Investigators have projected impending increases in the incidence and mortality rates of prostate cancer—especially among individuals in low- and middle-income countries—and proposed new strategies to improve screening, awareness, research diversification, and treatment in a recent The Lancet Commission on prostate cancer. These findings were published by James et al in The Lancet and simultaneously presented at the European Association of Urology Congress 2024.
Background
Prostate cancer is already a major cause of mortality and disability, accounting for 15% of all cancer cases among male patients. Among men, this cancer type is the second most common cause of cancer mortality in the United Kingdom and the most common type of cancer in more than half of the world’s countries.
Low- and middle-income countries have recently experienced an increase in prostate cancer incidence and mortality, whereas prostate cancer mortality has declined in most high-income countries since the mid-1990s.
Factors such as increased life expectancy may increase the size of the elderly population in the coming years. Since the main risk factors for prostate cancer—such as being aged 50 or older and having a family history of the disease—are often unavoidable, lifestyle changes and public health interventions will likely be ineffective at preventing the impending surge in prostate cancer cases.
“As more and more men around the world live to middle and old age, there will be an inevitable rise in the number of prostate cancer cases. We know this surge in cases is coming, so we need to start planning and take action now. Evidence-based interventions such as improved early detection and education programs will help to save lives and prevent ill health from prostate cancer in the years to come. This is especially true for low- and middle-income countries, which will bear the overwhelming brunt of future cases,” explained lead Commission author Nicholas James, MBBS, PhD, FRCP, FRCR, MRCP, Professor of Prostate and Bladder Cancer Research at The Institute of Cancer Research in London and a consultant clinical oncologist at The Royal Marsden National Health Service Foundation Trust.
Findings in Prostate Cancer Incidence, Mortality, and Early Detection
In the new Commission, the investigators predicted prostate cancer cases may double from 1.4 million per year in 2020 to 2.9 million per year by 2040, with low- and middle-income countries seeing the highest increases in cases. Globally, prostate cancer mortality was predicted to increase by 85%, from 375,000 deaths in 2020 to nearly 700,000 deaths by 2040. However, the true numbers were expected to be much higher because of underdiagnoses and missed opportunities for data collection in low- and middle-income countries, where a majority of these deaths may occur.
The investigators noted that in high-income countries, prostate cancer screenings typically involve the prostate-specific antigen (PSA) test. Nonetheless, these tests may detect prostate cancer that may never cause symptoms or require treatment. The current approach to prostate cancer diagnosis in many high-income countries relies on informed choice PSA testing, in which when men aged 50 or older with no disease symptoms can request a test from their physicians after discussing the potential risks and benefits.
The investigators argued that there is evidence to suggest this approach leads to excessive testing in low-risk older men but does not increase detection of prostate cancer in higher-risk younger men. They also highlighted significant variations in the likelihood of men being diagnosed with advanced prostate cancer with the informed choice PSA testing strategy. For instance, the UK’s National Prostate Cancer Audit found that in 2022, 12.5% (n = 1 in 8) of men with prostate cancer were diagnosed with advanced prostate cancer in London, whereas in Scotland, more than 35% (n = 1 in 3) of men were diagnosed when the disease was at a later stage.
As a result, the investigators recommended that men at high risk of prostate cancer—including those with a family history of the disease, those with African ancestry, and those with BRCA2 mutations—residing in high-income countries should undergo screening with both magnetic resonance imaging (MRI) scans and PSA tests. MRI scans are often useful at imaging tumors as well as providing information on the cancer’s aggressiveness, but biopsies can be more effective at identifying aggressive cancer. The combined screening approach may help reduce overdiagnosis and overtreatment while detecting potentially life-threatening disease.
The effectiveness of population-level PSA testing has not yet been examined in low- and middle-income countries, where there is an urgent need for cancer screening trials and new methods to enable earlier diagnosis. The investigators stressed that most men in these countries present with metastatic cancer. Consequently, these patients with late-stage prostate cancer may be much less likely to experience long-term survival compared with those who receive earlier diagnoses.
“With prostate cancer, we cannot wait for [patients] to feel ill and seek help; we must encourage testing in those who feel well but who have a high risk of the disease in order to catch lethal prostate cancer early. Pop-up clinics and mobile testing offer cost-effective solutions that combine health checks and education. In the [United Kingdom], we recently trialed a new innovative outreach program called The Man Van, which provided free health checks—including PSA tests—to high-risk men in London aged 45 and older,” detailed Dr. James. “By bringing a van with quick and easy testing straight to men at work and in the community and targeting those who have a higher risk of prostate cancer, we provided thousands of health checks that resulted in almost 100 cancer diagnoses in men who might otherwise have only seen a [physician] once their cancer has progressed to a more advanced stage. The mix of education, outreach, testing, and referral used in The Man Van trial may also be successful in [low- and middle-income countries], and we hope to see similar initiatives rolled out globally to improve early detection of prostate cancer,” he continued.
