Skid Row Cancer Study

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The Skid Row Cancer Study was a study conducted by urologist Perry Hudson on the homeless men of the Bowery, in Lower Manhattan. In the 1950s and 1960s, Hudson went to skid row, to convince men to volunteer for his study. More than 1,200 men were promised a clean bed, three free square meals a day and free medical care if they were found to have prostate cancer. Hudson's early experience with seeing patients dying at a tuberculosis hospital he was working at led him to develop an interest in prostate cancer. His discovery about the lack of information regarding treatment for the disease and medical training for rectal exams needed to diagnose the disease drove him to pursue research in prostate cancer.

Contents

At the beginning of the experiment, Hudson and his colleague selected 141 patients having symptoms and signs for urinary obstruction. However, as the experiment progressed, patients were selected randomly. [1] They were not informed that the biopsies searching for cancer had possible side effects, i.e., rectal tearing and impotence. According to Robert Aronowitz, before the biopsy, the patients underwent a physical examination including blood and urine assays, x-rays of the abdomen, massage of the prostate for cytology and intravenous pyelograms. [2] For the biopsy, a part of the prostate measuring 2.5 × 1.0 × 0.5 centimeters [3] was removed; one half was sent to a pathology laboratory to get tested while the other half was retained for permanent preparation. [4] If the results showed cancer, a perineal prostatectomy and orchiectomy was performed on the men, followed by diethylstilbestrol treatment. The homeless were targeted for these biopsies because they were painful and untested, and less vulnerable populations would not volunteer.

Background

Before securing a lead research position at Columbia University, Hudson received surgical training in the United States Navy and obtained a research position in urology at Johns Hopkins University under William Scott. Over time, Hudson's desire to learn more about prostate cancer led him to pursue a research position at Columbia University; where he led various research projects and was given ownership of various labs. In addition to his academic accomplishments, Hudson was appointed head of urology at Francis Delafield Hospital. Hudson's intent with the Skid Row cancer experiment was to figure out whether or not prostate cancer was terminal and how soon it could be diagnosed. He continued working in the urological field after leaving Columbia and also became involved in "tobacco research, laboratory science…[and] other major preventative research." In addition, the efficacy of Hudson's treatment for what he deemed "early" cancers using methods such as radical surgery, castration, and diethylstilbestrol therapy was still unknown at that time. [2] However, despite this, Hudson's studies were still cited in many urological journals and textbooks in the late 1950s and 60s as a new way to inspect the prostate. Only in a comment by the National Institutes of Health in a response to one of Hudson's requests for funding do they consider malpractice, asking for documentation of his compliance Public Health Service policy. Hudson has practiced in South Pasadena, Florida, Columbia University, New York City, and the Francis Delafield Hospital, in New York City. Hudson died in 2017 at age 99. [5]

Consequences

The ultimate goal of Hudson's research included finding a viable way to use open perineal biopsy (OPB) to diagnose prostate cancer at an early stage. He wanted to see the biological history of the disease and prove that the best way to treat it was to attack any signs of the cancer before it became a serious issue. [2] However, the Bowery Series lacked a control group of patients who were not biopsied, so he was unable to compare data with his experimentation group. [6] He lacked any proof or evidence that the people treated were able to live longer, and were actually subjected to further health risks. Thus, the Bowery Series yielded little effective data, and the patients suffered from side effects of the OPB. Although he was unable to accomplish his goals, Hudson set the precedent for future studies in a push for the screen-and-treat movement. Before the Bowery Series, prostate cancer could only be detected at its latest stages when it was already too late to save the patient's life. However, recent advancements have enabled medical professionals to diagnose the cancer in earlier stages. [7]

Over the course of a decade starting in 1951, Hudson recruited over 1200 subjects from the Bowery flophouses in the "Skid Row" of New York. [2] Many of the recruits were 'down and out' men who suffered from alcoholism and mental illness. To motivate enrollment into the study food, bedding, and medical care were offered but the risks involved with the open perineal biopsy procedures were not fully explained to the patients, and many of them suffered long term health consequences. Hudson claimed that the procedure, involving excising a 2.5x1x.5 cm core of posterior prostate [3] caused no harm, [2] however an independent research team proved otherwise, reporting post-op incidence of impotence, rectal laceration, and a diminishing sexual function in 24 patients. [8] The assertion that the biopsies caused no harm was again refuted in an interview by one of his residents who claimed that impotence was a common result. [2] The results of the study were published periodically as case series. In the preliminary case series, the symptoms of a 100-person cohort that tested positive for cancer was described. Hudson implemented radical treatments to this cohort that were ambitiously beyond the standard of care with little scientific backing of efficacy. In addition to the surgical castration of these 100 men, he treated them with estrogen hormone therapy, which was later proven to be ineffective and detrimental. The hormone therapy put the patients at risk for heart disease and stroke and caused a loss in muscle tone and overall stamina. [2] In a summarizing study, Hudson reported that out of 686 patients tested, the mortality rate for men with negative biopsies was 20% and the mortality rate for men with positive biopsies followed by rigorous treatment was 30%. Hudson did not publish results for a control group or a group with biopsies done without hormone treatment so the value of these results are unclear.

