cancer diagnosis

Greg Papa, the legendary sports radio voice in the Bay Area, is stepping away from his broadcasting duties while undergoing treatment for cancer, he announced Friday.

Papa, the radio voice of the San Francisco 49ers and a longtime host on KNBR (680 AM), did not specify the type of cancer he is battling in a statement released by the radio station but said he expects a full recovery.

“As I fully focus on my treatment and work toward a full recovery, I’m stepping away from my broadcasts but look forward to returning soon,” Papa said. “Thanks to everyone for your prayers and good wishes as I begin this fight.”

Papa, 62, began his career doing radio play-by-play for the Indiana Pacers in 1984 but launched a decades-long career in the Bay Area when hired by the Golden State Warriors in 1986.

He transitioned to television in the ‘90s, calling games for the San Antonio Spurs. He also called baseball games on TV, beginning with the Oakland Athletics before jumping to the San Francisco Giants in the mid-2000s.

When play-by-play announcer Dave Flemming’s microphone went dead for 10 seconds after Barry Bonds hit his 715th career home run to pass Babe Ruth on the all-time list in 2006, Papa took over the broadcast and explained what had transpired.

“To lose a mic like that, I’ve never seen it,” Papa said. “I’ve never been a part of something like this.”

Flemming was distraught but took it in stride with Papa’s help.

“I think it’s the last gasp of the curse of the Bambino,” Flemming joked. “Now, I’m starting to rethink my whole world.”

Papa’s coworkers rallied to support him when the diagnosis was announced.

“Greg is not just our teammate at The Sports Leader, he’s one of the most iconic play-by-play men in the history of our beloved Bay Area,” said Brian Murphy, the popular longtime KNBR talk show host. “Nobody else has done the Warriors, Raiders, Giants, A’s and 49ers like Greg, so he has every Northern California fan base rooting hard for him to come out healthy and get back behind the mic.”

Papa, a three-time winner of the California sportscaster of the year award, has been the radio play-by-play announcer for the San Francisco 49ers since the 2019 season. His contract with the 49ers extends through the 2028 season.

“The 49ers family extends our unwavering love and support to Greg Papa and his family following his recent cancer diagnosis,” the 49ers said in a statement. “We wish him a speedy recovery and look forward to welcoming him back to the radio booth as the ‘voice of the 49ers’ whenever he is ready.”

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.

WASHINGTON — The revelation that former President Biden has advanced prostate cancer generated more questions than answers on Monday, prompting debate among experts in the oncology community over the likely progression of his disease and resurfacing concerns in Washington over his decision last year to run for reelection.

Biden’s private office said Sunday afternoon that he had been diagnosed earlier in the week with an “aggressive form” of the cancer that had already spread to his bones, after urinary symptoms led to the discovery of a nodule on his prostate.

But it was not made clear whether Biden, 82, had been testing his prostate-specific antigens, known as PSA levels, during his presidency — and if so whether those results had indicated an elevated risk of cancer while he was still in office or during his campaign for reelection.

Biden’s diagnosis comes at a difficult time for the former president, as scrutiny grows over his decision to run for a second term last year — and whether it cost the Democrats the White House. Biden ultimately dropped out of the race after a devastating debate performance with Donald Trump laid bare widespread concerns over his age and health, leaving his successor on the Democratic ticket — Vice President Kamala Harris — little time to run her own campaign.

A book set to publish this week titled “Original Sin,” by journalists Jake Tapper and Alex Thompson, details efforts by Biden’s aides to shield the effects of his aging from the public and the press. The cancer diagnosis only intensified scrutiny over Biden’s health and questions as to whether he and his team were honest about it with the public.

“I think those conversations are going to happen,” said David Axelrod, a former senior advisor to President Obama.

President Trump, asked about Biden’s diagnosis during an Oval Office event Monday, said it was “a very, very sad situation” and that he felt “badly about it.”

But he also questioned why the cancer wasn’t caught earlier, and why the public wasn’t notified earlier, tying the situation to questions he has long raised about Biden’s mental fitness to serve as president.

PSA tests are not typically recommended for men over 70 due to the risk of false positive results or of associated treatments causing more harm than good to older patients, who are more likely to die of other causes first.

