As physicians, we spend our careers believing that if we gather enough data, follow the guidelines, and monitor closely, we can stay one step ahead of disease. We reassure patients that early detection saves lives. We quote statistics, interpret lab values, and project confidence. Nothing dismantles that illusion of control quite like becoming a patient.

I have written before about my prostate cancer journey, before the surgery, after the surgery, and the long stretch of emotional and physical recovery that followed. Recently, President Biden’s diagnosis with aggressive metastatic prostate cancer brought me back to those memories and to a question that has haunted me since my own diagnosis: How can someone under constant medical oversight end up with metastatic disease?

My first reaction was disbelief. My second was a blend of medical training and personal unease: How reliable are the numbers we lean on, especially PSA?

I asked my wife, a pathologist who has spent decades peering through microscopes at the tissue that decides so much of our patients’ fates, whether PSA levels correlate strongly enough with Gleason scores to predict aggressiveness.

She gave me a look that said, “That’s adorable, but no.” The physician in me wanted certainty. The patient in me wanted reassurance. The pathologist in my house gave me reality.

My own PSA never climbed above 7. I took comfort in that number. But PSA is a noisy biomarker, a protein released by both healthy and malignant prostate cells. It rises for reasons other than cancer, and because cancers can evolve in unexpected ways, some aggressive tumors produce little PSA. PSA is invaluable because it tells us when to look further, but it is not a verdict.

The Gleason score vs. PSA

The Gleason score is different. It is assigned by pathologists who examine the morphology of cancer cells and remains the most reliable predictor of how prostate cancer will behave. To borrow an analogy, imagine a bakery that wants to automate pricing. A camera that recognizes the shape and size of pastries can be remarkably accurate at identifying which item is which. In pathology, the Gleason score is that camera; it looks at form and structure and, from that morphology, infers behavior. Slightly odd-looking cells may represent low-grade disease that we monitor; markedly abnormal cells suggest a tumor that is biologically aggressive.

PSA and the digital rectal exam tell us when to biopsy. The biopsy, and the Gleason score assigned to that tissue, tells us what we are dealing with.

Living with two narrators

When I heard about Biden’s metastatic disease, I felt a mix of empathy and unease. If someone with the best care and constant oversight can develop advanced cancer, what does that mean for the rest of us? The sobering truth is that aggressive prostate cancer does not always produce high PSA levels. Some of the most dangerous tumors fly under the radar.

Being both a physician and a patient is like living with two narrators in your head. The physician’s voice says, “Stay objective. Trust the data.” The patient’s voice says, “Why me? What now?” Then there is the pathologist’s voice, the one that cuts through both: The tissue tells the truth. Pathologists do not speculate; they describe what is present.

What every man should know

After walking this road, here is what I wish every man and every clinician understood about prostate cancer:

• PSA is a tool, not a verdict. It is a reason to investigate, not a measure of severity.
• Gleason score is the real predictor. It reflects tumor architecture and aggressiveness.
• Low PSA does not guarantee low-risk disease. Some aggressive cancers produce little PSA.
• Even perfect monitoring has blind spots. Cancer is inherently unpredictable.
• Ask questions but accept uncertainty. Medicine is full of gray zones; cancer lives in many of them.

Navigating uncertainty

I often joke that being married to a pathologist is like having a built-in second opinion at home, one that comes with sarcasm and a reminder to take out the trash. Her perspective saved me from spiraling into complacency about test results and from the paralysis of what-ifs. She reminded me that cancer is not a math problem. It is a biological story, and each patient’s story is different.

My PSA was under 7, and my cancer still needed to come out. President Biden’s condition included aggressive disease despite close monitoring. Both stories reflect the complexity of prostate cancer and, more broadly, the limits of certainty in medicine.

I do not pretend to have all the answers, not as a physician, and certainly not as a patient. But I do know this: Early detection matters, understanding your disease matters, and having someone who can explain the pathology report over dinner is a privilege I do not take lightly.

Medicine is not about eliminating uncertainty. It is about navigating it with honesty, humility, and hope. And maybe, if you are lucky, with a pathologist who loves you enough to tell you the truth, even when you do not want to hear it.

Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness. 

Dr. Torres was born in Spain and grew up in Puerto Rico. He graduated from the University of Puerto Rico School of Medicine. Dr. Torres performed his physical medicine and rehabilitation residency at the Veterans Administration Hospital in San Juan before completing a musculoskeletal fellowship at Louisiana State University Medical Center in New Orleans. He served three years as a clinical instructor of medicine and assistant professor at LSU before joining Florida Spine Institute in Clearwater, Florida, where he is the medical director of the Wellness Program.

Dr. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine. He is a prolific writer and primarily interested in preventative medicine. He works with all of his patients to promote overall wellness.