Biden and Prostate Cancer Screening
Unpacking Peter Attia's Claims and Why He Is Wrong
“If Joe Biden had just gotten his PSA checked every year, he wouldn’t have metastatic prostate cancer.”
That’s the argument Peter Attia made in his recent video—and on the surface, it sounds convincing. Who wouldn’t want a $5 blood test to catch a deadly disease early?
The problem is that most of Dr. Attia’s claims are incorrect, and he omits a significant amount of critical information from his video.
I created this article/video at the request of some colleagues who asked for my opinion. For the record, I admire Peter Attia’s work. The challenge with creating videos for social media is that it’s difficult to have nuanced conversations in a short video (this applies to me, too).
Let’s dive in.
(The information below is not medical advice.)
The video version of this article is embedded below and available on my YouTube Channel.
The audio podcast and video versions are also available on the Podcasts Page.
Claim 1:
The decision to screen or not to screen is based on actuarial life expectancy.
Clinical guidelines (such as the USPSTF) are based on risk-benefit tradeoffs, not cost savings or the number of years a person will live per se. This means that the decision to stop screening is made because the risk of harm (i.e., false positives and overdiagnosis) increases as we age.
Claim 2:
PSA Velocity, Density, and Free PSA should be done, and would have helped.
These tests do show that they may reduce the risk of false positives, but none of them have been shown in RCTs to improve life expectancy. Therefore, these tests may slightly decrease the risk of harm, but on average, they will still cause harm.
Oh, and by the way, people need to get a transrectal ultrasound for PSA density!
The same concepts & data apply to the 4K blood test and multiparametric MRI.
Ignored Information 1:
Ignoring the risk of harm.
Elevated PSAs typically lead to prostate biopsies, which carry the risk of infection and bleeding.
Even if a watchful waiting approach is selected, many men eventually undergo prostatectomy due to anxiety, either because the patient or the physician becomes anxious. Prostatectomy carries significant risks:
Major surgery, with inherent cardiovascular risks
Erectile dysfunction
Urinary incontinence — requiring a permanent catheter with risk of infections
Ignored Information 2:
Biases in Cancer Screening.
The vast majority of prostate cancers are very slow-growing. On the other hand, aggressive cancers grow and spread rapidly within weeks to months. This means there is a significant bias in clinical studies and in how we think about prostate cancer:
Lead time bias: Cancer is diagnosed without extending survival
Length time bias: Preferential detection of slow-growing, indolent cancers
Overdiagnosis: Finding cancers that never would have caused harm
Therefore, even if Biden’s PSA was elevated at age 72, his metastasis would not have been detected by annual PSAs (remember aggressive cancers grow rapidly within weeks to months).
My prior article, “False Positives, Real Profits,” explains these biases and problems with cancer screening in more detail.
Risk-Based Screening
I agree with Dr. Attia that there is a case for risk-based screening, but we need a method to identify and quantify high-risk individuals.
Would we Have Had President Biden?
Assuming that Biden had a false positive and had undergone prostatectomy at 72, the question then becomes—would he still have had the physical and cognitive stamina to run for president at 78?
These are the real-world tradeoffs between the risks and benefits of screening.
Up Next
Next week, I will resume my regularly scheduled deep dives. I have one more article to go in the Quality series: The Madness of Medication Adherence.
References:
USPSTF. (2018). Screening for Prostate Cancer. JAMA. https://doi.org/10.1001/jama.2018.3710
Vickers AJ, et al. (2011). PSA velocity does not aid in prostate cancer detection. JNCI. https://doi.org/10.1093/jnci/djr028
Seaman E, et al. (2007). Prostate volume estimation: TRUS vs MRI. Urology.
Wilt TJ, et al. (2012). Radical prostatectomy vs observation. NEJM. https://doi.org/10.1056/NEJMoa1113162
Obiora, D., Orikogbo, O., Davies, B. J., & Jacobs, B. L. (2025). Controversies in prostate cancer screening. Urologic Oncology: Seminars and Original Investigations, 43(1), 49–53. https://doi.org/10.1016/j.urolonc.2024.06.022
I agree.
While I appreciate Dr. Attia’s broader commitment to prevention and patient education, I believe his position on prostate cancer screening overlooks some key clinical realities.
High-risk prostate cancers, such as Gleason 9, represent a minority—perhaps 10 to 15% of cases—and often arise de novo rather than progressing from indolent disease. That nuance is often lost in discussions about treatment/over-treatment.
I’ve also cared for patients with serious quality-of-life consequences following treatment, including a recent case where a patient required cystectomy due to radiation-associated bladder damage.
These are complex decisions that warrant shared decision-making, not blanket recommendations for PSA screening.