文章基本信息

标题：“Screening” for Prostate Cancer in New York’s Skid Row: History and Implications
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作者：Robert Aronowitz
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2014
卷号：104
期号：1
页码：70-76
DOI：10.2105/AJPH.2013.301446
语种：English
出版社：American Public Health Association
摘要：The Bowery series, open perineal biopsies performed on more than 1200 alcoholic men recruited from homeless shelters in New York City’s Bowery section, began in 1951 and persisted for more than a decade. If frozen sections revealed prostate cancer, men typically underwent radical perineal prostatectomy, orchiectomy, and diethylstilbestrol treatment. This poorly informed, vulnerable population was subjected to health risks that investigators knew others would not accept. Although the knowledge produced had little impact on practice, the Bowery practices foreshadowed and have troubling continuities with later developments. Currently, more than a million American men each year undergo prostatic biopsies. But the efficacy of prostate-specific antigen screening and the treatment that typically follows has never been established. The Bowery series and subsequent developments are part of one continuous story of how medical and lay people came to believe in the efficacy of population screening followed by aggressive treatment without solid supporting scientific evidence. THE RECENT US PREVENTIVE Services Task Force recommendation against prostate-specific antigen (PSA) screening for prostate cancer is the latest salvo in a controversy that has existed since it was introduced in the late 1980s. 1 But looking for prostate cancer in asymptomatic men and treating detected cases with radical interventions has a longer—if forgotten—history. Starting in 1951 and continuing for more than a decade, urologist Perry Hudson and his colleagues recruited more than 1200 homeless, alcoholic men from New York City’s skid row, the Bowery, to come to a new municipal cancer hospital for invasive tests and procedures, including open perineal biopsy (OPB) of the prostate gland. If frozen biopsy sections revealed cancer, the patients typically underwent radical prostatectomy and orchiectomy, followed by a course of diethylstilbestrol. To present-day observers, the unethical aspects of these practices—the failure to provide full informed consent and exposing a vulnerable population to undue risk—are disturbing. Yet the Bowery series, as Hudson called these practices, were published in leading medical journals and frequently cited, joining the long list of unethical studies performed in full public view, such as those revealed in Henry Beecher’s influential 1966 exposé. 2 I have detailed the history of the Bowery series, providing the medical and social context for why and how these practices were begun, persisted, and eventually faded away. Examining this history does more than explain—without excusing—an important but hitherto forgotten large-scale ethical misadventure. It also reveals continuities with prostate screening beliefs and practices today. Recounting and recovering this history is a window into what is at stake—ethically and scientifically—in the long-running controversy over the early detection and treatment of prostate cancer. The juxtaposition of past and present also opens up for ethical analysis new developments, such as the mass diffusion of interconnected clinical practices, each understood to work on the basis of limited endpoints by well-intentioned actors, before—and potentially subverting—robust evidence of their overall efficacy.