The 15 Most Devastating Truths About the PSA Screening Disaster

An Essay

The prostate-specific antigen (PSA) test has screened 30 million American men annually for over three decades. The man who discovered PSA in 1970, Richard Ablin, now calls mass screening “a public health disaster.” Two landmark 2012 studies found no survival benefit from radical surgery compared to watchful waiting. The U.S. Preventive Services Task Force concluded PSA screening does more harm than good. Yet the $3 billion annual industry continues largely unabated.

These revelations emerge from three insider accounts: Ablin’s The Great Prostate Hoax, urologist Anthony Horan’s The Rise and Fall of the Prostate Cancer Scam, and oncologist Mark Scholz’s Invasion of the Prostate Snatchers. Together they document how a test meant to monitor existing cancer patients became a screening juggernaut that has left millions of men incontinent, impotent, or dead from unnecessary treatment.

The numbers are staggering. Since 1987, when PSA screening exploded nationwide, over one million American men have undergone radical prostatectomies. Studies show 40 to 50 men must be diagnosed and treated to prevent one death from prostate cancer. The other 39 to 49 men receive no benefit but face permanent side effects. Medicare and the Veterans Administration fund most of this treatment, pouring billions into a system that prominent urologists privately acknowledge has failed.

What follows are the most damaging truths about how PSA screening became entrenched despite overwhelming evidence of harm, why it persists against scientific consensus, and what this reveals about American medicine’s inability to abandon lucrative practices even when they damage patients.

1. The Test’s Creator Calls It a “Public Health Disaster”

Richard Ablin discovered prostate-specific antigen in 1970 while researching cryosurgery’s effects on prostate tissue. He never intended PSA as a screening test for healthy men. The test cannot distinguish between the cancers that kill and those that remain harmless. Ablin has spent decades publicly denouncing mass screening, including a 2010 New York Times op-ed titled “The Great Prostate Mistake.”

Ablin compares PSA screening’s specificity to “a coin toss” - hardly the precision expected from a medical test that determines whether men undergo surgery or radiation. He testified before Congress, published papers, and gave countless lectures warning against screening’s misuse. The medical establishment ignored him. In his book, he writes that watching his discovery become “a hugely expensive public health disaster” has been “painful.” The man who found PSA receives angry emails from men whose lives were destroyed by unnecessary treatment triggered by elevated PSA levels.

2. 75% of Men with Elevated PSA Don’t Have Cancer

A PSA level above 4.0 triggers the treatment cascade, yet three-quarters of these men have no cancer. Infections, enlarged prostates, bicycle riding, and recent ejaculation all elevate PSA. The test measures inflammation as readily as malignancy. This 75% false positive rate means millions undergo invasive biopsies needlessly.

The Prostate Cancer Prevention Trial found that 15% of men with PSA under 4.0 - the “normal” range - actually had prostate cancer, including aggressive forms. Meanwhile, only 25% with elevated PSA had cancer at all. No blood test with such poor specificity would gain approval today. Yet once PSA became standard practice, removing it from clinical use proved impossible despite its fundamental unreliability.

3. The $3 Billion Annual PSA Gold Rush

PSA screening generates at least $3 billion annually, with Medicare and the Veterans Administration covering most costs. Each abnormal PSA triggers a cascade: repeat tests, biopsies, imaging, surgery or radiation, plus years of follow-up. A single radical prostatectomy bills $15,000 to $30,000. Radiation therapy can exceed $50,000. These procedures require expensive equipment, specialized facilities, and teams of providers.

Hospital systems depend on this revenue stream. Urology practices built business models around screening and treatment. Medical device companies profit from surgical robots, radiation equipment, and biopsy tools. This economic ecosystem resists evidence showing most treatment is unnecessary. When the U.S. Preventive Services Task Force recommended against routine screening in 2012, medical associations mobilized massive lobbying efforts to preserve the status quo. Money, not medicine, drives the screening machine.

