Joe Biden has been diagnosed with stage four prostate cancer which has spread to his bones. I am, of course, sorry to hear this. Biden has been through a lot in his life, including the death of a wife and two of his four children, as well as having one son who struggled with drug addiction.

I am a survivor of prostate cancer. I was diagnosed in 1996 and treated with a then-new radiation therapy called brachytherapy. In my case, about sixty radioactive seeds were implanted in my prostate. I experienced what is known as a PSA bounce. PSA is a blood marker that, when elevated, can indicate prostate cancer. In rare cases, PSA can rise temporarily after treatment—this phenomenon, now well known, was not yet recognized at the time. As a result, my doctors believed that my cancer had metastasized. There I was, in my early 50s, potentially facing a death sentence. Fortunately, it turned out well for me. In the process, I learned a lot about prostate cancer. I even became a board member of the Prostate Cancer Foundation, which was started by Mike Milken.

I find it hard to imagine that Biden and his physicians were unaware of his prostate cancer for some time. If they were, there was no public disclosure. While most prostate cancers are not deadly, about 15% will metastasize. But if detected early and treated, the risk is extremely small.

My guess is that Biden had prostate cancer for some time and it was not disclosed—possibly even before his first presidential term. It likely spread to his bones a few years ago but did not cause symptoms until recently.

Something about this situation just doesn’t make sense to me. You don’t end up with a Gleason score of 9 (10 is the highest) without many years of rising PSA levels. I find it hard to believe his routine physicals did not include this simple blood test. To be fair, It’s possible that Biden decided not to have the PSA test done. Many men as they get older make the decision not to have this test. But of course, they are not the president of the United Staes.

He will be treated with hormone therapy, which typically produces a remission that lasts 3–5 years. However, it often causes side effects such as cognitive decline and fatigue. There are other treatments available once hormone therapy stops working, which can add a few more years of survival.

Biden was already having difficulty functioning full-time. He appears to have some cognitive issues that were not acknowledged publicly but were evident in his appearances. Hormone therapy could have made this much worse. My guess is that he would have had to resign had he continued his run for president and won.