TABLE OF CONTENTS: The Great Prostate Hoax, Book Review
1. Introduction to the Prostate-Specific Antigen (PSA) Test and Its Impact
2. Background: The Origins and Intended Use of the PSA Test
3. Piana’s and Ablin’s Argument: Why the PSA Test is a “Hoax”
4. Profit Motives in Medicine: A Critique
5. The Human Cost of Misdiagnosis and Over-Treatment
6. Piana’s and Ablin’s Call for Change: What Should Be Done?
7. Conclusion: Lessons from The Great Prostate Hoax
1. Introduction to the PSA Test and Its Impact
The Great Prostate Hoax opens by framing the PSA (prostate-specific antigen) test as a tool initially intended to aid in managing diagnosed prostate cancer cases rather than screening the general male population. Co-authored by Ronald Piana, a seasoned journalist, and Dr. Richard Ablin, who developed the PSA test in the 1970s, the book critiques the way this test has been promoted as a universal screening measure despite being scientifically unreliable in detecting cancer accurately. This misuse has turned PSA testing into a widespread, fear-driven protocol that, according to the authors, has caused significant harm.
From its beginning, the book emphasises that while early detection of cancer is crucial, over-reliance on flawed testing methodologies like the PSA can have unintended, negative consequences. Piana and Ablin delve into how the test, due to its high rate of false positives, has led many men to undergo unnecessary and invasive treatments, including prostatectomy and radiation, with often life-altering side effects. The PSA’s unintended transformation from a monitoring tool into a screening standard has created a “public health disaster,” as the authors describe it, spurring billions in healthcare costs and emotional trauma for patients who undergo treatment based on misleading test results.
Piana’s exposé style, paired with Ablin’s scientific insight, sets the tone for a deep dive into the flaws of PSA screening, questioning the ethics of a medical practice that, they argue, puts profit over patient well-being. The book suggests that the widespread use of PSA testing was heavily influenced by profit-driven motives within the healthcare industry, which has continued to advocate for the PSA as a screening tool despite mounting evidence of its ineffectiveness.
2. Background: The Origins and Intended Use of the PSA Test
The origins of the PSA test begin with Dr. Ablin’s research in the 1970s, when he identified PSA as a biomarker for prostate health. However, Ablin was clear that the PSA test was never intended to screen for prostate cancer in healthy men. Rather, it was a tool for monitoring those already diagnosed with prostate cancer, helping to track changes in PSA levels that could signal cancer progression or treatment response.
Piana and Ablin explain that PSA is naturally present in the male bloodstream and that levels can fluctuate due to a variety of benign reasons—such as inflammation, benign prostatic hyperplasia (BPH), or even recent physical activity. The lack of specificity means that elevated PSA levels are not a reliable indicator of cancer. Despite this, the PSA test began to be marketed in the 1980s as a means to detect prostate cancer early, a move that the authors argue was based more on financial opportunity than on sound medical science.
The book describes how the U.S. Food and Drug Administration (FDA) approved the PSA test for prostate cancer screening in 1986, following intense lobbying from both pharmaceutical companies and influential figures in the medical community. Piana argues that this approval set off a chain of events that led to the PSA test being widely used in primary care, essentially transforming it from a niche tool for specific cases into a standard part of routine check-ups for men over a certain age. The authors contend that this was the start of an overdiagnosis epidemic, with many men receiving life-altering treatments for cancers that may never have progressed.
Dr Richard J Ablin
Ron Piana
3. Piana’s and Ablin’s Argument: Why the PSA Test is a “Hoax”
Central to The Great Prostate Hoax is Piana’s argument that the PSA test was marketed as an effective cancer detection tool without sufficient scientific evidence. According to the authors, the test’s high rate of false positives led to a “cascade effect,” where men who received high PSA results were pushed into further testing, biopsies, and treatments. This often culminated in radical treatments such as prostate surgery or radiation therapy, despite the fact that many of these cancers were either indolent or so slow-growing that they posed little immediate threat.
The term “hoax” in the book’s title reflects the authors’ view that the healthcare system misrepresented the PSA test’s capabilities for profit. Piana emphasises that the medical industry, by promoting PSA testing as a life-saving measure, has cultivated a climate of fear around prostate cancer that encourages men to seek aggressive treatments at the slightest sign of elevated PSA. The financial incentives are clear: the more men who test, the more revenue is generated from follow-up procedures, treatments, and ongoing care.
