A prostate story

Who benefits from testing to see if you have prostate cancer?

Being told “You’ve got cancer” can strike fear into a person’s heart. For middle-aged men, prostate cancer is the most common reason to hear this diagnosis.


Here’s how it usually happens. You have a simple blood test and receive a figure for your PSA, the prostate specific antigen. Anything above 4.0 is supposed to be a cause for worry, and possibly more tests. The number gives the PSA blood level in nanograms per millilitre.

I remember having the test done quite some years ago. A nurse rang to give me the results. She said “It’s 4.1”. I thought, this seems a bit high given my lifestyle. Then she said, “Oh, sorry, it’s actually 0.1”. That was okay, then. Little did I know.

An elevated PSA level is considered a cause for worry. The doctor might recommend a biopsy just to be sure, or the patient might want to know. This can lead to trouble. If the biopsy is positive for cancer, what next?


In the US, most urologists recommend removal of the prostate, an operation called a prostatectomy. This is supposed to get rid of the cancer. It sounds straightforward, but the operation is extremely delicate. The prostate straddles the urethra, the channel for urine and semen, and is surrounded by many sensitive nerves.

Sometimes the operation doesn’t get rid of the cancer. And quite often the operation has serious side effects: most men are left impotent and many become incontinent.

Instead of removing the prostate, another option is called “active surveillance” or “watchful waiting”, though it might better be called “worried waiting”. What this means is checking at regular intervals to see whether the PSA score is increasing.

Although most men in their 50s and 60s have cancer in their prostates, relatively few of them die of it. The cancer is usually slow-growing, so slow-growing that something else kills them first. They die with prostate cancer, not from prostate cancer.

Because the advantages of taking a PSA test are so limited, and the possible side-effects of unnecessary treatment are so severe, some researchers and policy-makers have argued that healthy men should not be screened using the test. On the other side are those – including urologists and advocacy groups, among others – who argue that PSA testing saves lives, and accuse the no-screening advocates of playing with men’s lives.

This debate has played out differently in different countries. In Britain, watchful waiting is more common; in the US, testing and aggressive treatment, especially removing the prostate if there is any sign of cancer, is standard.

Into this debate, there’s a new book titled The Great Prostate Hoax. The subtitle indicates the message: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster.


The author is Richard J. Ablin, assisted by Ronald Piana. Ablin has credibility in this area: he discovered PSA in 1970. And he is appalled at the widespread use of the PSA test in the US. He says that as the discoverer of PSA,

I have been linked to the 30 million American men … who undergo routine PSA screening for prostate cancer. The result: a million needle biopsies per year, leading to more than 100,000 radical prostatectomies, most of which are unnecessary. (p. 4, emphasis in the original)

Richard J. Ablin

Ablin provides one key point that undermines the argument for testing: the PSA test is not a test for prostate cancer. It is only a test for the prostate specific antigen, in extremely tiny amounts in the blood. This is not the same as a prostate-cancer specific antigen. Ablin says that using the PSA test is roughly as accurate as flipping a coin. Furthermore, the level of 4.0 as a warning of whether there might be cancer is arbitrary: it was more or less picked out of the air.

Researchers have been searching for a prostate-cancer indicator, but haven’t found one yet. The next question is how the PSA test ever became accepted, given its dubious diagnostic value.

This is where “big medicine” comes in. The PSA test does have some value. For men being treated for prostate cancer, the PSA level is an indicator of whether the cancer has returned, and therefore of how effective treatment is.

For a company selling a PSA test, there’s not much money to be made in testing men being treated for prostate cancer. But there are big bucks in screening. In the US, this means tens of millions of men per year.

Ablin tells the story of how the US Food and Drug Administration (FDA), which licenses medical tests, was swayed by emotion over rationality in approving a PSA test. For example, one of the test’s advocates, Jim Wise, used this approach:

Queried on the suffering of countless numbers of men harmed by PSA false positives, Wise circled the wagons around his insular community – men who claim they were saved by PSA screening – in essence, seemingly implying that their lives outweigh the harms to other men produced by false-positive PSA results. This is the common emotion-based type of exchange used by advocates to promote PSA screening. It’s a kind of flag-waving patriotism that people are loath to challenge; we’ve seen the results of that sheeplike mentality. (pp. 66-67)

But there is more to the FDA story than emotional pleas. Corporate interests played a role. Some FDA advisory committee members tried to expose the scientific shortcomings of the PSA test, but corporate connections prevailed. Ablin describes the FDA advisory committee meeting in considerable detail, down to individual exchanges, revealing a system that is corrupt at several levels.


