From 1990 to 2019, the total number of PCa mortalities worldwide increased by 108.94%, with the increase being relatively greater in all BRICS countries. Within the BRICS countries, there were significant differences both in terms of rates and temporal trends. Both globally and across all BRICS countries, the all-age mortality rate has shown an increasing trend. However, the age-standardized mortality rates for the world, Brazil, India, and China have exhibited a declining trend, while Russia and South Africa have experienced an increasing trend in age-standardized mortality rate.
Brazil has made remarkable strides in ameliorating PCa mortality. Period effects have played a pivotal role in this context, with a notable reduction in the risk of prostate cancer-related mortality since 2005. However, over the course of these three decades, cohort effects have predominantly yielded adverse consequences. In a time when the PCa incidence rates were stabilizing across the majority of Central and South American nations, Brazil emerged as the sole country exhibiting a drop trend1. This could be attributed to Brazil initiating the process of universal healthcare more than thirty years ago. Brazil has consistently been a leader in expanding the accessibility of medical care, achieving effective coordination between federal and state entities through constitutionally defined responsibilities6. Brazil's primary healthcare reform may contribute to policies aimed at the prevention and control of non-communicable diseases16. Since the World Health Organization took proactive measures against tobacco, including the establishment of the Framework Convention on Tobacco Control (FCTC) in 2003 and the introduction of the MPOWER initiative in 2008, Brazil has emerged as one of the foremost nations globally in tobacco control17. It was recognized as a leader in global tobacco control efforts: its smoking prevalence has significantly decreased from 34.8% in 1989 to 12.6% in 201918. Another contributing factor to the reduction in PCa mortality might be the increased number of males seeking medical services19. The enactment of the National Policy for Integrated Healthcare for Men in 2009 exemplified Brazil's dedication to male health concerns19,20. From 2008 to 2013, there was an increase in the number of males seeking medical services in Brazil, which contributed to the reduction in PCa mortality19.
China was the leading nation among BRICS countries in terms of total number of deaths. However, after adjusting for age-standardized population structure, the age-standardized mortality rate of PCa has exhibited a declining trend, particularly in the period after 2005 and among individuals born after 1950. Coinciding with these findings, a pooled analysis of 17 tumor registries in China revealed that the overall age-standardized 5-year relative survival rate for PCa was 66.4% during 2012–2015, exhibiting an incremental 3.8% increase every three years since 200321,22. The increase in crude mortality rate could be attributed to China's status as the most populous country in the world, coupled with a significant degree of population aging. PCa is a prototypical geriatric ailment, and the issue of aging population in China has garnered significant attention. In 2020, the proportion of the Chinese population aged 65 and above was 12.0%, with a projected increase to 23.7% by 204023. In the future, the focus of PCa prevention and control in our country will be to lower the occurrence and mortality rates of PCa in the elderly population. Special attention will be given to screening and prevention of PCa among the elderly. The decrease in age-standardized PCa mortality rates may be influenced by a combination of various factors. In 2012, the National Cancer Control Center was established by the Chinese National Health Commission to standardize practices in cancer diagnosis and treatment, foster nationwide uniformity and standardization in cancer care, ultimately improving survival rates and quality of life for individuals with malignant tumors24. With the ongoing progress in medical technology, the increasing variety of diagnostic and treatment methods for PCa holds significant importance in lowering PCa mortality and improving survival rates in China. Postoperative combined with androgen blockade therapy for radical prostatectomy demonstrated a 2-year PSA recurrence rate of 15.2%, with a significant improvement in quality of life21. The concept of the Multi-disciplinary Team (MDT) has gained broad acceptance within medical institutions throughout our nation22. It can optimize specialty strengths, delivering comprehensive, personalized care, and thereby improving diagnostic and treatment effectiveness.
Russia had the highest crude mortality rate and age-standardized mortality rate among the BRICS countries. However, post-2005, both the period effect and cohort effect for PCa indicated a slight decrease in mortality risk and a trend towards stability. Russia experienced an increasing risk of PCa mortality before 2000, which was consistent with previous research findings25. The Russian Federation introduced the PSA test in 1990 and incorporated it into the national health examination program in 2013. This could also be one of the factors contributing to the increase in PCa mortality rates26. Smoking is a significant factor in PCa mortality rates. Notwithstanding the implementation of an efficacious tobacco control strategy in Russia since 2008 resulting in a reduction in male smoking prevalence, these favorable developments are anticipated to exert a modest influence on the overall decrement in mortality rates among Russian males since 200527. Obesity and diabetes are associated with an increased risk of recurrence, all-cause mortality, and cancer-specific mortality among PCa patients28. According to research findings, the prevalence of obesity has primarily increased among males, particularly during the period of 2005 to 201229. From 2000 to 2009, the incidence of diabetes in Russia more than doubled30.
