Bracing for a Surge in Prostate Cancer Diagnoses

Driven by increased life expectancy and related changes in age structure, global prostate cancer cases will more than double over the next 15 years, a panel of experts concluded.

The number of new cases will increase from 1.4 million in 2020 to 2.9 million in 2040. Neither lifestyle changes nor public health interventions alone can alter the projections. At the same time, annual prostate cancer mortality will increase by 85% to almost 700,000, primarily among men in lower- and middle-income countries (LMICs). The frequency of late-stage diagnosis, which has become the norm in LMICs, will continue to increase worldwide, members of the Lancet Commission on prostate concluded in a report published in The Lancet.

Despite the report’s global perspective, the findings and conclusions readily apply to North America, according to co-author Brandon Mahal, MD, of the University of Miami Sylvester Comprehensive Cancer Center.

“We anticipate there will be an increasing incidence of prostate cancer in the United States, and that’s due to our aging population and our growing population, especially with the Baby Boomer generation coming into the age where prostate cancer is most common,” Mahal told MedPage Today. “Looking forward into the next 20 or 30 years, you’re going to start seeing the Millennial generation coming into that age group, so the United States should brace for an increasing public health burden of prostate cancer cases.”

Moreover, disadvantaged populations in the U.S. share some of the same characteristics as individuals in LMICs, such as limited healthcare resources and limited access to healthcare, he added.

Authors of the report call for new approaches to early detection of prostate cancer. In high-income countries (HICs), such as the U.S., early detection typically centers on prostate-specific antigen (PSA) testing, which often detects clinically insignificant disease that may never cause symptoms or require treatment.

In the U.S., England, and other HICs, “informed choice” PSA testing has become the norm: Men 50 or older can request a PSA test from their doctor after a discussion of the risks and benefits. Authors of the Commission report maintain that such an approach leads to overtesting in low-risk men with no increase in cancer detection among high-risk younger men. Additionally, informed choice increases the likelihood of late-stage diagnosis.

“With prostate cancer, we cannot wait for people to feel ill and seek help,” said report co-author Nick James, MBBS, PhD, of the Institute of Cancer Research in London. “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.”

James headed a recent outreach program that provided free health checks that included PSA testing to high-risk men 45 or older. Called the Man Van, the mobile clinic brought healthcare services to men at their places of work, resulting in more than 100 prostate cancer diagnoses in men who might otherwise have seen a doctor only after the disease became symptomatic.

By providing a variety of routine services, the Man Van addressed another issue raised in the Commission report: increased rates of other age-related conditions, such as diabetes and heart disease.

“Early diagnosis programs should focus not just on prostate cancer but on men’s health more broadly,” the authors stated.

Not all of the recommendations are consistent with current practice in the U.S. For example, the Commission recommends use of prostate MRI with PSA testing in high-risk men in HICs.

“Standard prostate cancer screening guidelines have not yet incorporated MRI, but there’s increasing expert consensus that MRI ought to be incorporated into screening,” said Mahal. “It’s already been incorporated into diagnosis of prostate cancer. MRI can help with detecting clinically significant prostate cancer and potentially reduce the chance of catching early cancers that don’t necessarily need to be treated. The Commission is urging consideration of this.”

With a forward-looking perspective, the panel acknowledged that germline testing for BRCA mutations has yet to gain acceptance as a part of routine clinical practice anywhere in the world. However, they stated that testing for such mutations “could make a meaningful contribution to the diagnostic pathway.”

Among other recommendations, the Commission called for implementation of programs to raise awareness of prostate cancer in LMICs and improve early diagnosis and treatment. The panel also supported more prostate cancer research involving men of different ethnicities, especially men of West African descent.

The authors acknowledged that improved rates of early detection will exert greater demand on under-resourced healthcare systems in LMICs. They suggested creation of regional hubs to provide the infrastructure needed to increase specialist training and improve patients access to radiotherapy and surgery.

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