The Great Prostate Hoax

1. The PSA Test: A Well-Intentioned Discovery, Dangerously Misused

I wrote this book, in part, as an apology to a man I’ve never met.

Humble beginnings. The author, Richard Ablin, discovered prostate-specific antigen (PSA) in 1970, initially intending it as a biomarker for prostate tissue, not specifically for cancer detection. However, the PSA test was later adopted as a screening tool for prostate cancer, leading to widespread and often unnecessary testing. This misuse has resulted in millions of men undergoing biopsies and treatments that may have done more harm than good.

Unintended consequences. Ablin expresses deep regret for the role his discovery played in the "public health disaster" of mass PSA screening. He emphasizes that PSA is not cancer-specific and that its use as a screening tool has led to overdiagnosis and overtreatment. The book serves as an apology to the countless men and their families who have suffered needlessly due to the misuse of the PSA test.

A cautionary tale. The story of the PSA test highlights the potential for scientific discoveries to be misinterpreted and misused, especially when financial incentives are involved. It underscores the importance of critical thinking, evidence-based medicine, and informed decision-making in healthcare. The author's personal connection to the issue, having lost his father to prostate cancer, adds a layer of emotional weight to his critique.

2. The FDA's Role: A Checkered Past and a Missed Opportunity

In a larger sense, the situation dramatized by John illustrates the grim reality of the health care system itself: encouraged by perverse incentives, many of the tests and procedures that doctors do are unnecessary, and quite a few are downright harmful.

Regulatory failures. The FDA's approval of the PSA test for early detection in 1994 is presented as a "fateful error" that opened the floodgates for mass screening. The author criticizes the agency for failing to adequately assess the potential harms of the test and for allowing device makers to promote off-label use. The FDA's decision is contrasted with the more cautious approach taken by regulatory bodies in other countries.

Conflicted interests. The book suggests that the FDA's approval process is susceptible to influence from the pharmaceutical industry and that the agency often prioritizes industry interests over public safety. The author points to the revolving door between the FDA and the pharmaceutical industry as a source of potential conflicts of interest. The approval process for medical devices is described as "sieve-like," allowing countless harmful devices to enter the market.

A call for accountability. The author calls for greater accountability from the FDA and for reforms to the medical-device approval process. He argues that the agency must prioritize patient safety and adhere to the principle of "first, do no harm." The book questions the FDA's ability to effectively monitor the safe use of medical products once they are approved.

3. Urology's Financial Incentive: A Conflict of Interest?

They get paid to prescribe drugs, deliver treatments, and cut.

Perverse incentives. The author argues that the fee-for-service payment system in healthcare creates perverse incentives for doctors to overtreat patients. Urological surgeons, in particular, are incentivized to perform radical prostatectomies, even when other options may be more appropriate. The book suggests that many urology practices would struggle financially without the revenue generated by PSA testing and subsequent procedures.

The business of prostate cancer. The author describes the prostate cancer industry as a "multibillion-dollar machine" fueled by greed and ego. He criticizes the marketing tactics used to promote PSA screening and the influence of pharmaceutical companies on medical decision-making. The book highlights the financial ties between doctors, advocacy groups, and the pharmaceutical industry.

A call for ethical practice. The author calls for a shift in the medical culture towards more ethical and patient-centered care. He argues that doctors should prioritize the well-being of their patients over their own financial interests. The book questions the motives of doctors who continue to promote PSA screening despite the mounting evidence of its harms.

4. The Four Cruxes: Why PSA Screening Fails as Public Health Policy

Put simply, the ability of the PSA test to identify men with prostate cancer is slightly better than that of flipping a coin.

PSA is not cancer-specific. The PSA protein is produced by both normal and cancerous prostate tissue, making it an unreliable indicator of cancer. Elevated PSA levels can be caused by a variety of factors unrelated to cancer, such as benign prostatic hyperplasia (BPH) and prostatitis. The author emphasizes that there is no "normal" PSA level and that the current cutoff of 4 ng/mL is arbitrary.

No specific level detects cancer. A man can have a low PSA level and still have prostate cancer, while another man can have a high PSA level and be cancer-free. The PSA test cannot distinguish between indolent and aggressive cancers. The test cannot differentiate between "turtles" (slow-growing cancers) and "rabbits" (fast-growing cancers).

Prostate cancer is age-related. The prevalence of prostate cancer increases with age, meaning that many men will be diagnosed with the disease even if it is unlikely to cause them harm. The author argues that PSA screening often leads to the detection of "low-hanging fruit," or cancers that would never have caused symptoms or death. The author is against population screening for prostate cancer because it does not extend the lives of men.

