Former President Joe Biden has been diagnosed with "aggressive" forms of prostate cancer and is scattered on the bones. But what does this cancer mean?
As a urology surgeon specializing in diagnosing and treating prostate cancer, I often explain to patients that aggressiveness is not based on one factor. Instead, it comes from understanding abnormalities in cancer cells, called tumor performance. How far they spread, known as the stage of tumors; and their genetic fingerprints.
Level: Decode the appearance of cancer cells
A key part of the puzzle is the cancer achievement, which indicates the growth potential of tumors. After a prostate biopsy, doctors who specialize in tissues (pathologists) graded the tumor by comparing the appearance of their cancer cells with the appearance of normal prostate cells.
Imagine healthy prostate cells are organized workers in factories, each performing a specific task. On the contrary, advanced cancer cells look messy and grow and divide quickly.
For prostate cancer, doctors use so-called grade groups, ranging from 1 (most non-aggressive) to 5 (most aggressive). These groups are simplified based on older classifications, called Gleason Scores. Biden's Gleason 9 cancer is in grade 5 and shows that cells look very abnormal and have strong potential for rapid growth and spread.
Although cancer grades help indicate tumor cells’ performance, they don’t tell the whole story. Some advanced cancers can be limited to the prostate for months or even years.
To understand the location of the cancer and its development distance, doctors determined its stage.
Stage: Map the cancer location and spread
The stage of the tumor describes whether the cancer has exceeded the location where it first formed. Doctors use physical examinations, imaging scans and laboratory tests to perform prostate cancer.
Medical professionals often use detailed systems called TNM - abbreviation of tumors, nodes, metastasis - to classify the stages of tumors. However, the stage of prostate cancer can be widely understood as:
Localization (Stages 1-2): Cancer is only in the prostate. Think about the weeds confined to the bed in the small garden. Many localized cancers, especially in low-level cases, may not be considered aggressive and can often be monitored safely.
Locally advanced (stage 3): Cancer has spread out of the prostate and grown in nearby tissues, like weeds sending roots from the surrounding lawn.
Metastasis (Stage 4): Cancer has spread to distant parts of the body. For prostate cancer, this usually means lymph nodes, bones (as in Biden's case) - the liver or lungs. It's like weeds spreading seeds on the streets and across the town.
Stage 4 prostate cancer is considered advanced and aggressive because it shows that it can spread and form new tumors.
[embed]https://www.youtube.com/watch?v=qwcbegjuluu[/embed]
The tumor stage seriously affects treatment plans and goals. For local or certain locally advanced cancers (stage 1 to stage 3), treatments such as surgery or radiation may be designed to cure. For metastatic cancer, it is usually incurable. Treatment focuses on controlling growth, managing symptoms and maintaining quality of life.
Many prostate cancers rely on androgens called as fuel for their growth. Therapies that block these hormones can be effective for a while – in most cases, especially for hormone-sensitive cancers like Biden.
Fortunately, about 69% of prostate cancers were found when it was still confined to the prostate (stage 1 to stage 2). About 8% of new cases are metastatic at diagnosis.
Genetics: A blueprint for DNA discovery of cancer
In addition to grades and stages, doctors are increasingly using cancer’s genomic profiles (its specific genetic makeup) to both provide insight into its aggressiveness and potential therapeutic pathways.
DNA, like a detailed instruction manual for cells, determines how they should grow and function, and when they should stop dividing or dying. In cancer, mutations work like typos in this genetic guidebook, causing cells to ignore these normal controls, growth and spread.
Genome testing can identify these specific genetic changes. This can be done on the tumor tissue itself to determine changes that occur after birth called somatic mutations. Otherwise, the changes you inherited can be detected through blood or saliva samples are called germline mutations.
For men with early stage prostate cancer, certain genomic tests of tumors can help clarify the risk of cancer development. This information is valuable for determining whether active surveillance (cancer without immediate treatment) is a safe approach or whether more direct treatment is necessary.
In advanced or metastatic prostate cancer, identification of specific mutations is particularly critical. For example, mutations in the BRCA1 or BRCA2 gene (BRCA1 or BRCA2) may also occur in prostate cancer. These mutations can make cancer more aggressive, but may also be sensitive to a specific type of drug called PARP inhibitors, especially if the cancer is resistant to hormone therapy.
Now, national guidelines recommend genome testing for all men with metastatic prostate cancer in search of these "viable" mutations. This approach towards personalized medicine means that unique fingerprints that can be customized increasingly for patients with cancer.
Understand the “aggressiveness” of cancer
It must be understood that “radical” is not only a simple label for cancer, but also a multi-layer assessment. Aggressive cancers that are captured early and are limited to the prostate (stages 1 and 2) may have a five-year relative survival rate of nearly 100%. However, if the same advanced cancer has spread widely (Stage 4), the five-year relative survival rate has dropped significantly, down to about 38%.
This serious difference in survival rates highlights a key point. To gain the clearest understanding of the potential threats to cancer, a comprehensive assessment combines insights from multiple qualities of the tumor to help patients and their medical teams make informed decisions.
Thankfully, advances in genomics, imaging and targeted therapies continue to improve the definition of aggressiveness, how their behavior is predicted and how it is personalized. This progress offers hope for better outcomes even for patients with the most aggressive prostate cancer.