The book’s critique extends to the culture within medicine that prioritises metrics over patient outcomes. Piana and Ablin argue that the PSA test serves as a cautionary tale about the dangers of “over-medicalisation”—where diagnostic tests and treatments are expanded beyond their intended purpose, driven by a system that profits from continuous patient engagement.
4. Profit Motives in Medicine: A Critique
One of the most contentious points raised by Piana is the role of profit motives in the healthcare industry’s adoption of the PSA test for routine cancer screening. According to the authors, the PSA test became a cash cow for pharmaceutical companies and medical equipment manufacturers, whose earnings grew as more men were tested, diagnosed, and treated. The cost of prostate cancer treatments can be enormous, from surgery to lifelong hormone therapy, and these procedures contribute significantly to healthcare spending.
Piana describes how, once the PSA test became widespread, its adoption was reinforced by those with vested interests in its continued use. Urologists, hospitals, and even advocacy groups pushed for routine screening despite growing evidence of the PSA test’s limitations. The authors argue that this pressure, largely driven by financial interests, led to a disregard for the medical ethics of “first, do no harm.” Ablin and Piana contend that the PSA test’s promotion was a product of a healthcare industry that prioritised profits over patient well-being.
The book is particularly critical of the “medical-industrial complex,” a term used to describe the network of corporations and organisations that profit from the healthcare industry. Piana and Ablin suggest that this system, incentivised by profits from diagnostics and treatments, led to widespread misuse of the PSA test. They advocate for a more patient-centred approach to healthcare that avoids unnecessary testing and treatment.
5. The Human Cost of Misdiagnosis and Over-Treatment
A significant part of The Great Prostate Hoax is dedicated to exploring the personal stories of men affected by the widespread use of PSA testing. Piana and Ablin recount cases of men who, after receiving elevated PSA test results, went through a series of invasive tests and treatments, only to suffer severe, lifelong side effects. Many of these men faced complications such as impotence, urinary incontinence, and emotional distress from undergoing radical treatments for cancers that might never have posed a significant risk to their health.
These stories highlight the human cost of over-treatment. Piana argues that the PSA test’s high rate of false positives often leads to a “worst-case scenario” approach in which patients are encouraged to undergo surgery or radiation as a precaution. This “overtreatment epidemic” reflects the harm caused by aggressive cancer treatments in cases where watchful waiting or less invasive options might have been more appropriate. The physical and emotional toll on patients, as described in the book, underscores the need for a more balanced approach to prostate cancer screening.
6. Piana’s and Ablin’s Call for Change: What Should Be Done?
In response to the problems caused by PSA testing, Piana and Ablin call for a fundamental shift in prostate cancer screening practices. They argue that PSA testing should be used more judiciously, reserved for cases where there is a specific indication rather than as a blanket screening tool. Their recommendation is a “risk-based” approach to prostate cancer screening, where individual patient factors, including family history and overall health, are taken into account.
The authors also emphasise the importance of informed consent, arguing that men should be fully aware of the potential risks associated with PSA testing and the likelihood of false positives. They advocate for transparent communication between patients and doctors, allowing men to make informed decisions about whether to pursue further testing or treatment following elevated PSA results. By promoting informed choice, Piana and Ablin hope to prevent the unnecessary physical and psychological burdens caused by over-treatment.
7. Conclusion: Lessons from The Great Prostate Hoax
The Great Prostate Hoax concludes with a call for patient-centred healthcare that prioritises evidence-based practices over profit-driven medicine. Piana and Ablin’s exposé on the PSA test serves as a cautionary tale about the dangers of over-medicalisation and the need for healthcare reform. Their work encourages readers to critically assess the motivations behind medical recommendations and advocate for transparency and integrity in healthcare.
In reflecting on the impact of PSA testing, the book suggests that patients and physicians alike should challenge norms that place financial interests above patient outcomes. The Great Prostate Hoax pushes for a new standard in cancer care, one that balances the benefits of early detection with the potential harm of over-treatment. Through its detailed critique of the PSA test, Piana and Ablin offer valuable lessons for all seeking a more ethical and effective healthcare system.