But annual physicals for sitting presidents — especially of Biden’s age — are more comprehensive than those for private citizens. And a failure to test for elevated PSA levels could have missed the progression of the disease.

A letter from Biden’s White House physician from February of last year made no mention of PSA testing, unlike the most recent letter detailing the results of Trump’s latest physical, which references a normal measurement. Biden’s current aides did not respond to requests for comment on whether his office would further detail his diagnostic testing history.

Even if his doctors had tested for PSA levels at the time, results may not have picked up an aggressive form of the cancer, experts said.

Some specialists in the field said it was possible, if rare, for Biden’s cancer to emerge and spread since his last physical in the White House. Roughly 10% of patients who are newly diagnosed with prostate cancer are found with an advanced form of the disease that has metastasized to other parts of the body.

Dr. Mark Litwin, the chair of UCLA Urology, said it is in the nature of aggressive prostate cancers to grow quickly. “So it is likely that this tumor began more recently,” he said.

Litwin said he does not doubt that Biden would have been screened for elevated PSA levels. But, he said, he could be among those patients whose cancers do not produce elevated PSA levels or whose more aggressive cancers rapidly grow and metastasize within a matter of months.

“The fact that he has metastatic disease at diagnosis, to me, as an expert in the area and as a clinician taking care of guys with prostate cancer all the time, just says that he is unfortunate,” Litwin said.

Litwin and other experts in prostate cancer from USC, Stanford, Johns Hopkins, Cedars-Sinai and the Dana-Farber Cancer Institute all told The Times that Biden’s diagnosis — at least based on publicly available information — was not incredibly unusual, and similar to diagnoses received by older American men all the time.

They said he and his doctors absolutely would have discussed testing his PSA levels, given his high level of care as president. But they also said it would have been well within medical best practices for him to decide with those doctors to stop getting tested given his age.

Dr. Howard Sandler, chair of the Department of Radiation Oncology at Cedars-Sinai, said he sees three potential explanations for Biden’s diagnosis.

One is that Biden and his doctors made a decision “to not screen any longer, which would be well within the standard of care” given Biden’s age, he said.

A second is that Biden’s was tested, and his PSA level “was elevated, maybe not dramatically but a little bit elevated, but they said, ‘Well, we’re not gonna really investigate it,’” again because of Biden’s age, Sandler said.

The third, which Sandler said was “less likely,” is that Biden’s PSA was checked “and was fine, but he ended up with an aggressive prostate cancer that doesn’t produce much PSA” and so wasn’t captured.

Zeke Emanuel, an oncologist serving as vice provost for global initiatives at the University of Pennsylvania and a former health policy official in the Biden administration, told MSNBC that Biden has likely had cancer for “more than several years.”

“He did not develop it in the last 100, 200 days. He had it while he was president. He probably had it at the start of his presidency, in 2021,” Emanuel said.

But Litwin, who said he is a friend of Emanuel’s, said most men in their 70s or 80s have some kind of prostate cancer, even if it is just “smoldering along” — there but not particularly aggressive or quickly spreading — and unlikely to be the cause of their death.

He said Biden may well have had some similar form of cancer in his prostate for a long time, but that he did not believe that the aggressive form that has metastasized would have been around for as long as Emanuel seemed to suggest.

Departing Rome aboard Air Force Two, Vice President JD Vance told reporters he was sending his best wishes to the former president, but expressed concern that his recent diagnosis underscored concerns over Biden’s condition that dogged his presidency.

“Whether the right time to have this conversation is now or in the future, we really do need to be honest about whether the former president was capable of doing the job,” Vance said. “I don’t think that he was in good enough health. In some ways, I blame him less than I blame the people around him.”

Trump’s medical team has also faced questions of transparency.

When Trump was diagnosed with COVID-19 during his first term, at the height of the pandemic, he was closer to death than his White House acknowledged at the time. And his doctors and aides regularly use superlatives to describe the health of the 78-year-old president, with Karoline Leavitt, his White House press secretary, referring to him as “perfect” on Monday.

“Cancer touches us all,” Biden posted on social media alongside a photo with his wife, Jill Biden, in his first remarks on his diagnosis.

“Like so many of you, Jill and I have learned that we are strongest in the broken places,” he added. “Thank you for lifting us up with love and support.”