A Prostate Cancer Tsunami Is Coming

On 4 April 2024, the Lancet Commission on Prostate Cancer warned that the world is on the brink of an inevitable rise in prostate cancer , with annual new cases expected to reach 2.9 million by 2040 and deaths to rise by 85 percent to nearly 700,000.

At a meeting of urologists in Paris, the commission said this acceleration had already begun, particularly in high-income countries such as the United States and the United Kingdom, but would gain momentum in low- and middle-income countries.

Report Summary

• Annual new prostate cancer cases are projected to rise from 1.4 million in 2020 to 2.9 million by 2040. Changes in age structure and improvements in life expectancy will cause major increases in the disease.
• The rise in prostate cancer cases cannot be prevented through lifestyle changes or public health interventions.
• Late diagnosis of prostate cancer is common worldwide, particularly in low- and middle-income countries, where it has become the norm. The only way to reduce the harm from rising case numbers is to urgently establish early detection systems in low- and middle-income countries. Screening trials are urgently needed to improve early detection.
• Early detection systems will need to integrate new combinations of personnel and the growing capabilities of artificial intelligence to help interpret screening results and biopsy samples.
• Because the rise in prostate cancer is likely to lead to increases in other conditions, such as diabetes and heart disease, early detection programs should focus more broadly on men's health rather than on prostate cancer alone.
• Outreach programs using smartphones, which are widely available worldwide, are needed to educate people about prostate cancer through both social and traditional media. Programs are also needed to help people navigate health systems.
• Most prostate cancer research has focused disproportionately on men of European ancestry, although disease rates are twice as high in men of African ancestry. Better understanding the drivers of ethnic differences in the disease is a major research priority.
• Treating advanced prostate cancer remains challenging. Cost-effective treatments are available but unevenly distributed. Consistent use of these treatments is a cost-effective way to reduce the harm caused by prostate cancer.
• Shortages of specialist surgeons and radiotherapy equipment persist in low- and middle-income countries. Addressing these shortages is key to improving prostate cancer care globally.

Expert Views

Dr. Nick James, lead author of the Lancet report and professor of prostate and bladder cancer research at the Institute of Cancer Research in London, said this increase was partly a medical success story.

James said in an interview, "Paradoxically, prostate cancer is a problem built into biology. Men develop prostate cancer as they age," he said.

"There is a major increase in high-income countries. But over the coming decades, we will see a large increase in the number of people in their 50s, 60s, and 70s in poorer countries, which means more prostate cancer. High-income countries such as the United Kingdom and the United States will also see smaller increases for the same reason."

According to the report, "The case for screening all men aged 50–70 in high-income countries (and all men of African ancestry aged 45–70) is growing stronger, thanks to the advanced use of technologies such as MRI and increasing evidence for active surveillance as a safe approach to monitoring the disease."

Andrew Vickers, a biostatistician at Memorial Sloan Kettering Cancer Center, said the Lancet Commission reached conclusions similar to those he and an international group of researchers reached in 2023 in an article published in The BMJ . According to Vickers, a major shortcoming is the misuse of prostate-specific antigen (PSA) screening.

Vickers said, "We found that a 'let the patient decide' policy has led to excessive PSA use by men, high rates of overdiagnosis and overtreatment, and economic and racial inequity. In our view, PSA screening should either be done well—using simple harm-reduction strategies such as limiting screening in older men and using secondary tests before biopsy—or not done at all."

James pointed out that advanced disease is often undertreated. For example, he noted that in the United States, metastatic (spread throughout the body) prostate cancer patients receiving the necessary hormone therapy account for only approximately 30-40% of men with the disease. "We could easily improve treatment outcomes by applying what we already know," he said.

James noted that men of African ancestry are twice as likely to develop prostate cancer, but it is unclear whether their treatment should follow a different approach. The new report emphasized the need to include more men of African ancestry in research.

Dr. Brandon Mahal, a report coauthor and vice chair for research at the University of Miami Sylvester Comprehensive Cancer Center, said new approaches are needed to diagnose prostate cancer earlier in men in low- and middle-income countries. Most patients in these countries present with metastatic disease and have a lower chance of long-term survival.

James proposed pop-up clinics and mobile testing to encourage men at high risk of prostate cancer who feel well to seek early detection of potentially fatal cancers.

In England, for example, James introduced an outreach program called The Man Van, providing free health checks, including PSA tests, to high-risk men in London.

"By taking a mobile vehicle offering quick and easy tests to workplaces and communities, and targeting people at greater risk of prostate cancer, we have provided thousands of health checks and diagnosed nearly 100 cancers in men who might otherwise only have seen a doctor after their cancer had progressed to a more advanced stage," he said.

James said the medical community was unprepared for the rise in prostate cancer cases worldwide.

"The solution cannot be to train more urologists, radiation oncologists, pathologists, and radiologists, because that would simply take too long," James said. Greater use of nurses and artificial intelligence could, however, help. "At my own hospital, biopsies are a nurse-led and nurse-delivered service. Artificial intelligence is already extraordinarily good at diagnosis, and it will only get better," he said.

In less developed countries, smartphones could fill an important gap in health care. Artificial intelligence technologies already perform very well in image-processing applications such as facial recognition, and these technologies can detect particular prostate cancers, such as Gleason 7. However, concerns that pathologists' incomes could be adversely affected are a barrier to wider adoption of these innovations in many Western countries.