Lancet Commission predicts sharp increase in global prostate cancer cases

Cases of prostate cancer are projected to double from 1.4 million per year in 2020 to 2.9 million per year by 2040, with low- and middle-income countries (LMICs) predicted to see the highest increases in cases, according to The Lancet Commission on prostate cancer which will be launched by a presentation at the European Association of Urology Congress.

The number of annual prostate cancer deaths worldwide is predicted to rise by 85% over the 20-year period, from 375,000 deaths in 2020 to almost 700,000 deaths by 2040. The true numbers will likely be much higher than the recorded figures due to under-diagnosis and missed opportunities for data collection in LMICs. 

Most of these deaths are expected to be in LMICs, due to the rising number of cases and increasing mortality rates in these countries. Deaths from prostate cancer have declined in most high-income countries (HICs) since the mid-1990s.

Prostate cancer is already a major cause of death and disability, accounting for 15% of all male cancers. It is the second most common cause of cancer deaths in UK men and the most common form of male cancer in more than half of the world's countries.

Aging populations and increasing life expectancy will lead to higher numbers of older men in coming years. As the main risk factors for prostate cancer – such as being aged 50 or older and having a family history of the disease – are unavoidable, it will not be possible to prevent the upcoming surge in cases through lifestyle changes or public health interventions.

Professor Nick James, lead author of the Commission, Professor of Prostate and Bladder Cancer Research at The Institute of Cancer Research, London, and Consultant Clinical Oncologist at The Royal Marsden NHS Foundation Trust, said: "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." 

Global need for new and improved early detection programs

In HICs, screening for prostate cancer often involves the PSA test, a blood test that measures levels of a protein called prostate-specific antigen (PSA). However, PSA tests often detect prostate cancer which may never cause symptoms and needs no treatment. The current approach to prostate cancer diagnosis in the UK and many other HICs relies on 'informed choice' PSA testing – when men aged 50 or over with no disease symptoms can request a PSA test from their doctor after a discussion of the risks and benefits. The Commission argues there is evidence to suggest this approach leads to over-testing in low-risk older men but does not increase detection of prostate cancer in younger men at higher risk. The authors also highlight huge variations in the likelihood of men being diagnosed with advanced prostate cancer with the 'informed choice' PSA testing strategy, for example The National Prostate Cancer Audit in the UK found that in 2022, 1 in 8 men (12.5%) with prostate cancer are diagnosed with advanced prostate cancer in London, whereas in Scotland more than 1 in 3 (35%) were diagnosed late.

Instead, the authors recommend using MRI scans in combination with PSA testing to screen men at high risk of prostate cancer in HICs, such as those with a family history of the disease, those of African origin and those carrying the BRACA2 mutation. They argue that this approach would both reduce over-diagnosis and over-treatment, while detecting potentially lethal disease. MRI is effective in imaging cancers and can be used to provide information as to whether the disease is aggressive and likely to be life-threatening. However, biopsies are more effective at identifying aggressive cancers, so MRI alone should not be used to investigate men at high risk of disease.

The effectiveness of population-level PSA testing has not been tested in LMICs and there is an urgent need for cancer screening trials in these countries. New approaches to enable earlier diagnosis in LMICs are vital, as most men in these countries present with metastatic cancer – an advanced form of disease where the cancer has spread to other parts of the body, often the bones. Men with late-stage prostate cancer are much less likely to survive for a long period of time than those who are diagnosed early.

"With prostate cancer we cannot wait for people 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 UK we recently trialled a new innovative outreach programme called The Man Van which provided free health checks – including PSA tests – to high-risk men in London aged 45 and over. 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 which resulted in almost 100 cancer diagnoses in men who might otherwise have only seen a doctor 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 LMICs and we hope to see similar initiatives rolled out globally to improve early detection of prostate cancer," said Professor Nick James (also project lead for the 'Man Van').

As well as being a major growing challenge, prostate cancer is also an indicator of a wider need to tailor future healthcare to cope with increases in several diseases, as the numbers of men reaching middle and old age increase worldwide. The Commission calls for trials of prostate cancer screening in LMICs to form part of holistic approaches with a broader focus on men's health.

Raising awareness of advanced prostate cancer and available therapies

There is a need to raise awareness of the dangers and symptoms of metastatic prostate cancer among men and their families in LMICs. Public awareness of the key features of advanced prostate cancer – such as bone pain, caused by metastatic disease – is poor in many LMICs. Similarly, there is generally low public awareness that treatments can prolong survival and decrease suffering – including cheap, effective ones such as hormone therapy – are available in many LMICs. As with early diagnostic capacity, there is a need to scale-up availability and improve access to treatments for advanced disease in LMICs. 

Improving education about the disease is critical, and the Commission authors suggest that programs should involve new technologies and channels such as smartphones, social media, and influencers. They highlight Project PINK BLUE, an organization that delivers a range of programs to raise awareness of breast, cervical, and prostate cancer in Nigeria, and provides free cancer screening. Many of Project PINK BLUE's programs utilize digital technologies and involve well-known public figures and celebrities.

Professor James N'Dow, Chair in Surgery, University of Aberdeen and Founder of Horizons Trust & Horizons Clinic, Gambia, said: "The issue in low- and middle-income countries is that late diagnosis of prostate cancer is the norm. Improved outreach programs are needed to better inform people 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." 

He continues, "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 LMICs. 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." 

Building capacity to diagnose and treat prostate cancer early in LMICs 

Optimal management of prostate cancer requires the availability of specialist staff and infrastructure to support diagnosis, surgery and radiotherapy to treat localized prostate cancer, and radiotherapy and hormone therapy for metastatic disease.

A major barrier to improved prostate cancer care in LMICs is a lack of trained staff and specialist facilities. These shortages are not limited to prostate cancer, and the 2015 Lancet Commission on Surgery found that 9 out of 10 people in LMICs cannot access basic surgical care. [4]

Expanding early diagnostic capabilities in LMICs will increase the rates of detection of early-stage prostate cancer, further increasing demand for surgery and radiotherapy. Urgent measures are therefore needed to build surgical and radiotherapy capacity in these countries. The Commission authors state that establishing regional hubs could provide the infrastructure needed to increase specialist training and improve patient access to radiotherapy and surgery.

For men with metastatic disease, earlier diagnosis and starting hormone therapy earlier will reduce deaths and prevent serious complications like painful spinal cord compression and urinary retention, which can lead to infection and kidney damage.

More research is needed on ethnic inequities in care and survival

The Commission authors highlight the need for more research to better understand prostate cancer in men who are not of White European origin, to enable improved detection and care in these groups. Research and knowledge of prostate cancer is heavily focussed on White European men, and most studies have been done in HICs. However, Black men, especially those of West African descent, have a higher risk of developing prostate cancer than White or Asian men, though the reasons for this are unclear. There is also a higher death rate from prostate cancer among Black men, but it is not known if this is driven by the differences in case rates or by other factors such as differing disease biology or societal factors such as deprivation or racism. More data is needed to identify the driving factors behind these trends. 

The Commission authors call for mandatory recording of ethnicity in clinical trials, and that trials should reflect the ethnic mix of the populations being studied to ensure that the findings apply to all groups. The Commission authors also call for trials examining prostate cancer screening, early diagnosis, and treatment in LMICs.