Longtime friends and allies of Joe Biden say they are worried about the toll an aggressive form of prostate cancer is taking on the former president and his health. But Biden and his aides say he is doing well, making progress on ongoing projects and maintaining public appearances.
Biden has been encouraged as he has gone through treatment and aides said the former president is doing as well as they could hope nearly a year after he announced his metastatic prostate cancer diagnosis. He is continuing to work on his memoir and build out his foundation and presidential library, attending board dinners and meetings. He was spotted last week on an Amtrak train from Washington to Delaware, where he took pictures with passengers.
Biden’s public engagements since leaving office last January have been fairly limited. He attended Tatiana Schlossberg’s funeral in January, traveled with his family to St. Croix during the holidays and has been seen on flights, planes, at Mass and restaurants. He is expected to visit South Carolina this month and deliver remarks at an event to mark the sixth anniversary of his victory in that state’s primary, which set the stage for his 2020 presidential win.
Four people close to Biden who have spoken with him in recent months, who spoke on the condition of anonymity to discuss sensitive details, said there have been no updates from the president on his condition. But the people, including two former Biden officials and an elected Democrat, said he has at times appeared more fatigued in private interactions over the past several weeks, a source of worry that they have attributed to the strain of cancer and its treatment.
A fifth person said Biden is staying active and engaged, and remains “encouraged and positive about his prognosis given his positive response to treatment.”
Biden’s personal office declined to comment for this story.
Biden, 83, announced last May that he was diagnosed with Stage 4 prostate cancer that had metastasized to the bone. The cancer is characterized by a Gleason score of 9, meaning it is an aggressive cancer that is more likely to spread quickly. (The scale ranges from 6 to 10.) At the time, Biden’s office said the cancer was responding to hormone therapy, “which allows for effective management.”
Biden rang the ceremonial bell at Penn Medicine Radiation Oncology in Philadelphia on Oct. 20 after completing a course of radiation therapy. He also underwent surgery in September to remove skin cancer lesions on his head.
Medical experts said metastatic prostate cancer is incurable — and most commonly spreads to the bones, as it has for Biden — though an array of advancements in recent years has made it possible to manage it effectively. That means patients can live with the cancer for years and end up dying of something else entirely, said Judd Moul, professor of urology at the Duke Cancer Institute at Duke University.
Without knowing additional details about Biden’s health and treatment, experts said his prognosis could vary widely. Biden’s office has not shared additional details that would indicate the degree to which the cancer has spread or how Biden responded to radiation last year. Oncologists said some men with advanced prostate cancer can live many years with effective treatment while others deteriorate rapidly.
The elements of Biden’s diagnosis that are publicly known — including his Gleason score and the fact that the cancer was Stage 4 and had already spread at the time of diagnosis — indicate he is facing a serious and advanced form of the disease, one that typically requires ongoing treatment and close monitoring.
“Bone metastasis is the most common place prostate cancer spreads but the degree is important and how it’s found,” Moul said. “The degree of spread or amount of spread is just as important as the fact there’s spread.”
Moul added: “There are a lot of men with advanced prostate cancer who can live many, many years. It’s unfair to all of our patients to paint a pessimistic picture for everyone because there are a lot of patients, even with metastatic cancer, who die of something else.”
The five-year survival rate for metastatic prostate cancer is 34 to 38 percent, according to the American Cancer Society, which notes that advancements in treatments have significantly improved outcomes.
It is also common for metastatic prostate cancer to spread to the spine, said Gerald Denis, Shipley Prostate Cancer Research professor at Boston University Chobanian & Avedisian School of Medicine. Doctors especially want to avoid a weakening of the bones, Denis said, noting that such weakening in the spine can lead to fractures. He said there are “highly effective end of life medications to reduce pain.”
“If the spine has been degraded by the tumor metastasis, it’s entirely possible to break your back simply by getting out of bed the wrong way,” Denis said, noting he does not know any of the specifics of Biden’s case. “This is a very painful and difficult stage of the terminal illness. … I am very sad for him and his family.”
Biden’s cancer diagnosis has raised uncomfortable questions for Democrats, who for months were embroiled in a debate over whether Biden’s decision to seek reelection paved the way for Trump’s return to office. Most have been loath to relitigate that controversy in recent months, focused instead on winning control of the House in this year’s midterms and picking up Senate seats.
Biden’s diagnosis has forced the party to privately grapple with what would have happened had he served a second term and then received his diagnosis just months in. That in part has fueled a broader discussion about when Democratic leaders and lawmakers should step aside, a debate that is playing out in some key primary races and some older lawmakers’ decisions to seek another term.
Several allies of the former president said they are saddened at the way Biden’s post-presidency has unfolded. Trump has attacked him relentlessly, fellow Democrats have not wanted to defend him because of lingering anger and resentment over the 2024 election and he has been battling an aggressive form of cancer.
Biden has faced a post-presidency with little modern precedent. He is the oldest president to leave office, giving him limited time to shape his legacy outside of his four-year term. And Trump — who has faced similar questions about his age, physical health and mental acuity — has remained fixated on his predecessor since returning to office last year, insulting him almost daily and repeating the false claim that he won the 2020 election.
“I think Joe Biden is the worst thing that ever happened to old people,” Trump said in an interview with the New York Times last month.
Barbara Perry, a presidential scholar at the University of Virginia’s Miller Center, said presidents who leave office on negative terms — whether they lost reelection or were unpopular — are often able to rehabilitate their image in their post-presidential years.
Jimmy Carter, another one-term Democrat who some referred to as a “failed president,” is often held up as the person with the most successful post-presidency. But while Carter’s work on housing and global poverty helped enhance his reputation, it did not alter perceptions among many about his time in office. Carter spent nearly two years in hospice after battling metastatic melanoma.
“We don’t know how long President Biden will have to correct for the ways things ended, which by all accounts was not a positive for him,” Perry said. “The other element of this in political and historical terms is what’s happening to him now raises questions about what was happening to him in the White House with his health.”
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