On NYC's Skid Row, Prostate Cancer Screening's Brutal Start

Nick Mulcahy

May 29, 2018

SAN FRANCISCO — A dark chapter in the history of American medicine was revisited this week during a presentation here at the American Urological Association (AUA) 2018 Annual Meeting.

Lawrence Wyner, MD, professor of urology at Marshall University in Huntington, West Virginia, who is also an amateur historian, gave a talk about the 2017 reappearance of a set of "priceless" anatomic drawings that are related to a now largely bygone surgical technique: approaching the prostate through the perineum.

The medical illustrations are of compelling interest now because of the men whose prostates and perineums are depicted in the drawings. "There's a face behind each of those drawings," said Wyner.

He explained that the men came through the rough streets of New York City's Bowery district in the 1950s, a world generally known as "skid row." Many of the men suffered from mental illness after the trauma of serving in World War II.

The men were a part of the Bowery series, said Wyner, which was "an infamous 1950s-era prostate cancer study in New York City, in which over a thousand asymptomatic homeless alcoholic men were enrolled to have their prostates biopsied, and then aggressive treatment for prostate cancer was performed if their biopsies were positive for cancer."

The study was "the first attempt to look at whether [early-stage] prostate cancer could be effectively identified and cured," said Wyner, but it involved a very invasive screening/diagnosis method — perineal biopsy surgery.

What did the men get out of this? "The opportunity to have three hot meals a day, clean sheets, and a temporary ticket out of skid row," commented Wyner, adding that it "seemed too good to pass up."

A "small army" of personnel, according to Wyner, were required to facilitate a process whereby nearly 1200 men on skid row were converted into study subjects in operating rooms at Columbia University's Manhattan cancer hospital.

If a man volunteered, "a van drove him to the hospital to make sure he did not back out," Wyner told the AUA audience.

A van drove him to the hospital to make sure he did not back out. Dr Lawrence Wyner

Wyner told Medscape Medical News that the full cast of Bowery series characters included principal investigator "Perry Hudson, MD (a gifted man with a vision), his associates (urological colleagues and residents), the underlings (cops, magistrates, social workers, and flop house managers), and lastly (and most importantly), a vulnerable population of homeless men who had nothing to lose by participating in such extreme research."

Hudson was extremely well supported, commented Wyner, benefitting from the post-war boom in federal funding for scientific research. At Columbia's cancer hospital, he had his own 45-bed unit for research as well as six laboratories with seven PhD assistants and 25 technicians.

In the study, all of the Bowery men underwent biopsy surgery, which was far more invasive than current-day needle biopsy. About 90% had no cancer. Roughly 10% had "latent" cancer (meaning it was nonsymptomatic) and subsequently underwent radical prostatectomy. Both surgeries produced complications, including rectal perforations and erectile dysfunction, none of which were ever reported in the medical literature, Wyner told the AUA audience.

Moreover, the men treated with prostatectomy also received surgical castration and estrogen therapy, which may have hastened their deaths.

"Overall mortality was greater in the treated group, probably on the basis of the aggressive male hormone deprivation employed; the cardiovascular toxicity of this approach was not realized until the 1970s," said Wyner.

Nevertheless, the study continued for 15 years, during which time Hudson and colleagues published "dozens of scientific papers about their findings, and it was even featured for the lay public in a 1958 Life magazine spread," Wyner said.

In 1966, an editor with the journal Cancer challenged Hudson about the study's ethics, and it was "abruptly terminated."

In recent years, the Bowery series has been "roundly castigated" by academics and journalists for its design and recruitment methods, said Wyner.

Hudson, who died in 2017 at the age of 99, always maintained that the study "followed the Nuremberg code" and that "his subjects were unpaid volunteers who participated of their own free will for a great societal purpose," added Wyner.

But Wyner told Medscape Medical News that the story of the Bowery series is also "almost like a Shakespearean tragedy."

At the end of his AUA presentation, Wyner queried the audience: "As with our current prostate cancer guidelines, Dr Hudson's study appropriated all that was known about prostate cancer at the time. But still, how could it have gone on for so long? Were the Bowery men invisible? Or was this a perfect storm of sorts?"

No comments were forthcoming from the audience, which was fairly sparse, as this presentation took place on the last day of the meeting, when many participants were already making their way home.

Far More Men Have Been Experimented On via PSA Testing

The irresponsible approach to medicine represented by the Bowery series has continued in the practice of American urology, argues Robert Aronowitz, MD, an internist and a professor of the history and sociology of science at the University of Pennsylvania in Philadelphia.

Aronowitz told Medscape Medical News: "From the year PSA [prostate-specific antigen] screening was introduced in 1985 to the first results of randomized, controlled trials in 2009, millions of American men, like the Bowery subjects/patients, were subjected to biopsies and radical surgery/radiation, with all the concomitant harms, without any evidence, good or bad, of the efficacy and safety of these practices."

Aronowitz's comments refer to the fact that US physicians employed the PSA test as a mainstream screening practice for 25 years before any results were presented from major clinical trials of PSA testing, such as the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial.

In a 2009 study, it was estimated that more than 1 million US men had been overtreated during the PSA testing era.

Aronowitz had interviewed Hudson in the past, but he was unaware of his death last year.

"We had not been in contact, and I have occasionally wondered how he was faring. I have a copy of one of Hudson's atlases, and it would be interesting to see these [newly discovered] drawings, which of course raise ethical issues about their use," he said, referring to the patients' participating in the study under duress.

Aronowitz is appalled by the Bowery series: "We today view his mutilating procedure done on an ill-informed vulnerable population with some horror."

We today view his mutilating procedure done on an ill-informed vulnerable population with some horror. Dr Robert Aronowitz

Aronowitz has researched American prostate cancer missteps and has written, among others, an article entitled From Skid Row to Main Street: The Bowery Series and the Transformation of Prostate Cancer, 1951–1966 (Bull Hist Med. 2014;88:287-318).

This research became the basis for a 2013 feature story in the New York Times.

Aronowitz argues that the Bowery series should be a wake-up call about how a much larger population of American men (ie, Main Street) were misused by urologists for a much longer time in more recent years in the name of curing men of prostate cancer, with many of the same tragic, damaging consequences.

"While I acknowledge this obviously sad ethical travesty, a good deal of what Hudson was doing is similar to practices that do not generally evoke strong ethical objections in us then or now — and that should bother us more," he said.

Dr Wyner and Dr Aronowitz have disclosed no relevant financial relationships.

American Urological Association (AUA) 2018 Annual Meeting. Abstract FR-11, presented May 21, 2018.

Follow Medscape senior journalist Nick Mulcahy on Twitter: @MulcahyNick

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