In 1970, Dr. Richard J. Ablin discovered the PSA, or prostate-specific antigen, which has been widely used as a screening test for prostate cancer since 1994.
That test, he says, is a terrible mistake — a disaster that spawned a multi-billion dollar industry and has destroyed millions of men’s lives with surgeries that often leave them incontinent and impotent.
In March, Ablin, a professor of pathology at the University of Arizona College of Medicine, Arizona Cancer Center and BIO5 Institute, published “The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster” (Palgrave/Macmillan), coauthored by science writer Ronald Piana.
PSA should never have been used to screen for cancer, Ablin told the AJP, explaining that it is not cancer-specific. The test records the levels of a protein found in normal as well as diseased prostates, and there are several reasons levels may be elevated besides cancer, including a fairly common condition known as benign prostatic hyperplasia (enlarged prostate) and another condition, prostatitis (inflammation of the prostate).
Ablin agrees that many screening tests, such as mammograms for breast cancer and colonoscopies for colon cancer, are very useful.
But PSA levels are not a good predictor of whether a man may have prostate cancer. A level of 4 has been set as the point of concern, but “a man could have a PSA of 0.5 and he can have cancer. And he can have a level of 11 and not have cancer,” Ablin says.
More important, says Ablin, is that most men who do have prostate cancer won’t die from it. It’s most often such a slow-growing cancer, he says, that men who have it will eventually die of something else entirely, such as heart disease.
Prostate cancer is age-related, he explains. The older a man is, the greater the chances he’ll develop prostate cancer. Ablin notes that as he is now 74, there’s a 70 to 75 percent chance a biopsy would show he has it.
But the big question, he says, is whether it is slow-growing and localized, as is the case with most prostate cancers, or aggressive.
Here Ablin brings out a simple illustration of a turtle and a rabbit that he uses in presentations, including one he gave in 2011 to the men’s club at Temple Emanu-El, where he’s a member. The turtle, lying on its back inside an open box, represents the indolent, nonlethal cancer that will remain in the box (the prostate), while the fast, unpredictable rabbit can leap out of the box, spreading cancer to other parts of the body.
The good news, says Ablin, is that there are many more turtles than rabbits. Unfortunately, as yet medical science cannot determine whether a prostate cancer is a rabbit or a turtle — and hearing the word “cancer” understandably frightens most people. Their reaction is most often to opt for surgery. “
But the side effects of a radical prostatectomy, surgery to remove the prostate, can be severe, says Ablin — impotence and/or incontinence.
Nowadays, more men and their doctors are opting for “active surveillance” — using frequent tests to monitor whether prostate cancer is progressing, says Ablin, who favors this approach but acknowledges it has inherent risks.
The misuse of PSA to screen for cancer also leads to millions of unnecessary and painful needle biopsies, says Ablin. After one of his Tucson talks, he says, a man told him the pain was like snapping a rubber band that had been stretched across I-10.There are often false positive results, as well as bleeding, infection and residual pain, says Ablin.
Ablin has been arguing against the use of the PSA test to screen for cancer for decades, including in a 2010 Op-Ed in the New York Times. But if the testing were to stop and unnecessary, expensive procedures were halted, he predicts, “half of the urology practices in the United States would go belly up.”
Other researchers have argued that since PSA screening for prostate cancer began, the percentage of men who die from the disease has decreased. Ablin cites several reasons for this. Most important is an increase in the number of cases being diagnosed, due to increased awareness. With more cases overall, but the numbers of those who die remaining the same, he explains, it gives the false impression that mortality rates are improving. There have also been advances in surgical and other treatments, he says.
The PSA test does have one important use, says Ablin: to check whether there is still PSA in the blood after a diseased prostate has been removed or destroyed by radiation or other therapy. Since PSA is prostate-specific, not found in any other gland, if more than a small amount of PSA is still present or it increases months after surgery, it means the treatment either didn’t remove or destroy the entire prostate, or the patient had micro-metastases, the spreading of cancer cells to other parts of the body, that didn’t show up when he was first diagnosed.
To those who say Ablin doesn’t understand the ravages of prostate cancer, he has a simple rebuttal: he watched his father die of prostate cancer at age 67. In one year, “he went from 185 pounds to 95 pounds. I could carry him,” he recalls.
Back when Ablin discovered PSA, he and two urologists at a hospital research institute in Buffalo, N.Y., were experimenting with cryosurgery, or freezing the tumor, to treat prostate cancer. He saw that in men who had advanced cancer, it provoked a profound immune response: tumors in other parts of their bodies regressed or vanished. He thought the frozen tissue destruction might have somehow liberated a cancer-specific antigen responsible for the immune effect. “I could not find one,” he writes in his book, “but I did discover a prostate-tissue specific antigen — PSA.”
Today, cryoimmunotherapy continues to hold promise in the search for a cure, says Ablin. And scientists are continuing to search for a true biomarker for prostate cancer — including Ablin, who is collaborating with a colleague at Cardiff University in Wales. But he also remains focused on spreading the message that using PSA to screen for cancer does more harm than good.