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Nicholas James: We are all here in Lugano because we want to improve the outcomes for men with prostate cancer. And we've spent a lot of time talking about the latest high-tech treatments, stereotactic radiotherapy, PARP inhibitors, and so on. But I think one of the things that's been very striking to me from this Lancet Commission—and I'll be the first speaker—is that really to impact prostate cancer globally, the issues are not around when do we give a PARP inhibitor, the issue is around how do we diagnose men promptly and get them on the right treatments quickly, as quickly as possible.

And this is something we don't do that well at already. And we're going to see a big change in the demography of prostate cancer in the coming years. And that's something that I want to highlight. And we've got a fantastic panel of global oncology and urologic oncology experts who are going to talk us through some of the issues. So these are my disclosures. To be honest, not really very relevant to the talk.

So The Lancet, as I'm sure you're all aware, is a medical journal. And they've been running these commissions on topics like women's health, global surgery, global radiotherapy for quite some while. And this was the first commission that they've commissioned on a specific disease. And they chose prostate cancer. So this has been a substantial process going back three or four years.

So the first meeting was in September 2020. But upstream, there was a whole load of work done on finding suitable experts who had the right perspective. So people had to be experts in their fields—oncology, urology, whatever—but also we wanted a geographically diverse spread, and we had health economics experts, public health, epidemiology, patient representatives, the whole spread. And it took a long time to assemble the right panel. And we then had a series of meetings. The final paper has 40 authors on. And a number of the authors are either in the audience or on the stage with me. And you can see they are indeed very diverse in every respect.

In order to look at the problem, we split it up into four subgroups. The first was just looking at what the evidence is, what we know already, chaired by Ian Tannock. The second was looking at the issues around diagnosis, chaired by James N'dow, who's on the stage and who will be taking part in the panel discussion. And then we had two disease management groups, one led by Felix Feng, who we were hoping would be here today but unfortunately, as he said yesterday, is unable to be here. And the second was looking at optimizing treatment for advanced disease.

So the first thing, just looking at the current evidence, was the striking [INAUDIBLE] and the overly high prevalence. So prostate cancer is the commonest male cancer in 112 of 185 countries in the world, which is something I didn't know myself. And it's 15% of all-male cancers globally. And that's the first thing. The second thing is you can see the distribution of current cases. This is what is going to happen in the next 15 years. The change is staggering. And what you can see is that the red bars, which are the new cases that will be seen, are huge. And they're in areas that are not necessarily seeing a lot of cases at the moment.

So if I draw your attention to Western Africa about halfway up, it's common already in Western Africa. It's going to get much, much commoner. And so this rate of change is going to exceed traditional disease management models of expanding numbers of urologists, oncologists, and so on. So although that is going to be important, it won't be able to keep pace with the rate of change in cases. So we're looking at more than doubling by 2040. And this is almost certainly an underestimate.

And if we look at deaths, we see the same pattern. So this is the current pattern of deaths. And what we're going to see is everybody will see increases. So Western Europe, North America, although we have relatively elderly populations, improving life expectancy is going to still drive up both the number of cases and the number of deaths. But you can see that the number of deaths is going to go up everywhere, and it's going to double in a lot of places, and particularly in low- and middle-income countries.

So moving on—and these are just the headline things—the diagnostic pathway is key because metastatic disease is—I don't need to tell this audience—is incurable. So if we want to improve the death rate or reduce the death rate, we need to diagnose the disease earlier. Against that—not against diagnosing it earlier, but one of the problems is that in high-income countries, there is an issue of overdiagnosis. But in low- and middle-income settings, it's the opposite. It's underdiagnosis that is the problem. And with rapidly rising cases, this is going to be an increasing problem.

In order to address this, we make some quite detailed suggested approaches. But just because of straightforward issues about how long it takes to train a urologist, we're going to need to base diagnostic systems around new case mixes, new skill mixes using nurse-based biopsy, for example—which in fact is what we already do at the Marsden where I work. So I'm not proposing a second-class solution here.

And we will also need to use tools that are rapidly becoming available, such as artificial intelligence, to augment and supplement the sparse availability of pathologists, for example. In parallel, because the rise in prostate cancer cases will be driven by improving life expectancy, we will see increases in things like heart disease, diabetes, and so on. So any strategy aimed at dealing with prostate cancer will, in parallel, have to deal with a whole lot of other things as well. And one of the things we identify is key—and I'll come back to this—is using things like smartphones as tools for change.

The second thing is ethnicity. And again, it'll be well-known to this audience that prostate cancer is more common in Black men than white men, particularly probably West African origin men. So ethnic mix, ethnic origin is globally a key driver of high death rates. And incidence rates are driven by a mix of how much PSA testing you do, how much early diagnosis, and so on, and by your stage at diagnosis. But ethnicity, per se, is something that is very much under-researched. And again, we make specific recommendations around how this needs to change in the future to improve outcomes for men globally.

Moving on to treatment—so we've spent the last day and a half talking about treatment, mostly for advanced disease. And it's clear that there are amazing treatments available and getting more amazing by the year. But we also know—and this has come up in a number of talks—that one of the striking things is that even in countries where expensive treatments are funded, they're not uniformly delivered. So under half of men in the United States and in the United Kingdom receive what you might want to call combination or intensified androgen deprivation therapy up front.

So simply delivering what we know works is a really easy way of improving outcomes. And we don't do it. In parallel, we have to plan for success. So if we plan to improve diagnostic pathways in low- and middle-income countries, we for sure will drive a need for more surgeons, more oncologists, more radiotherapy kit, and so on. And we need to plan for these two things in parallel.

So we make four headline specific recommendations. So the first is that if we're going to improve outcomes, we need to improve diagnostic pathways. And we make different recommendations for high- and low-income countries. The second is—and I think this is key—you need to empower men by giving them access to their own medical records. Now, smartphone penetration is very high in low- and middle-income countries. So this is an obvious tool to improve that. But it's a tool as well in high-income countries.

Thirdly, we need to make pragmatic practice recommendations affordable within the relevant settings for treatment. And by harnessing that to patient health records, you've got a route for improving use of things that we know work.

And then finally, there's a need for more research always. But particularly, there's a need for more research appropriate to the needs of low- and middle-income countries. So for example, we do not know whether we should do PSA-based testing. So we make specific recommendations about ethnicity because we don't know, for example, whether the treatments apply equally in all groups. So these are the headline recommendations: improved diagnosis, integrated with men's health more broadly, empower patients for informed care, implement resource-sensitive guidelines, and improve research and evidence-based practice. Thank you.