Former President Biden’s weekend announcement that he has an “aggressive” form of prostate cancer that has metastasized to his bone sparked the usual sympathy from supporters — and sharp suspicions among detractors.

The announcement comes amid fresh reporting on Biden and his inner circle hiding the degree to which his mental acuity was slipping during his presidency and campaign for reelection last year, and the advanced stage of his cancer drew immediate accusations from the right that the former president was also hiding problems with his physical health.

President Trump said he was surprised the cancer “wasn’t notified a long time ago,” suggested the public wasn’t being properly informed and said that “people should try and find out what happened.”

The Times spoke to six doctors who are experts in prostate cancer. They said the information Biden’s office has shared about his condition is indeed limited, but also that many of the assumptions being made publicly about the progression of such cancers, the tests that can screen for them and the medical guidelines for care among men of Biden’s advanced age — 82 — were simply off base.

The cancer

In its statement Sunday, Biden’s office said the former president was seen last week “for a new finding of a prostate nodule after experiencing increasing urinary symptoms,” and on Friday was “diagnosed with prostate cancer, characterized by a Gleason score of 9 (Grade Group 5) with metastasis to the bone.”

Dr. Mark Litwin, chair of UCLA Urology, said that description indicated Biden has a more advanced and aggressive form of prostate cancer than is diagnosed in most men, but that it was nonetheless “a very common scenario” — with about 10% of such cancers in men being metastatic at diagnosis.

Dr. Howard Sandler, chair of the Department of Radiation Oncology at Cedars-Sinai, agreed.

“It’s a little unusual for him to show up with prostate cancer that’s metastatic to bone at first diagnosis, but not extraordinary,” he said. “It happens every day to elderly men.”

That’s in part because of the nature of such cancer, the modern screening guidelines for older men, and the advanced treatment options for such cancer when it is found, the doctors said.

Prostate cancer in small, slow-growing amounts is prevalent among men of Biden’s age, whether it’s causing them problems or not. Most prostate cancers can be slowed even more dramatically — for years after diagnosis — with medical intervention to block testosterone, which feeds such tumors.

For those reasons, many doctors recommend men stop getting tested for prostate-cancer-related antigens, through what’s known as a PSA test, around age 70 or 75, depending on the individual’s overall health.

That advice is based in part on the idea that finding a slow-moving prostate cancer and deciding to act on it surgically or otherwise — which many alarmed patients are inclined to do when they get such news — can often lead to worse outcomes than the cancer would have caused if simply left alone. That includes impotence, incontinence and life-threatening infections.

Also, if an older patient does start experiencing symptoms and is found to have a more advanced prostate cancer, modern treatments are capable of stalling the cancer’s growth for years, the doctors said — often beyond the point when those patients are statistically likely to die from something else.

Even when older patients are tested and show somewhat elevated PSA levels, it is not always of immediate concern, and they are often told to just keep an eye on it, Litwin said. Simply put, doctors “typically don’t get too exercised about a diagnosis of prostate cancer in an 82-year-old,” he said.

Dr. Sunil Patel, a urologic oncologist and an assistant professor of urology and oncology within the Brady Urological Institute at the Johns Hopkins University School of Medicine, said that’s because the average life expectancy for an American man is under 85.

“And so most men at that time, at 75, they’re like, ‘OK, well, if it’s not going to kill me in the next 10 years, I’m going to leave it alone,’” Patel said. “That’s a really shared decision between the patient and the physician.”

When advanced, aggressive prostate cancers are found, as with Biden, the prognosis — and treatment plan — is of course different, the doctors said. “He is for sure going to need treatment,” Litwin said. “This is not the type that we can just observe over time like we often do.”

But that doesn’t mean Biden’s doctors dropped the ball earlier, he and others said.

The diagnosis

Biden’s office has not said whether he was receiving PSA screenings. A letter from Biden’s White House physician in February of last year made no mention of PSA testing, despite other recent presidents’ medical assessments including that information. Biden’s aides did not respond to requests for comment.

The doctors The Times spoke to had no special insight into Biden’s medical care, but said his diagnosis did not make them feel any less confident about the caliber of that care or suggest to them any nefarious intent to hide his condition.

For starters, “it would be considered well within the standard of care” for Biden to have forgone testing in recent years, given his age, Sandler said. “Certainly after 80.”

Litwin said he believes Biden probably was still tested, given his position, but that doesn’t mean he was necessarily hiding anything either. Some forms of aggressive prostate cancer don’t secrete antigens into the blood at levels that would be flagged in a PSA test, while others can grow and even metastasize rapidly — within a matter of months, and between routine annual screenings, he said.