Ethics

The ethical integrity of the tactics that Hudson used to recruit volunteers for his experiment has been questioned. Some of his methods exploited the fact that his volunteers were mostly homeless men. For example, Hudson would offer his volunteers compensation in the form of meal tickets and temporary shelter in a hospital room. Then, in order to ensure participation, authorities would only present the meal ticket to a volunteer once he showed up for the study. [9] Because they were homeless, the volunteers saw these rewards as very attractive. [2] Additionally, their lack of education made it more likely for the Bowery men to volunteer for Hudson's experiments, as they could not fully understand what they were signing up for. In particular, at the time of the experiment, the method of open perineal biopsy was new and largely untested, and it would have been unlikely for someone to voluntarily undergo the procedure.

Moreover, the volunteers were very ill-informed. They were not provided with clearly written papers about the dangers of the biopsies, such as rectal tearing. Even though the perineal biopsy approach seemed to have its benefits, its potential risk for rectal perforation was quite high. [2]

In an interview, Hudson defended his experiment's ethics. He said he felt no regret, saying the volunteers seemed to him to be fully aware of the aspects involved in the study. Also, they did not receive any monetary incentives from him to participate, which, otherwise, he thought, would "constitute coercion". Once becoming aware of Hudson's practices, an editor of the journal Cancer wrote him a letter asking what protection he had from the university's legal department. Hudson subsequently stopped publishing the results of his research. [2]

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<span class="mw-page-title-main">Prostate</span> Gland of the male reproductive system in most mammals

The prostate is both an accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation. It is found in all male mammals. It differs between species anatomically, chemically, and physiologically. Anatomically, the prostate is found below the bladder, with the urethra passing through it. It is described in gross anatomy as consisting of lobes and in microanatomy by zone. It is surrounded by an elastic, fibromuscular capsule and contains glandular tissue, as well as connective tissue.

<span class="mw-page-title-main">Prostate cancer</span> Male reproductive organ cancer

Prostate cancer is the uncontrolled growth of cells in the prostate, a gland in the male reproductive system just below the bladder. Early prostate cancer usually causes no symptoms. As the tumor grows, it can damage nearby organs causing erectile dysfunction, blood in the urine or semen, and trouble urinating. Some tumors eventually spread to other areas of the body, particularly the bones and lymph nodes. There, tumors cause severe bone pain, leg weakness or paralysis, and eventually death.

<span class="mw-page-title-main">Prostate-specific antigen</span> Mammalian protein found in humans

Prostate-specific antigen (PSA), also known as gamma-seminoprotein or kallikrein-3 (KLK3), P-30 antigen, is a glycoprotein enzyme encoded in humans by the KLK3 gene. PSA is a member of the kallikrein-related peptidase family and is secreted by the epithelial cells of the prostate gland.

<span class="mw-page-title-main">Biopsy</span> Medical test involving extraction of sample cells or tissues for examination

A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a disease. The tissue is then fixed, dehydrated, embedded, sectioned, stained and mounted before it is generally examined under a microscope by a pathologist; it may also be analyzed chemically. When an entire lump or suspicious area is removed, the procedure is called an excisional biopsy. An incisional biopsy or core biopsy samples a portion of the abnormal tissue without attempting to remove the entire lesion or tumor. When a sample of tissue or fluid is removed with a needle in such a way that cells are removed without preserving the histological architecture of the tissue cells, the procedure is called a needle aspiration biopsy. Biopsies are most commonly performed for insight into possible cancerous or inflammatory conditions.

<span class="mw-page-title-main">Rectal examination</span> Medical assessment or diagnostic procedure

Digital rectal examination (DRE), also known as a prostate exam, is an internal examination of the rectum performed by a healthcare provider.

<span class="mw-page-title-main">Rectal prolapse</span> Medical condition

A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved.

Proctitis is an inflammation of the anus and the lining of the rectum, affecting only the last 6 inches of the rectum.

<span class="mw-page-title-main">Prostatectomy</span> Surgical removal of all or part of the prostate gland

Prostatectomy is the surgical removal of all or part of the prostate gland. This operation is done for benign conditions that cause urinary retention, as well as for prostate cancer and for other cancers of the pelvis.

<span class="mw-page-title-main">Prostate biopsy</span>

Prostate biopsy is a procedure in which small hollow needle-core samples are removed from a man's prostate gland to be examined for the presence of prostate cancer. It is typically performed when the result from a PSA blood test is high. It may also be considered advisable after a digital rectal exam (DRE) finds possible abnormality. PSA screening is controversial as PSA may become elevated due to non-cancerous conditions such as benign prostatic hyperplasia (BPH), by infection, or by manipulation of the prostate during surgery or catheterization. Additionally many prostate cancers detected by screening develop so slowly that they would not cause problems during a man's lifetime, making the complications due to treatment unnecessary.