India has effectively controlled the mortality rate of prostate cancer, achieving the highest age-standardized decrease in mortality rate among BRICS countries. As is well known, PCa is an age-related disease. Despite being the world's second most populous country, India's population aging is not as severe as that of China. India remains a relatively young nation. Over 50% of the population is aged 25 or younger, and over 65% of the population is aged 35 or younger31. Due to the 2003 "Cigarettes and Other Tobacco Products Act" (COTPA) in India, smoking was banned in public places32. Between the years 2005–2006 and 2015–2016, there was a decrease in age-standardized smoking prevalence for both men and women33. In India, there was limited data available regarding the true incidence of prostate cancer. Only a few population-based cancer registries existed, and there was also a scarcity of community-based studies focused on prostate cancer31. This could potentially lead to an underestimation of the mortality of prostate cancer.
South Africa has witnessed an slightly increase for PCa mortality rate over the past 30 years; however, since 2005, there has been a more favorable trend in PCa mortality rates within the recent period and cohorts. Despite the reduction in the number of smoking-related deaths from 34,739 in 2000 to 31,078 in 2012 in South Africa, smoking continued to be the predominant attributable cause of mortality in 201234. Racial/ethnic disparities in epigenetic changes have been observed within PCa tissues and are associated with racial differences in cancer prognosis and survival rates35. Globally, men of African ancestry exhibit worse outcomes in prostate cancer, primarily driven by socio-cultural factors that influence biological, environmental, and healthcare risks36. PCa awareness is low in South Africa. Only 46% of males aged 35 and older have heard of PCa [39]. Diagnosis of PCa occurs at a later age and stage. In Sub-Saharan Africa (SSA), there are no systematic screening programs, and there is a lack of data on opportunistic PSA testing incidence [40]. A hospital-based retrospective study in South Africa revealed that patients had to wait an average of 3 months to receive prostate biopsy results and formulate a treatment plan and 93% of the population in Sub-Saharan Africa lacked timely, safe, and affordable access to surgery and anesthesia37.
Over the past three decades, the BRICS countries have undertaken or been committed to significant healthcare system reforms, aimed at improving the equity, quality, and financial protection of healthcare service utilization, and ultimately achieving universal health coverage6. The varying trends of PCa within the BRICS nations may potentially reflect different stages of healthcare system reforms.
Brazil not only stood out as a nation with well-managed PCa mortality, but also as a country within the BRICS group that exhibited relatively effective control over tuberculosis38 and cardiovascular mortality39. The successful experience of Brazil is worthy of being drawn upon and studied by other BRICS nations as well as developing countries. China and India have also demonstrated relatively good performance. China currently needs to proactively address social issues such as population aging. India should take proactive and effective measures to address the potential impact of population aging over the next two to three decades on PCa mortality rates. Inadequate coordination at various levels has consistently been an issue in Russia's healthcare system reform6. South Africa needs to implement effective public health measures to address the rise in PCa mortality, while also enhancing public awareness of prostate cancer.
This study introduces the novel use of the age-period-cohort model to analyze in-depth trends in PCa mortality across BRICS nations. This model aids in tracking changes in PCa mortality risks and identifies significant trends within specific populations through peroid and birth cohort analyses, facilitating the formulation of targeted recommendations. Inevitably, this study also carries certain limitations. Firstly, individuals under the age of 20 were not included in the analysis of this study, as the PCa mortality rate for this age group was extremely rare and unlikely to have impacted our conclusions. Secondly, the PCa data for GBD 2019 were based on secondary data from existing registries. The PCa mortality data for each year unavoidably carried some degree of bias, which could have had an impact on the results. Finally, despite utilizing age-period-cohort effects for trend analysis, our examination of the age-period-cohort was based on cross-sectional GBD estimate data spanning from 1990 to 2019. Conducting extensive cohort studies across various countries is essential to determine the relative risks for specific locations and timeframes.
In conclusion, the BRICS countries have achieved commendable progress in managing PCa mortality rates. The differences in risk factors for specific cancers, international cancer control programs, and cancer screening strategies among different regions could be the fundamental causes of variations in mortality rates across regions. Brazil, India, and China have shown positive results, but the overall improvement is lower compared to developed nations. South Africa and Russia face substantial burdens of PCa mortality. Finally, each BRICS country should tailor specific screening models and management guidelines based on their own circumstances.