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The Lancet Commission on prostate cancer: planning for the surge in cases

Executive summary

Prostate cancer is the most common cancer in men in 112 countries, and accounts for 15% of cancers. In this Commission, we report projections of prostate cancer cases in 2040 on the basis of data for demographic changes worldwide and rising life expectancy. Our findings suggest that the number of new cases annually will rise from 1·4 million in 2020 to 2·9 million by 2040. This surge in cases cannot be prevented by lifestyle changes or public health interventions alone, and governments need to prepare strategies to deal with it. We have projected trends in the incidence of prostate cancer and related mortality (assuming no changes in treatment) in the next 10–15 years, and make recommendations on how to deal with these issues.

For the Commission, we established four working groups, each of which examined a different aspect of prostate cancer: epidemiology and future projected trends in cases, the diagnostic pathway, treatment, and management of advanced disease, the main problem for most men diagnosed with prostate cancer worldwide. Throughout we have separated problems in high-income countries (HICs) from those in low-income and middle-income countries (LMICs), although we acknowledge that this distinction can be an oversimplification (some rich patients in LMICs can access high-quality care, whereas many patients in HICs, especially the USA, cannot because of inadequate insurance coverage). The burden of disease globally is already substantial, but options to improve care are already available at moderate cost. We found that late diagnosis is widespread worldwide, but especially in LMICs, where it is the norm. Early diagnosis improves prognosis and outcomes, and reduces societal and individual costs, and we recommend changes to the diagnostic pathway that can be immediately implemented. For men diagnosed with advanced disease, optimal use of available technologies, adjusted to the resource levels available, could produce improved outcomes. We also found that demographic changes (ie, changing age structures and increasing life expectancy) in LMICs will drive big increases in prostate cancer, and cases are also projected to rise in high-income countries. This projected rise in cases has driven the main thrust of our recommendations throughout. Dealing with this rise in cases will require urgent and radical interventions, particularly in LMICs, including an emphasis on education (both of health professionals and the general population) linked to outreach programmes to increase awareness. If implemented, these interventions would shift the case mix from advanced to earlier-stage disease, which in turn would necessitate different treatment approaches: earlier diagnosis would prompt a shift from palliative to curative therapies based around surgery and radiotherapy. Although age-adjusted mortality from prostate cancer is falling in HICs, it is rising in LMICs. And, despite large, well known differences in disease incidence and mortality by ethnicity (eg, incidence in men of African heritage is roughly double that in men of European heritage), most prostate cancer research has disproportionally focused on men of European heritage. Without urgent action, these trends will cause global deaths from prostate cancer to rise rapidly.

Key messages

  • We project that the number of new cases of prostate cancer annually will rise from 1·4 million in 2020 to 2·9 million by 2040. Changing age structures and improving life expectancy are predicted to drive big increases in the disease.

  • The projected rise in prostate cancer cases cannot be prevented by lifestyle changes or public health interventions.

  • Late diagnosis of prostate cancer is widespread worldwide but especially in LMICs, where late diagnosis is the norm. The only way to mitigate the harm caused by rising case numbers is to urgently set up systems for earlier diagnosis in LMICs. Trials of screening are urgently needed in LMICs to better inform ways to improve early diagnosis.

  • Early diagnosis systems will need to incorporate novel mixes of personnel and integrate the growing power of artificial intelligence to aid interpretation of scans and biopsy samples.

  • As the rise in prostate cancer is likely to be mirrored by rises in other conditions such as diabetes and heart disease, early diagnosis programmes should focus not just on prostate cancer but on men's health more broadly.

  • Outreach programmes are needed that harness the broad global availability of smartphones as tools for education about prostate cancer (using both social media and traditional media), as are programmes that assist people with navigation of health-care systems.

  • Most prostate cancer research has disproportionally focused on men of European origin, despite rates of prostate cancer being twice as high in men of African heritage. Better understanding of drivers of ethnic differences in prevalence of the disease is a key research priority.