FDA officials tried to cover themselves by issuing warnings about inappropriate use of the test, but their inaction sent a different message. The FDA did nothing about massive off-label promotion of the PSA test.

Advocacy groups were part of the promotion of PSA screening; many of them are sponsored by the companies. Before long, PSA screening became the basis for a massive commercial enterprise. Screening is only the beginning. False positives keep the money rolling in. Men are told their PSA might indicate prostate cancer and should have a biopsy. Then, quite commonly, cancer is detected in the prostate, and prostatectomy is recommended.

An experienced surgeon can usually do a good job, but many men opt for a much more expensive method using a robot. The surgeon is still involved, but using a complicated piece of equipment. Robotic prostatectomies have become the primary method used in the US, even though there is little evidence they are any more successful than conventional surgeries.

If radiation is the preferred option, the latest generation of high-tech treatment is proton-beam therapy, in centres costing over $100 million to construct. Without sufficient patients, these centres would go bankrupt.

Then there are the side effects of treatment, though they might be better described as the main effects: impotence and incontinence. Ablin offers some moving stories from men whose lives have been seriously damaged by prostate removal. Some of them feel their manhood has been lost.

and so does a prostatectomy

Because of impotence and incontinence, there’s an additional market in medical fixes, for example penile implants and bulbourethral sling surgery. Ablin quotes experts saying that half of urology practices in the US would go out of business if not for the steady stream of patients whose problems begin with PSA testing.

From Ablin’s perspective, PSA testing is a gravy train for urologists and for drug and medical device manufacturers, with a seemingly inexhaustible stream of men entering the shadow of a prostate cancer diagnosis. Ablin calls PSA testing a hoax because there is no good evidence that it reduces the death rate and there is ample evidence that it causes a huge amount of suffering.

The Great Prostate Hoax is powerful testimony to the dangers of a profit-driven health system. It can be added to the growing body of writing about corruption in corporate healthcare, something that causes far more suffering and death than most of the hazards that exercise the public mind.

The book does have some limitations. It deals almost exclusively with the situation in the US, giving little attention to practices and debates in other countries. The US situation is important, to be sure, but insight into ways to control the PSA-testing juggernaut could be obtained by an examination of what is happening in countries where different attitudes and policies prevail. (For an Australian critical commentary on PSA testing, see Let Sleeping Dogs Lie?)

Another context for the book is screening for other conditions. A decade ago, H. Gilbert Welch wrote Should I Be Tested for Cancer? Maybe Not and Here’s Why, providing close scrutiny of the hazards of screening people with no symptoms. More recently, he and two colleagues extended their critique of screening to a wide variety of conditions, in a 2011 book titled Overdiagnosed: Making People Sick in the Pursuit of Health.

The implication of Ablin’s book is that any man without symptoms should be reluctant to enter the screening roller coaster. But is there anything else worth doing? Ablin doesn’t mention non-standard treatments of prostate cancer, for example hyperthermia, available in Germany. Nor does he mention the possibility of nutritional prevention. There is a considerable body of information about the possible benefits of selenium, zinc, fish oil, natural vitamin E and saw palmetto, as well as more general benefits from a diet with cruciferous vegetables. Hyperthermia and nutritional prevention are controversial, to be sure, but their hazards are far lower than conventional treatment.

For men concerned about their personal risks from prostate cancer, it is worth considering a range of information, about prevention, screening and treatment methods. In this, The Great Prostate Hoax is essential reading, especially to appreciate the intersection between science and politics. Ablin deserves the last word.

Medical industry profiteers have squandered trillions of health care dollars since the PSA test was first brought to the market. Given the utter failure of PSA screening, scientifically and clinically, why are we continuing to drain our health care system by repeating something we already know does not work. The late Albert Einstein defined insanity as doing the same thing over and over again and expecting different results. Repeating the same mistakes borne at the beginning of the PSA saga borders on criminal insanity. (p. 228, emphasis in the original)

Brian Martin

An online mobbing

Tom Flanagan was mobbed online. His experience provides several sorts of lessons.

