Joe Biden’s metastatic prostate cancer diagnosis, coupled with revelations about his decline in recent years, has renewed chatter and anxiety about the former president’s health. The concerns being discussed — what’s been going on, for how long, and what should have been done? — often arise when someone receives a serious illness diagnosis. The hardest question is about prognosis — what will happen now?
We don’t know much about Mr. Biden’s situation. We know that the cancer is aggressive, and that it has spread to his bones. This isn’t enough information to tell us when the cancer started, or how it will progress. What we do know, however, is that metastatic prostate cancer is considered treatable, but usually not curable. We also know that Mr. Biden is frail, and that frailty — an accumulated loss of resilience to bodily insult and injury — makes cancer, and cancer treatment, harder to withstand.
This isn’t unique to Mr. Biden, who is 82. It’s a fact that applies to anyone in a similar circumstance, including many of his former colleagues in Congress who continue in their roles despite advanced age and health struggles. As a palliative care doctor, I wait to discuss the prognosis until a patient is ready. But when it comes to the people running the country, these conversations should be approached with compassion, not patience. Avoiding a clear understanding of what a health change might mean is an evasion of responsibility.
That’s the real connection between Mr. Biden’s diagnosis and the concerns about his gait, cognitive lapses and reported fatigue. The cancer news doesn’t tell us much about what caused Mr. Biden’s decline, or imply that a diagnosis was covered up. Rather, it gives us insight into how he might fare through serious illness.
A person’s prognosis, whether they have aggressive cancer or another disease, is informed by their overall health, the treatment they receive, their ability to tolerate that treatment, and, importantly, their priorities. I saw a patient this week who plans to decline cancer treatment in favor of traveling to his home country to spend time with his family. As a result, his life expectancy is shorter than it might be. His decision is not wrong; it’s extremely personal.
Being able to make such a choice requires forthright information from one’s physicians, and a willingness to hear that information. It’s true that there are many 82-year-old men with metastatic prostate cancer who might reasonably expect to live for years to come — to die with cancer, not from cancer. Mr. Biden might die of some other cause. Medicine has made incredible strides in the past decade in treating metastatic cancers and mitigating the harms of cancer therapies. This is especially true of prostate cancer.
But it is also true that older patients on average have worse prognoses than younger patients, and that frail elders tend to do worse than their nonfrail peers. They are also more likely to suffer side effects from treatment; from, for example, even gentler interventions like the testosterone blocking therapy used to treat prostate cancer, which can worsen cognitive decline and fatigue. Often, such risks are worth taking to treat a disease; but they are real concerns and can impact both the quality of life and the prognosis. They can also affect a person’s so-called functional status — that is, the ability to move through the world with relative independence.
When people are very sick, they have to make decisions — not only about their treatment plan, but about what’s most important to them, and how they want to spend their time. A common approach to such conversations in palliative care is to “hope for the best, plan for the worst.” Some people outlive even our sunniest prognostic estimates, or stay sharp and feeling well long past when others begin to falter. But holding hope is a conscious act, distinct from denial. Denial is the opposite; it is a refusal to engage the challenging odds, a defensive reaction rather than an optimistic one.
Perhaps, when Mr. Biden fought to run for a second term, he was acting on hope. But it’s hard not to think that he, and the people around him, were partly operating out of denial. Denial prevents people from being able to plan for the worst. Planning for the worst is not about giving anything up. It doesn’t mean focusing on death. It means thinking about how to shift priorities and roles if time is short. Planning for the worst is an exercise in weighing risks and benefits and making an effort to ensure that the world you care about will be OK after you’re gone.
It is hard to be certain about Mr. Biden’s prognosis. He may well live for years. But, even with the promise of extraordinary treatment, he is unlikely to be in great health in January 2029, when his second term as president would have ended. And while he did not have this cancer diagnosis when he was running for re-election, he was, by all accounts, already showing signs of impairment and brittleness. That frailty predicted both decline and vulnerability to serious illness, and serious illness is not a rare event in people who are over 70 years old.
People who are in particularly powerful positions of responsibility have a special obligation to face the realities of aging, rather than deny them. They also benefit from access to attentive health care, and so are more likely than many other people to get early warning signs that their health may be faltering.
Whether representing us in Congress, occupying the White House or sitting on the Supreme Court, many of the leaders who make up our gerontocracy choose every day to try to uphold our fragile democracy, in part, with their physical bodies. That is a noble instinct but also a risky one; and it is also a reason to be particularly attuned to the realities of the life cycle.
I hope very much that Mr. Biden’s coming months are full of grace and meaning, that his cancer responds to treatment and that his prognosis is good. I wish, however, that he had done a better job earlier of planning for the worst, and hope that others in similar circumstances — especially those worried about their own legacies — learn from his example.
Rachael Bedard is a geriatrician and palliative care doctor.
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