Patel said he has personally found “very aggressive disease” in patients who had relatively normal PSA levels. “I don’t think anyone can blame anyone in terms of was this caught too late or anything like that,” he said. “This happens not too infrequently.”

Dr. Alicia Morgans, associate professor of medicine at Harvard Medical School, a genitourinary medical oncologist and the director of the Survivorship Program at the Dana-Farber Cancer Institute, agreed. Even if a patient is diligent about getting screened annually, “there will be some cancers that arise between screening tests,” she said.

Morgans said things gets even more complicated as men get older, when their PSA number may increase and start getting monitored before it is considered a clear indicator of cancer.

“Maybe it’s up a while. It was not cancer before, it hasn’t really changed that much. Now it has become cancer. It’s not the fault of anyone,” she said. “You can do everything right and things like this can happen.”

The treatment

Biden’s office said his cancer appeared “to be hormone-sensitive, which allows for effective management.”

The doctors The Times spoke to were relatively bullish about Biden’s short-term — and even medium-term — prognosis. “It’s not curable, but it’s highly treatable,” Morgans said.

“Without meaning to sound glib, there’s never been a better time to have metastatic prostate cancer in the history of medicine,” Litwin said — in part thanks to Biden’s own cancer “moonshot” initiative and the funding it sent to institutions such as UCLA, which has helped develop new drugs.

“There are numerous, very effective treatments for a patient in his situation,” Litwin said.

The standard and most likely course of care for Biden will be ADT, or androgen deprivation therapy, which involves a pill or shot that will shut down testosterone production, the doctors said.

“Now, an 82-year-old doesn’t have the same testosterone production as a 22-year-old anyway, so there’s not that far to go. But we shut it off,” Litwin said. “And by shutting it off, it cuts out the principal hormone that feeds the prostate cancer. That alone can be very, very effective.”

Dr. Geoffrey Sonn, urologic oncologist and associate professor of urology at Stanford Cancer Center, said Biden’s cancer is serious, but the ADT treatment “will make prostate cancer cells shrink down, stop growing, at least temporarily, in the vast majority of guys.”

“That is, it’s not a permanent fix, in that those cells will eventually figure out a way to grow even with low levels of testosterone,” Sonn said. “But that can take several years, and sometimes longer.”

Recent studies have shown that adding additional medications to an ADT regime can extend life even further, Sonn said, to “four, five, seven, 10” years or more after a metastatic prostate cancer diagnosis.

Dr. Mihir Desai, a urologist with Keck Medicine of USC, said with modern advancements, prostate cancer is just different than other cancers.

“If you find, say, colon cancer or pancreatic cancer or liver cancer are metastasized, then the deterioration is fairly fast and the outcomes are very poor,” he said. But with previously untreated metastatic prostate cancer, “there are many lines of treatment that can, if not cure it, certainly keep it under control for many years, with good quality of life.”

Sandler, who focuses on radiation oncology, said ADT treatment can cause loss of bone density or muscle mass, so Biden will likely be encouraged to stick to a fitness regimen or take medications to counter those effects.

He may also receive radiation to more heavily target specific pockets of cancer, including where it has metastasized to the bone, but that would depend on the number of metastatic sites, Sandler said — with radiation more likely the fewer sites there are.

“If there’s cancer all over the place, then there’s probably no benefit,” he said.

If you have been to an ER lately — or if you’ve watched the disturbingly accurate TV show “The Pitt” — you’ve seen scenes that resemble field hospitals more than state-of-the-art medical centers. Waiting rooms have been turned into makeshift care zones. Chairs, cots and cubicles serve as gurneys. Providers eyeball the sick and injured and “shotgun” orders for patients. It feels chaotic and unwelcoming because it is.

This is the new normal for emergency departments in the United States, the result of a dramatic rise in the number of ER beds occupied by patients waiting for a space on a traditional hospital ward. We call them “boarders” and in many emergency departments, they routinely account for half or more of all available care space.

With a fraction of beds in play for new arrivals, waiting room patients — even some arriving by ambulance — are increasingly likely to be seen, examined and treated in the lobby. The consequences are as predictable as they are devastating: worse patient outcomes, fragmented care, longer hospital stays, ballooning costs and rising frustration and anger among staff and patients.

Less visible — but no less harmful — is the toll this takes on young doctors in training.