Tom Flanagan
Tom Flanagan

Tom Flanagan, a Canadian political scientist, worked for 45 years at the University of Calgary. He became a prominent public figure, appearing on television and writing columns for newspapers and magazines. He also had experience in the political system, having served as campaign manager for several politicians seeking office.

Along the way, Flanagan made some enemies. Much of his research related to First Nations and their claims over land, and he took a position contrary to activists in the area. Flanagan’s political leanings might be characterised as conservative: he had managed campaigns for conservative politicians.

On 27 February 2013, Flanagan gave a talk at the University of Lethbridge. Unknown to him, some First Nation activists attended and planned to use the talk to discredit him. They secretly recorded his talk and asked him a question about an extraneous topic, about which he had once made a passing comment: child pornography.

In the several hours it took Flanagan to drive home the next morning, a social media storm blew up, leaving his reputation in tatters. An extract of his talk, out of context, had been posted on YouTube with the misleading tagline “Tom Flanagan okay with child pornography.” Before long, he was widely denounced, including by Canada’s prime minister, Stephen Harper, for whom Flanagan had once been campaign manager, by the premier of Alberta, and by numerous mainstream media outlets, with front-page stories.

MacDougall tweet
A hostile tweet

Flanagan soon lost many of the connections he had built up over the years. The Canadian Broadcasting Corporation cancelled his contract and his own university put out a weak-kneed media release.

Several things about this storm of protest especially annoyed Flanagan. First, he had only made passing comments about child pornography; it wasn’t a topic he had carefully investigated. Second, he had been speaking to an academic audience, in his teacher role in which he tried to stimulate thinking about the topic, but his enemies had treated it as a political opportunity to catch him out and discredit him.

Third, his views on child pornography had been seriously misrepresented. He opposed child pornography, and had only said that penalties for merely viewing it (in Canada, a minimum of several months in prison) might be too stiff. Fourth, those who denounced him and his views had not waited to hear Flanagan’s perspective before rushing to make public comment.

Vulnerability to online mobbing

Mobbing is collective bullying. It’s when a group of people combine to attack a target by abuse, undermining, sidelining, defaming and otherwise causing harm to a person’s morale and reputation. Most commonly, mobbing occurs in workplaces, when a group of workers — usually including the boss, though not always — use verbal and physical methods against a fellow worker. Flanagan experienced a different sort of mobbing. His attackers were online, whereas his colleagues were largely supportive of him.

Flanagan in his book Persona Non Grata (discussed below) says several factors were involved in the online mobbing he experienced. One is that the news cycle has sped up enormously. Before the Internet, it would take a day or two for a story to be taken up widely. Now it can occur in minutes. In the face of a crowd baying for blood, politicians and public bodies did not want to wait a day for claims to be checked out. Instead, they made statements immediately to reduce the potential harm to themselves of being seen as sympathetic to Flanagan’s alleged views.

Another factor is that Flanagan had enemies who were unscrupulous. They set him up with a leading question, made a recording without telling him, produced a clip omitting context, posted it on YouTube with a misleading label and started raising the alert about it. Most people never acquire enemies like this. Flanagan, by being a public commentator who was willing to challenge orthodox views in some areas, was vulnerable.

A third factor in Flanagan’s case was moral panic, which is widespread alarm about an issue out of all proportion to its actual harm. In his book, Flanagan traces the evolution of moral panics over child sexual abuse, including claims about Satanic rituals at US preschools and claims based on recovered memories, in which innocent workers and parents were charged with crimes and some of them imprisoned despite lack of any material evidence. Child pornography, he says, is the latest version of this genre of moral panic. By making comments questioning the severe penalties for viewing child pornography, Flanagan entered territory in which the merest association with a topic can create a stigma.


Finally, Flanagan says online mobbing occurs because so few people check out the facts before passing judgement. Hundreds of people who didn’t know Flanagan personally were willing to condemn him without hearing his side of the story. Even worse, some individuals who knew him well, sometimes for many years, condemned him without hearing his side first. The rush to judgement overwhelmed their critical capacity: they assumed he was guilty as charged and apparently were afraid of being seen to support him, so they joined the attack.


