often than usual), urgency (the feeling you need to urinate) or a weak stream, although it's important to note that not all urinary symptoms are caused by cancer.
This raises an important question: why are more men not being diagnosed earlier?
The fact that a high-profile figure such as a former US president may not have undergone regular screening is both surprising and concerning.
Thoughts about screening
If you're a man – or someone who cares about one – this is a good moment to stop and think.
Have you ever talked to a doctor about prostate cancer screening?
If you're in your 50s or older, or in your 40s with a family history of prostate cancer, this is the recommended time to consider it.
And if you're a partner, friend, daughter or colleague, asking something as simple as "Have you ever had a PSA test?" or "Do you think it’s time to check on this?" could make all the difference.
The primary tool for early detection is the prostate-specific antigen (PSA) test.
This is sometimes combined with a digital rectal examination (DRE), particularly for men at higher risk.
This examination allows doctors to feel for any hard or unusual areas in the prostate that might suggest cancer.
However, PSA screening has long been a subject of debate.
In 2012, the US Preventive Services Task Force advised against routine PSA screening due to concerns that it led to the detection and treatment of many low-grade prostate cancers that might never have caused any health problems during a man's lifetime or affected how long he lived.
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This recommendation resulted in a decline in PSA testing and sparked debate over whether fewer screenings might contribute to later-stage diagnoses.
In 2018, the Task Force revised its stance, recommending that men aged 55 to 69 engage in shared decision-making with their healthcare provider to weigh the benefits and risks of screening.
Routine screening remains not recommended for men over 70, given the lower likelihood of benefit in this age group.
While this cautious approach aims to avoid unnecessary treatment, it underscores the need for better risk stratification tools to catch aggressive cancers like the one diagnosed in Biden, while minimising intervention for slow-growing ones.
How often then should men be screened?
For those who choose PSA testing, screening is typically recommended every one to two years, depending on baseline PSA levels and personal risk, consistent with guidance from the American Urological Association and National Comprehensive Cancer Network.
Understanding the risks
To understand screening implications, we must look at the Gleason grading system, which scores prostate cancer from 6 to 10 based on microscopic appearance:
- Gleason 6 (Grade Group 1)
This cancer is low-grade, slow-growing and often managed with active surveillance, i.e. a "watch-and-wait" approach that avoids immediate treatment and monitors the cancer closely through regular checkups and tests.
- Gleason 7 (Grade Groups 2 and 3)
This cancer carriers intermediate risk.
Ttreatment may involve surgery or radiation.
- Gleason 8–10 (Grade Groups 4 and 5)
There are high-grade, fast-growing cancers that need quick and often combined treatments like surgery, radiation or hormone therapy, to keep them under control.
In localised high-grade prostate cancer, treatments that aim to cure (radical prostatectomy or radiation therapy with hormonal therapy) are employed.
But once the cancer is advanced or metastatic, the treatment shifts focus to disease control with the therapies listed below, to ensure that patients tolerate therapy well and maintain a good quality of life.
Treatment in advanced disease
Thanks to advances in treatment, many men with stage 4 prostate cancer can live for years with well-controlled disease, and may ultimately pass away from other age-related health conditions.
The main treatment for advanced prostate cancer is hormone therapy, also known as androgen deprivation therapy (ADT).
This approach lowers testosterone, the hormone that fuels prostate cancer growth.
Most men are able to tolerate therapy well with the main side effects reported being hot flashes, tiredness, weight gain, mood changes and a drop in sex drive, which are all symptoms related to the lowering of testosterone.
In men, whose cancer has spread widely or to organs like the liver or lungs, doctors often add chemotherapy (such as docetaxel) to the hormone therapy.
This combination has been shown to help men live longer.
We now live in the era of precision oncology, where genetic testing is helping doctors tailor cancer treatment to the individual.
In prostate cancer, checking the tumour’s DNA (deoxyribonucleic acid) can reveal changes in genes like BRCA1, BRCA2 or ATM.
These are found in about 10-15% of men with advanced prostate cancer, based on global data.
These changes can make the cancer more responsive to a group of drugs called PARP inhibitors, including olaparib and rucaparib, which help slow disease progression in men with certain types of resistant prostate cancer.
While international estimates guide current practice, data on how common these gene mutations are in Malaysian men is still limited, pointing to the need for wider access to testing and research in this region.
The treatment options for advanced prostate cancer that no longer responds to hormone therapy are improving quickly.
New pills that block the effects of testosterone – like enzalutamide, apalutamide and darolutamide – can help men live longer.
Another newer option is radioligand therapy, which delivers targeted radiation to cancer cells using a special radioactive drug called Lu-177-PSMA-617.
These treatments are now being used more often for men whose cancer has spread or no longer responds to standard therapies.
Biden's diagnosis of Gleason 9 disease suggests a highly aggressive form, and the "advanced" designation implies either locally advanced or metastatic spread.
His case underscores the importance of early detection, nuanced understanding of risk, and individualised treatment planning.
In conclusion, prostate cancer remains a major health issue with varying presentations and outcomes.
The diagnosis of a global figure may offer a moment to re-examine current screening practices, particularly for high-risk populations, and reinforce the need for personalised care based on tumour biology, grade, stage, and now, molecular profile (when available).
Most importantly, it’s a reminder: have the conversation.
Early detection could save your life, or that of someone you love.
Professor Dr Devalingam Mahalingam is a Malaysian medical oncologist and clinical researcher at Northwestern University in the United States. For more information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only, and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this article. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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