The four cruxes. The author summarizes his argument against routine PSA screening with four key points:

• PSA cannot diagnose prostate cancer.
• There is no specific level of PSA that detects prostate cancer.
• The PSA test cannot distinguish an indolent cancer from an aggressive cancer.
• Prostate cancer is age-related.

5. The Human Cost: Crippling Side Effects and Lost Manhood

There was postsurgery incontinence, a constant dripping of urine that forced John to wear an absorbent pad—his diaper, as he wryly called it.

Beyond the numbers. The book emphasizes the human cost of unnecessary prostate cancer treatments, such as radical prostatectomy and radiation therapy. These treatments can lead to debilitating side effects, including incontinence, impotence, and bowel dysfunction. The author argues that these side effects are often downplayed by doctors and that men are not fully informed about the risks before undergoing treatment.

Loss of manhood. The author highlights the psychological impact of prostate cancer treatments on men's sense of masculinity and self-worth. He argues that the loss of sexual function and urinary control can be devastating and that these issues are often overlooked in the medical literature. The book includes personal stories from men who have experienced these side effects firsthand.

The importance of informed consent. The author stresses the importance of informed consent and shared decision-making in prostate cancer care. He argues that men should be fully aware of the risks and benefits of all treatment options before making a decision. The book encourages men to seek second opinions and to question their doctors' recommendations.

6. The Allure of New Technologies: Gizmo Idolatry in Prostate Cancer

Today, many medical technologies are developed looking for a clinical question to answer.

The medical arms race. The author criticizes the "medical arms race" in prostate cancer, in which new technologies are rapidly adopted without sufficient evidence of their effectiveness. He points to proton-beam therapy and robotic surgery as examples of expensive treatments that have not been proven to be superior to less costly alternatives. The book suggests that the adoption of new technologies is often driven by financial incentives rather than clinical need.

Gizmo idolatry. The author introduces the concept of "gizmo idolatry," which refers to the tendency to believe that more technological approaches are intrinsically better, even when there is no evidence to support this belief. He argues that this mindset has led to the overuse of expensive and unproven treatments in prostate cancer. The author notes that the need to keep the da Vinci robots humming with patients might be one reason for a recent spate of reported injuries and adverse events (AEs).

A call for evidence-based medicine. The author calls for a greater emphasis on evidence-based medicine and for more rigorous evaluation of new technologies before they are widely adopted. He argues that healthcare decisions should be based on data, not on hype or marketing. The book questions the role of celebrity endorsements in promoting unproven treatments.

7. The Power of Fear: How Emotion Drives Unnecessary Treatment

There is a tendency to want to do something to prevent this disease even if there is no proven benefit and even if it means ignoring potential harms.

The C-word effect. The author emphasizes the powerful emotional impact of a cancer diagnosis, which can short-circuit rational decision-making. He argues that the fear of cancer often leads men to undergo unnecessary treatments, even when the potential harms outweigh the benefits. The book highlights the role of advocacy groups in promoting PSA screening and creating a climate of fear.

Exploitation of vulnerability. The author suggests that the prostate cancer industry exploits men's fear of cancer for financial gain. He criticizes the use of scare tactics and misleading information to promote PSA screening and subsequent treatments. The book questions the ethics of profiting from patients' vulnerability.

A call for rational decision-making. The author encourages men to approach prostate cancer screening and treatment decisions with a clear and rational mind. He argues that it is important to weigh the risks and benefits of all options and to avoid being swayed by emotion or hype. The book stresses the importance of seeking second opinions and consulting with doctors who are not financially incentivized to recommend treatment.

8. The Search for a Better Marker: Hope for the Future

I, along with others, am still searching for a true prostate cancer-specific marker.

Limitations of current tools. The author acknowledges the limitations of current prostate cancer detection and treatment methods. He emphasizes the need for a better marker that can accurately identify aggressive cancers and distinguish them from indolent ones. The book highlights the ongoing research efforts to find a true prostate cancer-specific marker.

Personalized medicine. The author expresses hope for the future of personalized medicine, in which treatments are tailored to the individual characteristics of each patient's cancer. He suggests that this approach could lead to more effective and less harmful treatments for prostate cancer. The author's own research in cryoimmunotherapy is presented as a potential avenue for future breakthroughs.

A call for continued research. The author calls for increased funding for prostate cancer research, particularly for studies focused on identifying new biomarkers and developing more targeted therapies. He argues that the focus should shift from mass screening to more individualized and evidence-based approaches. The book concludes with a message of hope, emphasizing that progress is possible with continued research and a commitment to ethical and patient-centered care.

Last updated: March 2, 2025