Flanagan says that if he had been expecting an attack and had been closely monitoring social media, he might have been able to organise resistance at the very beginning and prevent the worst consequences. However, his attackers had operated surreptitiously. While driving home, listening to music, he received initial word of the media storm, but was not well placed to mount a concerted response. Anyway, why should someone like him — an academic who had just given a guest lecture at another university — have to be constantly monitoring social media just in case of adverse comments?

When he got home, he discovered the scale and seriousness of the attack and started responding. Luckily, he still had friends and supporters, and he was able to write explanatory articles in several influential publications. Furthermore, his colleagues at the University of Calgary were largely supportive. Flanagan, having been a campaign manager for several political candidates, knew quite a lot about media dynamics and management, far more than some others who have been targets of virtual mobbing. Even so, he felt overwhelmed, noting that a rushed response, while under siege and before he obtained full information, might make things even worse.

One of Flanagan’s sympathisers arranged an opportunity to write a book, and that is what he did. Before the end of the year, he finished writing Persona Non Grata: The Death of Free Speech in the Internet Age (Toronto: McClelland & Stewart, 2014). Flanagan had written many previous books, so he was quite capable of such a rapid yet considered response.


Persona Non Grata

Flanagan’s book is a powerful account of his experiences and an indictment of his attackers. One thing that makes the book powerful is his clear, engaging narrative. His treatment is careful and measured, with some degree of outrage to be sure, but more along the lines of being a concerned investigation into a problem about which he has first-hand experience.

By being clear, informative, calm and readable, Persona Non Grata will reach audiences who had never heard about Flanagan before and who would be unsympathetic to his political views. I wrote an article, “When you’re criticised,” on how to respond to attacks, recommending writing a response that is clear, calm and factual, and that is what Flanagan has done in his book.

One of the features of Persona Non Grata is a chapter on penalties for possessing child pornography. As he describes, he had never had more than a passing interest in this topic, but because a false representation of his views was the pretext for mobbing him, he started investigating further. He addresses various arguments and, while expressing his abhorrence at the production of child pornography, and his personal distaste for it, he affirms his previous tentative view that mandatory jail sentences for only possessing or viewing child pornography may be excessive. This is his careful, considered riposte to those who mobbed him.

Academic freedom

In the urgency of the initial online mobbing, the University of Calgary, Flanagan’s long-time employer, issued a statement that was pathetically weak. Flanagan was especially disappointed that an academic institution would put out such a statement without waiting a few extra hours to consult with him. So in Persona Non Grata, Flanagan devotes a chapter to academic freedom.

He gives one of the most cogent accounts of the arguments for academic freedom in the classroom that I have read. Most studies of academic freedom focus on research, inquiry and public comment. Flanagan, in giving attention to teaching, spells out the justification for academics being given the opportunity to teach what they want in the way they want, as well as to speak out on issues of public importance. He is well aware that academics are inhibited and constrained in various ways, and gives good reasons to continue claiming academic freedom as an important contribution to students and society.

Professors have to have room to discover what works well for them, in their discipline, with their personality, with their particular bundle of strengths and weaknesses. Typical undergraduate students at a large university will be exposed to perhaps three dozen instructors in the course of getting a bachelor’s degree. Out of those three dozen, they will probably find a small handful that seemed especially memorable and another handful that seemed like a complete waste of time or worse. But the variety gives all students a chance to find at least a few inspirational professors whose memory can be cherished for a lifetime. If that doesn’t happen, the student has been cheated. (pp. 162–163)

Flanagan tells about some of the students in his classes over the years, and what careers they have entered, many of them taking different political trajectories than Flanagan himself.


Quite a number of individuals have been caught in a whirlwind of online abuse and condemnation, which harms their reputations and careers far out of proportion to their alleged misdemeanours, as astutely described by one of the leading researchers into academic mobbing, Canadian sociologist Kenneth Westhues. Tom Flanagan has produced the most insightful and readable account available of what it is like to be a target of an online mob. In Persona Non Grata he has shown how to rise above the abuse and respond in a calm, reflective fashion that is the exact opposite of the way he was treated.

Brian Martin

Thanks to Zoë Barker and Ian Miles for helpful feedback on drafts.