4. 30 Million Tests, 1 Million Unnecessary Biopsies Per Year

Annual PSA screening of 30 million American men triggers approximately one million prostate biopsies. Since most elevated PSAs are false positives, at least 750,000 of these biopsies find no cancer. Each biopsy involves 12 to 18 needle cores punched through the rectal wall into the prostate. Serious infections requiring hospitalization occur in 1-4% of cases. Sepsis can be fatal.

Even negative biopsies don’t end the cascade. Urologists often recommend repeat biopsies for persistently elevated PSA, subjecting men to multiple rounds of needles, infection risk, and anxiety. Some undergo four, five, even six biopsies chasing ghost cancers that either don’t exist or would never threaten their lives. The psychological toll - months of fear between tests, the dread of results, the pressure to “do something” - devastates men and families. This suffering serves no medical purpose for the vast majority subjected to it.

5. The “Arbitrary” 4.0 Cutoff That Changed Everything

The PSA threshold of 4.0 ng/mL that triggers intervention was, according to New York Times reporting, chosen “just sort of arbitrarily.” William Catalona’s influential 1991 New England Journal of Medicine article established this cutoff without reporting false positive rates - a basic requirement for screening tests. The entire world adopted this number uncritically.

No scientific process determined that 4.0 represented a meaningful boundary between health and disease. The number could have been 3.0 or 5.0 or 6.5. Each choice would have swept millions more or fewer men into the treatment vortex. This arbitrary threshold, selected without rigorous validation, has determined the fate of millions. Men with 4.1 undergo biopsies while those with 3.9 are deemed safe, though this 0.2 difference has no biological significance. A random number became medical dogma, and challenging it meant confronting an entire industry built on its foundation.

6. 2,600 Post-Surgery Deaths at the 1992 Peak

Radical prostatectomy deaths peaked at 2,600 in 1992, five years after PSA screening exploded nationally. These men died from surgical complications - bleeding, infections, blood clots, anesthesia reactions. They underwent surgery for cancers that, in most cases, would never have threatened their lives. The operation killed them before their cancer could.

Anthony Horan documents how radical surgery was “revived without new evidence” in the 1980s after being largely abandoned. The combination of PSA screening and renewed surgical enthusiasm created a perfect storm. Thousands died on operating tables for a disease that grows so slowly most men die with it, not from it. These deaths represent only immediate surgical mortality - not the men who died months later from complications, or whose lives were shortened by surgical trauma. Each death was preventable had screening not detected their harmless cancers.

7. Radical Surgery Shows No Survival Benefit Over Watchful Waiting

Two randomized controlled trials reported in 2012 found no difference in cancer-specific mortality between radical surgery and watchful waiting. The Prostate Cancer Intervention Versus Observation Trial (PIVOT) followed 731 men for up to 15 years. The Scandinavian trial tracked men for over 20 years. Both reached the same conclusion: surgery doesn’t save lives compared to monitoring.

These studies destroyed the rationale for early detection. If removing the entire prostate doesn’t extend life compared to doing nothing, then finding cancer early serves no purpose except to subject men to treatment side effects. The medical establishment largely ignored these findings. Surgery rates declined modestly but remained far higher than evidence justified. Mark Scholz writes that these studies should have “removed the rationale for early diagnosis with PSA” entirely. Instead, the industry adapted its messaging while continuing essentially unchanged.

8. The FDA Approval Based on 3.8% Detection Rate

The FDA approved PSA for screening in 1994 based primarily on a study showing it could detect 3.8% more cancers than digital rectal examination. This marginal improvement became justification for testing millions annually. The agency relied heavily on this single statistic while downplaying false positive rates and overdiagnosis risks.

