While former President Joe Biden’s prostate cancer diagnosis may have been a shock to the world, he could have known for some time.

According to urologist Dr. David Shusterman, that could indeed be the case.

“It’s very unlikely that someone could get annual checkups and not notice a PSA elevation over the past, you know, but this is what I typically would see in a VA hospital, where a patient hasn’t had medical attention in 10 years presents to an emergency room with bone pain, and then they find that it’s metastatic prostate cancer,” Shusterman said.

“Usually, it takes from the first diagnosis of prostate cancer to spread would take five to 10 years, even in the most aggressive form,” he added.

In a statement released on Sunday afternoon, Biden’s office confirmed he was diagnosed with prostate cancer with metastasis to the bone.

“In the modern age of medicine, especially the fact that he was a former president, he had intensive state-of-the-art care…” Shusterman added.

“I mean, it’s very unusual to hear that someone has prostate cancer, where they’re annually being followed up, and the fact that we just find it at a Gleason nine is just pretty much unheard of in this day and age of medicine.”