<span class="mw-page-title-main">Pelvic exenteration</span> Surgical removal of all pelvic organs

Pelvic exenteration is a radical surgical treatment that removes all organs from a person's pelvic cavity. It is used to treat certain advanced or recurrent cancers. The urinary bladder, urethra, rectum, and anus are removed. In women, the vagina, cervix, uterus, Fallopian tubes, ovaries and, in some cases, the vulva are removed. In men, the prostate is removed. The procedure leaves the person with a permanent colostomy and urinary diversion.

<span class="mw-page-title-main">Radical retropubic prostatectomy</span>

Radical retropubic prostatectomy is a surgical procedure in which the prostate gland is removed through an incision in the abdomen. It is most often used to treat individuals who have early prostate cancer. Radical retropubic prostatectomy can be performed under general, spinal, or epidural anesthesia and requires blood transfusion less than one-fifth of the time. Radical retropubic prostatectomy is associated with complications such as urinary incontinence and impotence, but these outcomes are related to a combination of individual patient anatomy, surgical technique, and the experience and skill of the surgeon.

<span class="mw-page-title-main">Radical perineal prostatectomy</span>

Radical perineal prostatectomy is a surgical procedure wherein the entire prostate gland is removed through an incision in the area between the anus and the scrotum (perineum).

Prostate cancer screening is the screening process used to detect undiagnosed prostate cancer in men without signs or symptoms. When abnormal prostate tissue or cancer is found early, it may be easier to treat and cure, but it is unclear if early detection reduces mortality rates.

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High-grade prostatic intraepithelial neoplasia (HGPIN) is an abnormality of prostatic glands and believed to precede the development of prostate adenocarcinoma.

Treatment for prostate cancer may involve active surveillance, surgery, radiation therapy – including brachytherapy and external-beam radiation therapy, proton therapy, high-intensity focused ultrasound (HIFU), cryosurgery, hormonal therapy, chemotherapy, or some combination. Treatments also extend to survivorship based interventions. These interventions are focused on five domains including: physical symptoms, psychological symptoms, surveillance, health promotion and care coordination. However, a published review has found only high levels of evidence for interventions that target physical and psychological symptom management and health promotion, with no reviews of interventions for either care coordination or surveillance. The favored treatment option depends on the stage of the disease, the Gleason score, and the PSA level. Other important factors include the man's age, his general health, and his feelings about potential treatments and their possible side-effects. Because all treatments can have significant side-effects, such as erectile dysfunction and urinary incontinence, treatment discussions often focus on balancing the goals of therapy with the risks of lifestyle alterations.

<span class="mw-page-title-main">Active surveillance of prostate cancer</span>

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Caroline M. Moore is the first woman to be made a professor of urology in the United Kingdom. She works in the diagnosis and treatment of prostate cancer at University College London.

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References

  1. ↑ Hudson, P. B.; Finkle, A. L.; Hopkins, J. A.; Sproul, E. E.; Stout, A. P. (1954-07-01). "Prostatic cancer. XI. Early prostatic cancer diagnosed by arbitrary open perineal biopsy among 300 unselected patients". Cancer. 7 (4): 690–703. doi:10.1002/1097-0142(195407)7:4<690::aid-cncr2820070410>3.0.co;2-m. ISSN   0008-543X. PMID   13172685.
  2. 1 2 3 4 5 6 7 8 9 10 Aronowitz, Robert (2013-10-17). ""Screening" for Prostate Cancer in New York's Skid Row: History and Implications". American Journal of Public Health. 104 (1): 70–76. doi:10.2105/AJPH.2013.301446. ISSN   0090-0036. PMC   3910041 . PMID   24134358.
  3. 1 2 Totten, Robert S. (2016-11-16). "Some Experiences with Latent Carcinoma of the Prostate". Bulletin of the New York Academy of Medicine. 29 (7): 579–582. ISSN   0028-7091. PMC   1877332 . PMID   13051702.
  4. ↑ Hudson, P. B. (1953-02-01). "Prostatic cancer. IV. Combined surgical and endocrine management of curable lesions". Surgery, Gynecology & Obstetrics. 96 (2): 233–234. ISSN   0039-6087. PMID   13015376.
  5. ↑ Wyner, Lawrence M. (2 April 2019). "Artist, Rediscovered: Images and Ethics of Early Prostate Cancer Screening". JAMA. 321 (13): 1236–1238. doi:10.1001/jama.2019.1600. PMID   30938779.
  6. ↑ Kolata, Gina (2013-10-17). "Decades Later, Condemnation for a Skid Row Cancer Study". The New York Times. ISSN   0362-4331 . Retrieved 2016-11-12.
  7. ↑ "Skid Row Cancer Study Has Implications for Treatment Today, Penn Researcher Says". news.upenn.edu. Retrieved 2016-11-12.
  8. ↑ Finkle, Alex L.; Moyers, Thomas G.; Tobenkin, Mark I.; Karg, Sara J. (1959-07-18). "Sexual Potency in Aging Males". Journal of the American Medical Association. 170 (12): 1391. doi:10.1001/jama.1959.03010120027008. ISSN   0002-9955. PMID   13664538.
  9. ↑ Bendiner, E. (1961). The Bowery Man. New York: Thomas Nelson & Sons. p. 169.
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