Alexander Baumgarten, one of FDA’s own expert advisers, warned officials: “Like Pontius Pilate, you cannot wash the guilt off your hands.” Susan Alpert, who directed FDA’s Office of Device Evaluation during approval, later acknowledged the decision’s problems. The agency never required studies showing screening actually saved lives or improved quality of life. This regulatory failure, approving a test based on detection rates rather than patient outcomes, enabled the disaster that followed. The FDA has never revisited its decision despite overwhelming evidence of harm.

9. Prostate Cancer Grows So Slowly Most Men Die WITH It, Not FROM It

Autopsy studies reveal that 30% of men in their 40s and 70% in their 70s have prostate cancer cells. Most never knew and were never affected. The cancer’s typical growth rate means decades pass between initial cellular changes and potential lethality. A 65-year-old diagnosed with early-stage prostate cancer has less than 3% chance of dying from it within 15 years if left untreated.

Men diagnosed at 75 almost certainly will die of something else first - heart disease, stroke, other cancers. Yet screening doesn’t discriminate by age or life expectancy. Elderly men in nursing homes receive PSA tests and undergo biopsies. Some receive radiation or surgery in their 80s for cancers that could never outlive them. This fundamental biological reality - that most prostate cancers are clinically insignificant - undermines screening’s entire premise. Finding these cancers serves only to transform healthy men into cancer patients unnecessarily.

10. The Biopsy Train: 18-Gauge Needles and Serious Infections

Modern prostate biopsy involves 12 to 18 hollow-bore needles, each 18-gauge in diameter, fired through the rectal wall. The needles extract tissue cores while potentially spreading bacteria from the bowel into the prostate and bloodstream. Fluoroquinolone-resistant bacteria have made infections increasingly dangerous. Some men develop sepsis requiring intensive care.

Richard Ablin receives emails from men describing their biopsy experiences as “spinning out of control,” having “panic attacks,” and living in a “nightmare.” The procedure’s violence - needles punching through tissue, the sound of the spring-loaded gun, blood in urine and semen for weeks - traumatizes men regardless of results. Those with negative biopsies face pressure to repeat the procedure if PSA remains elevated. Some endure annual biopsies for years, each carrying infection risk, each failing to find cancer that likely isn’t there or doesn’t matter. The biopsy itself becomes a recurring assault that serves no medical purpose.

11. Incontinence and Impotence: The “Acceptable” Side Effects

Radical prostatectomy leaves 20-30% of men with permanent urinary incontinence requiring pads or diapers. Erectile dysfunction affects 60-80%, depending on age and surgical technique. These rates come from centers of excellence; community hospitals report worse outcomes. Surgeons routinely minimize these risks, calling them “acceptable” trade-offs for cancer treatment.

For men whose cancers would never have threatened them - the majority who undergo surgery - these side effects represent pure harm. They lose sexual function and bladder control to treat a disease that required no treatment. Their marriages suffer. Depression is common. Some become recluses, afraid to leave home without knowing bathroom locations. The medical profession’s casual acceptance of these devastating outcomes reflects a stunning disregard for quality of life. No other medical specialty would tolerate routinely destroying normal function to treat non-threatening conditions.

12. PSA Isn’t Even Prostate-Specific

Despite its name, prostate-specific antigen isn’t specific to the prostate. Breast tissue produces PSA - it’s a normal component of breast milk. Salivary glands make it. Some lymphomas produce PSA. Women have measurable PSA levels. This basic biological fact undermines the test’s fundamental premise.

Anthony Horan notes he personally reported PSA production in B-cell lymphomas. The protein’s presence throughout the body means elevated levels can reflect numerous non-prostatic processes. Yet the medical establishment treats PSA as if it were a precise prostate cancer marker. This scientific sloppiness - naming and using a test based on false assumptions about specificity - exemplifies the intellectual bankruptcy underlying mass screening. If PSA were discovered today with current knowledge, it would never be approved for screening healthy men.