A recent study led by Dr. Katja Goldflam, a Yale professor, documents the scale of the problem. Nearly three-quarters of the emergency medicine residents she surveyed reported that boarding had highly negative effects on their training. They expressed anxiety and a mounting emotional toll over their diminishing ability to manage patients or handle department surges with confidence, and their growing sense that they could not provide the kind of care they’d expect for their own families.

As emergency medicine educators with a combined six decades of experience, this feels personal to us. We are failing our trainees. We are failing our patients. And we are compromising the future of doctors and patients alike.

The damage is not theoretical. One of us recently experienced it personally, when his father — during the final months of his life — visited two prestigious ERs. Both times, recently trained physicians missed straightforward but life-threatening problems after brief, stopgap-style encounters. Poor clinical judgment is more likely, and more consequential, in a hurried and overwhelmed care environment.

Today, medical education is no longer centered on memorizing facts. With smartphones, decision-support tools and now AI, information is everywhere. What sets a good doctor apart is judgment — the ability to navigate uncertainty, synthesize complex data and make decisive, accurate choices. Building this kind of judgment requires many patient encounters — “reps.”

No amount of classroom learning, reading or podcast listening can replace the formative experience of confronting a clinical puzzle in a patient who has entrusted you with their care. Yet in today’s crowded ERs, physicians in training are losing access to these crucial face-to-face encounters and the skills, competence and confidence they teach.

Shift change “rounds” — once a space for discussion and reflection — now operate more like inventory checks: Here’s a 78-year-old with heart failure, there’s a 35-year-old with appendicitis still awaiting an OR.

Meanwhile, as the waiting room overflows, doctors scatter into the lobby to see new arrivals, hoping to reduce the backlog. “Lobby medicine” — a sanitized term for care delivered in a setting stripped of privacy, dignity and safety — is more than a logistical nightmare. It sends a terrible message to young physicians: that cursory patient assessments, firing off broad-spectrum tests and “moving the meat” is acceptable. It is not.

Why is boarding getting worse?

COVID-19 was the inflection point. While volumes dipped early in the pandemic, they rebounded within a year — and in 2024, according to national hospital metrics, stood at 10% above 2021 levels. In 2023, research showed a 60% increase in boarding and fourfold increase in median boarding times compared with pre-pandemic ERs.

The reasons are complex and systemic: financial pressure to keep hospital beds full (every open space is lost revenue), an aging population with greater needs, dwindling access to primary care and a collapsing system of rehab, skilled nursing or home health options. Hospitals are boxed in, forced to provide basic care while waiting days, sometimes weeks, for aftercare services to become available. It is not uncommon for a third or more of the patients in a hospital to be on hold pending an appropriate discharge destination. The bottleneck trickles down: Wards become holding areas, the ER becomes a de facto ward and the lobby becomes the ER.

So, what’s the fix?

The simple answer — just end boarding — has been the rallying cry of well-intentioned efforts for decades. Nearly all have failed. Why? Because emergency department crowding is not the root problem. It’s the canary in the coal mine of a dysfunctional healthcare delivery system riddled with misaligned incentives and priorities.

Real change will require collective outrage that spills beyond the ERs, into the inboxes and onto the agendas of hospital administrators, insurance executives and elected officials.

Consider air travel. Imagine if Los Angeles International Airport shut down three of its four runways, forcing all takeoffs and landings onto one. Travelers would revolt. The Federal Aviation Administration would intervene. The system would be made to fix itself — because it’s unsafe, ineffective and unsustainable.

But when the same thing happens in healthcare, some patients may bark in anger and frustration at the multi-hour waits, but most simply shrug, grateful, finally, for an exhausted ER doc’s time.

Enough.

If we want better healthcare it means investing more — adding beds, staffing and aftercare capacity. It means creating primary care options other than a default trip to the ER. It means reclaiming the ER not just as a place for healing, but as a place for learning. A place where doctors are taught not in disaster zones, but in environments that allow for connection and understanding of our patients and their diseases. Finally, it means recognizing that designing and investing in better systems and in medical education is crucial to public safety.

Training a great doctor is like training a great athlete. You can’t learn to sink a three-pointer by watching YouTube. You have to step onto the court. In medicine, that means standing in front of a patient and deciding: What now?

That experience — raw, real and imperfect — is irreplaceable. And we’re losing it.

How we care for patients today will define how we all will be cared for tomorrow.

Eric Snoey is an attending emergency medicine physician in Oakland. Mark Morocco is a Los Angeles physician and professor of emergency medicine.

