- Annual prostate cancer
cases are projected to rise from 1.4 million in 2020 to 2.9 million in
2040, and annual deaths to increase by 85% to almost 700,000 over the same
timeframe, mainly among men in low-and middle-income countries (LMICs).
- The Lancet Commission on prostate cancer
argues that the ‘informed choice’ programme for prostate cancer screening
with PSA testing, which is common in high-income countries (HICs), may
lead to over-testing and unnecessary treatment in older men, and
under-testing in high-risk younger men. The authors advocate instead for
early-detection programmes for those at high risk.
- The Commission also calls for urgent
implementation of programmes to raise awareness of prostate cancer and for
improvements in early diagnosis and treatment in LMICs – where most men
present with late-stage disease.
- More research involving men of different
ethnicities, especially those of West African descent, are needed, as
current knowledge of prostate cancer is largely based on studies of White
men.
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.
Ageing 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
programmes, 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 programmes
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. [1] 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. [2]
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'). [3]
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 programmes should involve new technologies and channels such as
smartphones, social media, and influencers. They highlight Project PINK BLUE,
an organisation that delivers a range of programmes to raise awareness of
breast, cervical, and prostate cancer in Nigeria, and provides free cancer
screening. Many of Project PINK BLUE’s programmes utilise 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 programmes 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
ageing 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 programmes, 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 localised 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.
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