Former President Joe Biden has been diagnosed with a particularly aggressive type of prostate cancer that has metastasized to his bones. This raises questions about the implications of being labeled as aggressive.

A urologic surgeon specializing in prostate cancer notes that the term 'aggressive' is not defined by a single characteristic. Instead, it encompasses several factors including the cancer cells' appearance, the extent of their spread, and their genetic profile.

Grade: Evaluating Cancer Cell Appearance

A critical aspect of assessing a cancer's aggressiveness is its grade, which reflects the tumor's potential for growth. After a biopsy, a pathologist examines the cancer cells and assigns a grade by comparing them to normal prostate cells. Healthy prostate cells are organized, while high-grade cancer cells exhibit chaotic growth patterns.

Prostate cancer is graded on a scale from 1 to 5, with 1 being the least aggressive and 5 the most aggressive. Biden's cancer, classified as Gleason score 9, falls into grade group 5, indicating a significant potential for rapid growth and spread. However, it's important to note that some high-grade cancers may remain localized for extended periods.

Stage: Assessing Cancer Spread

The stage of a tumor describes its spread beyond the initial site. Physicians utilize physical examinations, imaging tests, and lab results to determine the cancer's stage. The TNM system, which stands for tumor, nodes, metastasis, is commonly used for classification.

Prostate cancer staging can be summarized as follows:

• Localized (Stages 1-2): Cancer is confined to the prostate. These cases, especially low-grade tumors, may not be deemed aggressive and are often monitored.
• Locally Advanced (Stage 3): Cancer has spread from the prostate into nearby tissues.
• Metastatic (Stage 4): Cancer has disseminated to distant body parts, often affecting lymph nodes or bones, as seen in Biden's case. This stage is considered advanced and aggressive due to its capacity to form new tumors elsewhere.

The stage of prostate cancer significantly influences treatment options. For localized cancers, treatments such as surgery or radiation may aim for a cure. Conversely, metastatic cancer typically focuses on growth management and symptom control.

Many prostate cancers depend on hormones called androgens for growth. Therapies that inhibit these hormones can be effective for a duration, especially in hormone-sensitive cancers like Biden's.

Thanks to advancements in screening, approximately 69% of prostate cancers are diagnosed while still localized, with only about 8% classified as metastatic at the time of diagnosis.

Genetics: Understanding Cancer's DNA

In addition to grade and stage, the genomic profile of cancer--its unique genetic makeup--is becoming increasingly important in assessing aggressiveness and determining treatment options. DNA serves as an instruction manual for cells, dictating growth and function, with mutations leading to uncontrolled cell proliferation.

Genomic testing can identify specific mutations. This can be done on tumor tissue for somatic mutations or through blood samples for inherited germline mutations.

For early-stage prostate cancer, genomic tests can help predict cancer progression risk, aiding in decisions regarding monitoring strategies versus immediate treatment. In advanced cases, identifying mutations becomes crucial, as certain genetic alterations can make cancer more aggressive but also responsive to targeted therapies like PARP inhibitors.

National guidelines now advocate for genomic testing in all men with metastatic prostate cancer to identify actionable mutations, paving the way for personalized treatment approaches.

Defining Cancer Aggressiveness

The term 'aggressive' in cancer classification involves a comprehensive evaluation rather than a simplistic label. An aggressive cancer detected early and confined to the prostate can have a survival rate nearing 100%. However, if the same cancer has spread extensively, the five-year relative survival rate drops significantly to around 38%.

This stark contrast underscores the importance of a thorough assessment, combining multiple tumor characteristics to inform treatment decisions. Ongoing advancements in genomics and targeted therapies are enhancing our understanding of cancer aggressiveness, leading to improved outcomes even for those facing severe forms of prostate cancer.