Improving Awareness Programs, Research, and Management in Prostate Cancer
The investigators identified a need to raise awareness of the symptoms of metastatic prostate cancer among men and their families in low- and middle-income countries. Although therapies—even inexpensive but effective ones such as hormone therapy—that can prolong survival and decrease suffering are often available in many low- and middle-income countries, public awareness of disease indicators such as bone pain as well as the benefits of treatment may be poor. As with early diagnostic capacity, treatment availability and access should be scaled up in patients with advanced disease in these countries. Involving new technologies and channels such as smartphones, social media, and influencers may help bolster education programs. They highlighted that Project PINK BLUE—an organization delivering a range of programs to raise awareness for breast cancer, cervical cancer, and prostate cancer in Nigeria—provides free cancer screenings, uses digital technologies, and involves well-known public figures and celebrities to raise awareness.
Additionally, the investigators stressed the need for more research involving non-White men to better understand prostate cancer and enable improved detection and care in these patient groups. Research and knowledge of prostate cancer are currently focused primarily on White men residing in high-income countries. However, Black men, especially those of West African descent, may have a higher risk of developing and dying of prostate cancer compared with White or Asian men. However, it is not known whether the increased rate of mortality is driven by the differences in case rates, other factors such as differing disease biology, or societal factors like deprivation or racism. More data may be needed to identify the driving factors behind these trends. The Commission urged for mandatory recording of ethnicity in clinical trials; encouraged researchers to reflect the ethnic mix of the populations being studied in their trials to ensure the findings apply to all groups; and called for prostate cancer trials examining screening, early diagnosis, and treatment in low- and middle-income countries.
Optimal management of prostate cancer may require the availability of specialists and infrastructure to support diagnosis, surgery, and radiotherapy to treat patients with localized prostate cancer; and radiotherapy and hormone therapy to treat those with metastatic disease. The investigators stated that a major barrier to improved prostate cancer care in low- and middle-income countries may be the lack of trained staff and specialist facilities. These shortages are not limited to prostate cancer, and a previous The Lancet Commission published by Meara et al in The Lancet on surgery found that 90% of patients in low- and middle-income countries cannot access basic surgical care. Expanding early diagnostic capabilities in these countries may help increase the rates of detection in early-stage prostate cancer, further increasing demand for surgery and radiotherapy. Urgent measures may need to be undertaken to build surgical and radiotherapy capacity in these countries. Establishing regional hubs could provide the infrastructure to increase specialist training and improve patient access to radiotherapy and surgery. Further, earlier diagnosis and initiation of hormone therapy could reduce the rate of mortality and serious complications such as painful spinal cord compression, urinary retention, infections, and kidney damage among men with metastatic prostate cancer.
Conclusions
The investigators revealed that the current state of prostate cancer represented a wider need to tailor future health care to cope with increases in several diseases, as the number of men reaching older ages rises across the world. The Commission called for new trials exploring prostate cancer screening in low- and middle-income countries to establish part of holistic approaches with a broader focus on men’s health.
“The issue in low- and middle-income countries is that late diagnosis of prostate cancer is … [normal]. Improved outreach programs are needed to better inform [individuals] of the key signs to look out for and what to do next. Implementing these in tandem with investments in cost-effective early diagnostic systems will be key to preventing deaths from prostate cancer, as cases inevitably rise with a global aging population,” underscored co–study author James N’Dow, MB ChB, FRCS, Chair in Surgery at the University of Aberdeen, founder of Horizons Trust & Horizons Clinic in Gambia. “As well as the obvious direct effects on individual men’s health, rising numbers of cases and deaths from prostate cancer could have huge economic and social impacts on families in [low- and middle-income countries]. Men in these countries are very often a family’s main breadwinner, so if they die or become seriously ill, this can lead to families facing major economic hardship. By preparing now for the upcoming surge in prostate cancer cases, with a particular emphasis on improved education and earlier diagnosis programs, many of these harms could be reduced substantially,” he concluded.
Disclosure: For full disclosures of the Commission authors, visit thelancet.com.
