Each year, millions of men are screened for prostate cancer using the prostate-specific antigen, or PSA, test. An abnormal result can lead some of these otherwise healthy men to pursue aggressive treatment, causing harm at questionable benefit.
How did such an approach rise to prominence in the absence of firm scientific evidence of its usefulness? This is the quandary at the heart of two new papers by Robert Aronowitz, a professor and chair of Penn’s Department of History and Sociology of Science.
As he was researching the history of prostate cancer interventions, Aronowitz read about a medical trial that took place in the 1950s and ‘60s. The study was known as the Bowery series, named for the then-marginalized New York neighborhood from which participants were recruited. More than 1,200 men took part in the trial, which was led by a urologist who aimed to prove that prostate cancer could be detected early and successfully treated.
By today’s standards of medical ethics, however, the study’s methods trigger alarm bells, Aronowitz says. The men were homeless and alcoholic, and may not have fully understood the risks of participating in the research, which involved having a sizable tissue biopsy. If the sample showed signs of cancerous cells, the men were offered aggressive treatment, involving removal of the prostate gland and testes, and the administration of a synthetic estrogen.
“There’s no documentation or evidence that these men gave adequate informed consent to be part of this research,” Aronowitz says.
Aronowitz explores what he sees as “continuities” between the Bowery series and the prostate cancer screening, diagnostic, and treatment measures that doctors advise patients to pursue today. Participants in the Bowery study were subjected to invasive tests without knowledge about whether the outcome would be worth the risk. Similarly, men today continue to undergo PSA tests, and subsequent biopsies and treatment, even though randomized clinical trials have shown either no effect of tests and the interventions they trigger on mortality, or a marginal impact but at great financial and health cost.
Moreover, says Aronowitz, the massive expansion of the screen-and-treat paradigm occurred before results from these trials were available.
Aronowitz says his publications bring to light a long-forgotten chapter in cancer screening history, and serve as “a call to reflection” about medical innovation.
“When a medical procedure will be offered at a population level with the potential to transform society and everything we think we know about the targeted disease, we ought to proceed with a very high level of caution, reflection, knowledge production, and evaluation,” he says.