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

Abstract

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.

Figure 1. Overview of prostate cancer staging and biology

Figure 2. Global variations in prostate cancer incidence (A) and mortality (B), 2020

ASR(W)=age-standardised incidence rates.

Figure 3. Regional variations in prostate cancer incidence (A) and mortality (B), 2020

Minimum and maximum national rates in each region are shown.

Figure 4. Temporal trends in prostate cancer incidence and mortality in countries in the Americas, Asia, and Oceania (A) and Europe (B)

Solid lines represent incidence, whereas dashed lines represent mortality. Note the use of semi-logarithmic scale. The trend lines have been smoothed by using Loess regression. *Data for these countries come from regional registries.

Figure 5. Estimated number of new cases of (A) and deaths from (B) prostate cancer among men and boys aged 0–85 years in 2020 and 2040, by UN world region

Predictions to 2040 take into account national population projections and regional trends in prostate cancer incidence and mortality rates based on recent reports.^,,, Custom annual percent changes have been applied for both incidence (Northern America –1%, Eastern Asia 2%, Eastern Africa 3%, Middle Africa 3%, Northern Africa 3%, Southern Africa 3%, Western Africa 3%, Caribbean 0·5%, Central America 1%, South-eastern Asia 2%, South-central Asia 3%, Western Asia 3%, Eastern Europe 3%, Northern Europe –1%, Australia and New Zealand –1%, and South America: 0·5%) and mortality (Northern America –1·5%, Eastern Asia –0·5%, Eastern Africa 1%, Middle Africa 1%, Northern Africa 1%, Southern Africa 1%, Western Africa 1%, Central America –0·5%, South-eastern Asia 0·5%, South-central Asia 1%, Western Asia 0·5%, Eastern Europe 0·5%, Northern Europe –2%, Southern Europe –1·5%, Western Europe –1·5%, Australia and New Zealand –1%, and South America –0·5%).

Figure 6. Radiotherapy coverage as a function of gross national income

Each circle represents a distinct country. The diameter of the circle is the actual yearly number of fractions delivered. Coverage is reported for an assumed 8 h operating day. Source: Atun et al (2015).

Figure 7. Access to radiotherapy worldwide per million population

Source: Abdel-Wahab et al (2021).

Figure 8. Distributed opioid morphine-equivalent (morphine in mg per patient in need of palliative care, average 2010–13), and estimated proportion of need that is met for the health conditions most associated with serious health-related suffering

Source: International Narcotics Control Board and WHO Global Health Estimates, 2015. Reproduced from Knaul et al (2018).

Figure 9. Sensitivity of PSMA PET and CT compared to CT alone in metastasis detection

The left-hand panel is a coronal whole-body PET image. Black areas show normal tissue tracer uptake (by the salivary glands, liver, spleen, and kidneys). The red areas represent cancer-related PET tracer uptake in metastatic lymph nodes and the prostate. The upper panels are CT images of lymph nodes with cancer in the para-aortic region. In the lower panels, the addtion of PET to CT clearly shows tracer uptake by low-volume lymph node metastasis, which would be impossible to discriminate in the CT only images. PSMA=prostate-specific membrane antigen.