  • Treatment of advanced prostate cancer remains a problem, and affordable therapies are available but are unevenly distributed. Consistent use of these therapies is a cost-effective way to reduce harm from prostate cancer.

  • There remains a shortage of specialist surgeons and radiotherapy equipment in LMICs, and addressing this shortage is key to improving prostate cancer care globally.

LMICs=low-income and middle-income countries.

On the basis of our assessments of the evidence base, we have identified and prioritised several recommendations for both immediate and long-term interventions to mitigate the current and projected future global impact of prostate cancer. We make detailed practical recommendations for the four highest-priority areas identified. First, diagnostic pathways should be modified to facilitate early detection of prostate cancer while avoiding overdiagnosis and overtreatment of trivial disease. These pathways should be linked to broader men's health checks in LMICs in view of expected rises in diseases such as diabetes driven by the same demographic trends. The case for prostate cancer screening for all men aged 50–70 years (and all men of African origin aged 45–70 years) in HICs is strengthening with improved use of technologies such as MRI and growing evidence for the safety of active surveillance.

Second, novel methods of empowering patients, such as cloud-based medical record systems, should be exploited to enable doctors and patients to make informed, personalised case-management plans. Artificial intelligence systems could supplement deficits in health profession numbers and skills, especially—but not only—in LMICs. Such systems could not only already accurately diagnose cancers but also subdivide disease into potentially valuable additional subgroups to help with treatment selection. In environments with few or no pathologists, these changes could be transformational. In HICs, the additional information provided by artificial intelligence-supported diagnosis (eg, from rapid processing of large numbers of tissue sections) compared with conventional pathology alone also has huge potential to rapidly drive change. Giving control of records to patients can be an effective way to empower people. Linking cloud-based records to artificial intelligence systems could allow access to context-sensitive, up-to-date advice for both patients and health professionals, and could be used to drive evidence-based change in all settings. Clearly there are concerns about the potential risks of such systems, such as misinterpretation of data. However, in low-resource settings, the emerging evidence is that accuracy—for pathology, for example—is already high and improving. With careful implementation, artificial intelligence could contribute to improvements in quality of care, particularly in LMICs, in particular in the near future.

Third, resource-sensitive guidelines should be implemented to maximise the effect of available therapies, especially surgery and radiotherapy, use of which is often limited in LMICs. There is a linked urgent need for expansion of radiotherapy and surgery services (mainly in LMICs but also in some HICs with uneven provision), and, in view of the timelines for investment in equipment and training of staff, these changes need to be set in motion now to deliver projected future care needs. Similar considerations with regards to access and distribution apply to drug therapies: optimal use of available therapies in all settings could improve outcomes. Even where resources are adequate, consistent evidence suggests that application of best practice is variable.

In addition to these recommendations, research and the development of risk-stratified regulatory models need to be facilitated. Drug repurposing and dose de-escalation should be supported and studied. Novel clinical trial designs, such as multi-arm platforms, should be supported and expanded. Lessons should be learned from how low-cost HIV drugs were made available and distributed globally to better meet the needs of men with prostate cancer in LMICs. Additionally, the rapid roll out of studies of COVID-19 vaccines and therapies shows that effective, large-scale trial programmes are feasible and can lead to improvements in care. More research is needed into how disease prognosis, outcomes, and treatment effects (and side-effects) differ in different ethnic groups and socioeconomic settings.

The Lancet Commission on prostate cancer provides an agenda for a realistic programme of changes, which, if implemented, will improve the health of men globally both now and in future. The coming increases in prostate cancer are brought about by rising life expectancy and changes in population age structures. Unlike other large-scale problems, such as lung cancer or cardiovascular diseases, this rise in cases is not preventable by public health strategies. Nonetheless, the effects of the global rise in prostate cancer can be mitigated. The findings in this Commission provide a pathway forwards for health-care providers and funders, public health bodies, research funders, governments, and the broader patient and clinical community.

The Lancet Commission on prostate cancer
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