Exercise has long been linked with stronger brains and reduced risk of dementia and other cognitive diseases. But new research suggests that older adults can significantly improve brain health with only a few minutes of daily movement.

Researchers from the University of South Australia and the U.S.-based AdventHealth Research Institute found that as few as five minutes of moderate-to-vigorous exercise a day correlated to significantly better cognitive performance. The study, published in the British journal Age & Ageing in early April, examined data from hundreds of people 65 to 80 years old.

Researchers found that “huff-and-puff” movements, like running or lap swimming, were associated with better brain functions including information processing, focusing and multitasking and short-term memory. They also found that even a few minutes of moderate exercise like walking improves brain functions.

“Our key finding was that moving from doing zero minutes or very little moderate-to-vigorous physical activity to doing just five minutes a day — that’s where the biggest gain in cognitive function was seen,” said the study’s lead author, Maddison Mellow, a research associate at the University of South Australia.

The researchers distinguished between moderate and vigorous exercise by applying a simple test: whether subjects could still manage to speak full sentences after moving around. Vigorous exercise makes that impossible, said Audrey Collins, a postdoctoral research scientist at AdventHealth Research Institute and the paper’s co-lead author.

The study observed 585 people, all in good health. Their physical activity was measured using accelerometers they wore on their wrists; the researchers tested cognitive functions using online and paper-based tests.

Worth noting: This study also found a “strong relationship” between spending little to no time doing moderate to vigorous activity and poorer cognitive performance, Mellow said. One slightly surprising finding, she added, was that the cognitive performance gains from exercise don’t extend to longer-term memory and visual-spatial functions like judging distances or sizes.

The study was novel in that it categorized how people divided their days into three behaviors: sleep, sedentary and active. And though getting enough quality sleep is important to brain health in midlife and beyond, the researchers said that when forced to choose between minutes spent sleeping and minutes spent exercising, reducing sleep time to spend more time moving resulted in better brain function.

“It didn’t really matter, in this sample, where time was coming from, whether from sleep, sedentary behavior or light intensity physical activity,” Mellow said. “So long as time was being increased in moderate vigorous activity, that’s where the benefits were being shown for cognitive outcomes.”

With that in mind, what are some moderate or vigorous bursts of exercise for older adults to do every day? We consulted experts to give you five accessible options.

1. Walking

Two experts I spoke with each said the easiest way to clock those five daily minutes for brain health is by walking.

“Walking is No. 1, because that’s the easiest,” said E. Todd Schroeder, professor of clinical physical therapy and the director of the Clinical Exercise Research Center at USC. Very sedentary older adults may want to start with simple flat-ground walking at their normal pace, Schroeder says.

If you’re already a steady, regular walker, kick up the pace to elevate your heart rate into that all-important moderate category.

“A brisk walk is considered to be moderate activity,” said Rob Musci, an assistant professor of health and human sciences at Loyola Marymount University. On a scale of 1 to 10, moderate exercise is what you would consider being in the 4 to 6 range, Musci said.

To achieve a real huff-and-puff workout, walking or hiking briskly uphill is excellent, Schroeder said, because it also necessarily requires walking back down hill.

“That interval-type training is good,” he said, “where your heart rate goes up for a time then comes back down.”

2. Swimming

Swimming is a terrific way to get a full-body workout and raise your heart rate.

“It’s easy on the joints,” Shroeder said. “Even if you struggle with the technique of swimming, you can put on fins and get some at least moderate exercise.”

3. Cycling

Cycling can be on a stationary bike or an outdoor bike, many of which are now battery-assisted, making pedaling up hills almost too easy. One reason I like old-fashioned outdoor bikes, sans batteries, is that they also train balance and require your brain to keep you safe.

4. Resistance training

Lifting weights is one of the best ways to maintain muscle strength as we age, Musci said. Try these simple exercises you can easily do at home in fewer than three minutes. They include:

• Tossing a weighted ball from one hand to another (try it standing on one leg)
• Squats holding a kettlebell, dumbbell, a bag of oranges or nothing at all
• Weighted chest presses in boat pose

5. Gardening and housework

Gardening can be a great way to engage core muscles, encourage flexibility and practice fine motor skills. Even basic house cleaning, like scrubbing a bathtub or mopping a floor, can qualify as moderate exercise.

“Anything that gets your heart going is what we’re looking for,” Musci said. “You hear about all these high-end interventions, fitness programs and boot camps, but in reality, it’s just movement.”

The most important thing, he said, is “just getting off the couch.”

Von Zielbauer is the creator of Aging With Strength on Substack.