13. The Veterans Administration’s Role in the Screening Epidemic

The Veterans Administration extensively promoted and funded PSA screening, making it routine for millions of veterans. The VA’s electronic medical records prompted doctors to order PSA tests, created quality metrics based on screening rates, and facilitated the treatment cascade. Veterans, trusting their government healthcare, underwent screening at higher rates than the general population.

The VA spent billions on screening, biopsies, and treatment. Veterans suffered disproportionately from overdiagnosis and overtreatment. Many underwent surgery or radiation at VA hospitals with limited experience in these procedures, likely experiencing higher complication rates. The government that sent these men to war later subjected them to medical harm through systematic overscreening. Only after the 2012 USPSTF recommendation did the VA begin moderating its approach, too late for hundreds of thousands of veterans already harmed.

14. Why Urologists Can’t Stop Screening Despite the Evidence

Urologists understand the evidence against screening yet continue promoting it. Professional self-interest explains this cognitive dissonance. Prostate cancer diagnosis and treatment represent major revenue sources for urology practices. Academic urologists depend on prostate cancer research grants. Professional status derives from surgical volume and technical expertise in procedures that shouldn’t be performed.

Mark Scholz describes the “surgeon personality” that sees every problem as requiring surgical solution. Urologists train for years to perform radical prostatectomies. Abandoning these procedures means acknowledging that much of their training and practice caused unnecessary harm. The psychological and economic barriers to accepting screening’s failure prove insurmountable. Even urologists who privately acknowledge the problem continue participating in the system. Professional conferences feature token debates about screening while exhibit halls showcase million-dollar surgical robots. The specialty cannot reform itself when its economic survival depends on perpetuating harm.

15. Active Surveillance Works for 99% of Low-Risk Cases

Multiple studies demonstrate that active surveillance - monitoring without immediate treatment - works for virtually all low-risk prostate cancers. Memorial Sloan Kettering reported that fewer than 1% of men on surveillance die from prostate cancer over 15 years. Johns Hopkins found similar results. These men avoid treatment side effects while maintaining the option to treat if their cancer progresses.

Despite this evidence, most men with low-risk disease still receive immediate treatment. Doctors present surveillance as “doing nothing” rather than an active management strategy. Patients fear leaving cancer untreated, not understanding their cancer’s indolent nature. The medical system’s financial incentives favor treatment over monitoring. Each patient choosing surveillance represents lost revenue. This proven alternative that could spare hundreds of thousands from unnecessary treatment remains underutilized because it threatens the economic foundation of prostate cancer care.

Conclusion

The PSA screening disaster exposes American medicine’s darkest impulses: the primacy of profit over patient welfare, the persistence of harmful practices despite overwhelming evidence, and the medical establishment’s inability to acknowledge error. Thirty years of mass screening has transformed millions of healthy men into cancer patients unnecessarily, subjecting them to treatments that left many incontinent, impotent, or dead.

The men who exposed this scandal from within - Richard Ablin who discovered PSA, Anthony Horan who practiced urology during screening’s rise, Mark Scholz who treats screening’s victims - deserve recognition for their courage in challenging their profession’s orthodoxy. Their accounts reveal not isolated mistakes but systematic failure: arbitrary thresholds adopted without validation, regulatory approval based on minimal evidence, and an entire medical specialty economically dependent on perpetuating harm. Until American medicine can abandon lucrative practices that damage patients, the PSA disaster will repeat in other forms, with other tests, harming other victims who trusted their doctors to first do no harm.

References

Ablin, Richard J., with Ronald Piana. The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster. New York: Palgrave Macmillan, 2014.

Horan, Anthony H. The Rise and Fall of the Prostate Cancer Scam. 3rd ed. Broomfield, CO: On the Write Path Publishing, 2019.

Scholz, Mark, and Ralph H. Blum. Invasion of the Prostate Snatchers: An Essential Guide to Managing Prostate Cancer for Patients and Their Families. Revised ed. New York: Other Press, 2021.

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