As a urologist, I consider myself an expert on the subject of prostate cancer. Here is a urologist’s view of a hypothetical announcement from a former U.S. president, five months after leaving office, of widespread high-grade metastatic prostate cancer.

Prostate cancer is the most common cancer in males. It begins as a cancer in the prostate, and with progression, metastatic disease occurs, primarily in the axial skeleton. Prostate cancer is known for slow growth. Typically, the progression from the development of local disease in the prostate to metastatic disease occurs over the course of many years.

First of all, the diagnosis of widespread metastatic prostate cancer would indicate that the former president had prostate cancer during his four years in the White House. It is most likely true that he had the disease before his election. Widespread metastatic bone disease does not occur overnight. This is true, independent of the cancer’s high-grade status. There is no question that even this advanced stage of prostate cancer would have been present during his years in office. It likely progressed after the end of his presidency, but it is not believable that this stage of his disease was not present during those four years. I believe then, that a president in this situation would have had metastatic prostate cancer while in the White House. There is little doubt that with the presence of metastatic disease, the patient would have been treated with the standard of care, hormonal therapy.

The issue of when this prostate cancer was detected is the next subject. Reportedly, the patient had a normal PSA several years before his election. It is believable that after the age of 70, no further PSA screening was obtained. However, he had access to world-class medical care. It is not true that all men after 70 do not receive further PSA screenings. Many choose to continue these blood tests. I believe, given the patient’s access to medical care and his position, that it is likely that PSA screening continued after his 70th birthday, and continued after he was elected president.

In the present era, only 5 to 7 percent of prostate cancer patients in the United States present with metastatic disease. The likelihood that one of the most powerful people in the world, surrounded with state-of-the-art medical care, would be one of those rare individuals to present with widespread metastatic prostate cancer defies logic to a urologist and the general public at large.

If we assume that the former president had a normal PSA and then had no further screening after the age of 70, most will assume that detecting prostate cancer and its progression was not possible. Recall pre-PSA prostate cancer facts. First of all, the rectal exam in that era was the typical way that the disease was first detected. I would hope that this simple portion of routine physical exams was done regularly. When the hypothetical cancer was announced, the report indicated that a prostate nodule was detected on the rectal exam. Some prostate cancers are not detectable by rectal exam. This is obviously not the case with this patient. In addition, before PSA, other markers of prostate cancer, such as alkaline phosphatase and acid phosphatase, were often obtained. While not as predictive as PSA, their abnormality would frequently lead to the diagnosis of prostate cancer. The alkaline phosphatase test is part of routine liver function screening. As metastatic disease begins, this assay is nearly always elevated.

The presence of widespread metastatic bone disease, in my opinion, was nearly certainly present during the administration. What symptoms do these patients have? They all have significant bone pain. X-rays and bone scans would have been obtained in working up this pain, especially in a president of the United States. These studies, especially the bone scan, would have detected the bony lesions, leading to the diagnosis of prostate cancer.

In summary, it is not believable that a former president presented five months after leaving the White House with widespread, high-grade metastatic prostate cancer. It is virtually certain that prostate cancer was known to be present during his administration. He had likely known metastatic disease during his administration. In addition, if this stage of prostate cancer had been detected, there is no question that it would have been treated with the standard of care, hormonal therapy. Not only was the fact that prostate cancer was present in the White House denied, but his treatment with hormonal therapy, which likely occurred, was not reported as well.

The ongoing announcements of this hypothetical president’s health did not report any of these findings. In a prior announcement, the president’s physician, Dr. Kevin O’Connor, announced to the world that the president was fit to serve. In my opinion, if the subsequent diagnosis were true, this would be a sign of a completely negligent health care team, or more likely, a deliberate withholding of information.

As physicians, we dedicate our lives to detecting and treating medical conditions in our patients. Dr. O’Connor either would have failed to fulfill that responsibility, which constitutes negligence, or was directed to withhold information from the American people. If he was directed to do so, Dr. O’Connor should have resigned. Gross negligence and withholding information are violations of the physician’s code of conduct. We physicians are held to the highest standards of ethical behavior. The medical community must insist on the removal of Dr. O’Connor’s medical license immediately. In addition, he must have all board certifications and medical society memberships to which he belongs revoked. Dr. Kevin O’Connor must never again be allowed to practice medicine.

A lack of transparency regarding a president’s medical condition, requiring a physician to be complicit, is a serious issue of public trust.

Hopefully, a revelation of such unforgivable actions would ensure that this never happens again. Unfortunately, I have little optimism that those responsible for such violations of the public’s faith would ever be held accountable for their actions.

William Lynes is a urologist and author of A Surgeon’s Knot.