Prostate cancer is the second most common cancer in men, accounting for around 15% of all cancer cases in the male population. In many parts of the world, it’s the most common form of cancer in men.

Advances in research into prostate cancer

Prostate cancer has been the focus of a huge amount of research in recent years. We have seen huge advances in treatment for the disease, including robot-assisted surgery, high precision radiotherapy, and many new therapies for advanced disease.

The revolution in genomic tools has been central to advances in this field of research. These are likely to become more important in treatment decisions, as are advances in imaging, particularly PSMA-PET-CT.

Reshaping care

Both imaging and DNA technologies are potentially scalable, affordable and often widely available in lower to middle income countries. The challenge lies in identifying the how to best deploy these technologies. These types of changes have cost and delivery challenges for all healthcare systems. But they also present opportunities to reshape and optimise care.

Aims of the commission

The Lancet commission aims to:

• explore the optimal changes to treating prostate cancer
• provide advice on what's likely to be the best approach in different healthcare settings
• make policy and clinical practice recommendations
• make recommendations for future global investment and research priorities

Key findings

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 Low- and Middle-income countries (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 disproportionately 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.

Key areas for action

Action 1: Improve diagnostic pathways in all healthcare settings to facilitate early detection of clinically significant prostate cancer and integrate with a broader focus on men's health issues

In high income settings

• Incorporation of pre-biopsy MRI scanning in at least 50% of cases with suspected prostate cancer to reduce over-diagnosis of low-grade disease.

In low- and middle-income settings

• Establishment of outreach services offering information, PSA testing and onward referral for diagnosis and treatment.
• More than 50% of men are diagnosed in LMICs with advanced disease leading to an overall death rate in Africa of over 60%.
• If the proportion diagnosed late were reduced to 1 in 3, this death rate would be halved.

Action 2: Create cloud-based medical record systems to improve access to health information and to facilitate use of artificial intelligence to complement or supplement deficits in health profession numbers and skills

• Access to and control of medical information allows tailored advice and assistance with navigation of medical systems.
• Leveraging the broad availability of smartphones globally and linkage to the extensive online information resources could transform how people in LMICs access health care.
• In High-income countries (HICs), smartphone health apps are increasingly popular. Their use should be strongly supported to give more control patients have over their health care.

Action 3: Implement pragmatic practice recommendation for maximum benefit, tailored to national resource levels and patterns of disease

• Guidelines should be resource-appropriate and linked to patient-held record systems (see action 2).
• At present, in HICSs  with funded health care, evidence shows low levels of compliance with guidelines. Consistently delivering what is known to work can rapidly improve outcomes.

Key deliverables

• In HICs, 80% of men with metastatic disease should received combination androgen deprivation therapy
• Savings can be used to pay for additional therapies such as generic low dose abiraterone

Action 4: Support research on risk-stratified regulatory models and on better understanding of the effects of ethnic differences

• Research on cost-effective diagnostic methods and drug repurposing or dose de-escalation

• In LMICs, at least one trial each of screening, early diagnosis and treatment should be established within the next 5 years

Ethnicity

• Trials should reflect the ethnic mix of the study population. In international trials, broad geographical spread is a route to better ethnic representation,

• Ethnic representation in licencing trials should be measured and mandated by regulatory bodies
  Under-representation in studies of men of African origin is a particular, but not the only, concern.

Researchers on the commission

Nick James will be supported in the commission by four working group chairs: Professor Ian Tannock, Professor James N’Dow, Professor Felix Feng and Professor Silke Gillessen. 

See full list of commissioners