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Focus on improving education and early diagnosis programs!
Written by丨The Lancet
Prostate cancer accounts for 15% of all male cancers, is the second leading cause of cancer death among men in the UK and is the most common male cancer in more than half of the world's countries.
On April 4, 2024, The Lancet Commission on prostate cancer: planning for the surge in cases predicted that the number of prostate cancer cases worldwide will increase from 1.4 million per year in 2020 to 2.9 million per year in 2040, and the number of cases will double. Among them, low- and middle-income countries saw the largest increases.
In addition, the number of people who die from prostate cancer each year worldwide will increase by 85% over 20 years, from 375,000 in 2020 to nearly 700,000 in 2040. The majority of deaths are expected to occur in low- and middle-income countries due to the increasing number of cases and rising mortality rates in low- and middle-income countries.
Figure 1 Screenshot of the report
Prostate cancer screening: The world needs new, improved testing options
- High-income countries
Prostate cancer screening usually uses a prostate-specific antigen (PSA) test, which measures the level of the prostate-specific antigen protein in the blood. However, prostate cancer, which is usually detected by a PSA test, may never show symptoms and may not require treatment. As a result, current prostate cancer diagnostics in the UK and many other high-income countries rely on the "informed choice" PSA testing scheme – men aged 50 and over who are asymptomatic can request a PSA test after discussing the risks and benefits with their doctor.
Significant reports suggest that this testing program leads to overtesting of low-risk older men without increasing the detection of prostate cancer in high-risk young men [1]. The report also highlights that there is a huge difference in the likelihood of men being diagnosed with advanced prostate cancer under the "informed choice" PSA testing strategy. For example, the UK's National Prostate Cancer Audit found that 1 in 3 people (35%) in Scotland were diagnosed with advanced prostate cancer in 2022 [2].
Because magnetic resonance imaging (MRI) can be used to provide information on whether the disease is aggressive and potentially life-threatening, and prostate biopsy is more effective in identifying aggressive cancer, the report recommends the use of MRI scans in combination with PSA testing to screen men at high risk of prostate cancer in high-income countries (e.g., family history, people of African descent, and those with BRACA2 mutations). This reduces overdiagnosis and overtreatment, while detecting potentially fatal cases of prostate cancer.
- Low- and middle-income countries
Low- and middle-income countries that have not yet tested the effectiveness of population-level PSA tests need to conduct cancer screening trials as soon as possible. New approaches to early diagnosis in low- and middle-income countries are critical, as most men in these countries are diagnosed with metastatic cancer – advanced cancer that has spread to other parts of the body, usually bones. Men with advanced prostate cancer survive much shorter times than men diagnosed with early-stage prostate cancer.
For prostate cancer screening, mobile clinics and mobile testing offer a cost-effective solution that combines physical examination and education. Professor Nick James, project leader at The Man Van [3], said: "We drove a van with quick and easy tests directly to men's workplaces and communities, providing thousands of tests to people at high risk of developing prostate cancer, resulting in nearly 100 men diagnosed with cancer who may only see a doctor when their cancer has progressed to an advanced stage. The combination of education, outreach, testing and referral used in The Man Van trial is also likely to be successful in low- and middle-income countries, and we hope to see similar initiatives replicated globally to improve early detection of prostate cancer." ”
Prostate cancer is not only a major and growing challenge, but also a reminder that the future of healthcare needs to respond more broadly to the expansion of multiple diseases as the number of middle-aged and older men increases globally. The report calls for prostate cancer screening trials in low- and middle-income countries to develop a holistic approach that focuses on men's health in general.
Advanced prostate cancer: Raising awareness of existing treatments through new technologies and new channels
In many low- and middle-income countries, there is insufficient public awareness of the main features of advanced prostate cancer, such as bone pain due to metastasis from the cancer. Similarly, in many low- and middle-income countries, people generally have low awareness of treatments that can prolong survival and reduce suffering, including inexpensive and effective treatments such as endocrine therapy. As with early diagnosis, there is a need to expand treatment for advanced cancer and improve access to it in low- and middle-income countries.
The report recommends the adoption of new technologies and channels, such as smartphones, social media and influencers, to enhance disease education. Project PINK BLUE has carried out a series of awareness-raising campaigns in Nigeria to raise awareness about breast, cervical and prostate cancer, as well as providing free cancer screenings. Many of the organization's projects leverage digital technology and involve well-known public figures and influencers.
James N'Dow, Professor of Surgery at the University of Aberdeen in the UK and founder of the Horizons Trust & Horizons Clinic in The Gambia, said: "The problem that low- and middle-income countries are currently facing is that prostate cancer is generally diagnosed late. Outreach programmes need to be improved to better understand the main signs to look out for and what to do next. As the global population ages, the incidence of prostate cancer will inevitably rise, so investing in cost-effective early diagnosis systems alongside these programs will be key to preventing prostate cancer deaths. ”
Early Adenocarcinoma: Building Diagnostic and Therapeutic Capacity in Low- and Middle-Income Countries
The optimal treatment of prostate cancer requires expertise and infrastructure to support diagnosis, surgery, and radiation therapy for organ-limited prostate cancer, as well as radiation therapy and endocrine therapy for metastatic cancer.
Improving early diagnosis capacity in low- and middle-income countries will increase the detection rate of early-stage prostate cancer, further increasing the need for surgery and radiation therapy. Therefore, urgent measures are needed to improve the surgical and radiotherapy capacity of these countries. The report notes that the establishment of regional centers could provide the infrastructure needed to enhance specialist training and improve patient access to radiotherapy and surgery [4].
For men with metastatic cancer, early diagnosis and early initiation of endocrine therapy will reduce deaths and prevent serious complications such as spinal cord compression pain and urinary retention, which can lead to infection and kidney damage.
Cancer Care and Survival: More Research on Racial Disparities
Currently, research and understanding of prostate cancer is focused on white European male populations, and most studies have been conducted in high-income countries. However, black men, especially men of West African descent, have a higher risk of prostate cancer than white or Asian men, but the reasons for this are unknown. In addition, prostate cancer mortality is also higher in Black men, but more data is needed to identify the drivers behind these trends.
The report calls for mandatory recording of ethnicity in clinical trials, and for trials to reflect the racial composition of the population being studied to ensure that the findings are applicable to all groups. The report also argues that trials should be conducted in low- and middle-income countries to test prostate cancer screening, early diagnosis and treatment.
Professor of Prostate and Bladder Cancer Research at the London Cancer Institute, Chief Clinical Oncologist at the Royal Marsden Cancer Centre, UK. "As more men around the world move into middle and old age, prostate cancer cases will inevitably increase, so it's time to start planning and taking action," said Nick James. Evidence-based interventions, such as improved early detection and education programmes, will help prevent prostate cancer and save lives in the coming years, which is particularly important in low- and middle-income countries. ”
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References: [1] https://www.bmj.com/content/381/bmj-2022-071082
[2]https://www.npca.org.uk/content/uploads/2022/09/NPCA_Short-report-2022_Final-08.09.22.pdf
[3]https://www.royalmarsden.nhs.uk/your-care/cancer-types/urological/prostate-cancer/man-van
[4]https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)60160-X.pdf
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