Diagnosis and treatment of metastatic prostate cancer in low- and middle-income countries: challenges, adaptive strategies, and lessons from sub-Saharan Africa

Abstract

Prostate cancer remains a leading cause of cancer morbidity and mortality among men globally, with the highest death rates observed in low- and middle-income countries (LMICs). Although therapeutic advances have substantially improved outcomes in high-income settings, their impact in LMICs has been limited by late presentation, diagnostic constraints, restricted access to effective treatments, and health system fragility. Metastatic prostate cancer therefore dominates clinical practice in many LMICs, necessitating context-adapted diagnostic and management strategies. This narrative review synthesizes evidence from population-level datasets, international clinical trials, observational studies, and global oncology policy literature to examine the diagnosis and management of metastatic prostate cancer in low- and middle-income countries, with particular emphasis on sub-Saharan Africa where the burden of late-stage disease and the implementation constraints are most consistently documented. Evidence was selected for clinical relevance, feasibility, and health system applicability rather than for statistical pooling. Across many LMIC settings, 40–70% of men with prostate cancer present with metastatic disease at diagnosis, contributing to five-year survival rates below 40%, compared with over 90% in many high-income countries. Diagnostic pathways are constrained by limited access to Prostate-Specific Antigen (PSA) testing, pathology services, conventional imaging, and advanced staging technologies, necessitating risk-stratified and symptom-directed approaches. In metastatic castration-sensitive prostate cancer, reliable androgen deprivation therapy remains the treatment foundation, with surgical orchiectomy offering a durable and cost-effective option where medical castration is unaffordable or unreliable. Docetaxel provides meaningful survival benefit in selected fit patients but requires minimum supportive care capacity, while access to androgen receptor pathway inhibitors remains highly variable. In metastatic castration-resistant disease, most patients depend on chemotherapy, symptom control, and palliative care. Cross-cutting barriers include financial toxicity, workforce shortages, fragmented referral pathways, and unreliable medicine supply chains. Nonetheless, implementation models from several LMICs demonstrate measurable improvements in access, continuity of care, and affordability through integrated financing, task-shifting, and centralized procurement. Outcomes for men with metastatic prostate cancer in LMICs are shaped more by health system capacity than by therapeutic efficacy alone. The evidence supports a tiered approach that prioritizes timely diagnosis, uninterrupted androgen deprivation therapy, selective treatment intensification, and accessible palliative care. Lessons from sub-Saharan Africa show that measurable gains are achievable through task-sharing, simplified referral pathways, centralized procurement, and financial protection for essential cancer services. Most prostate cancer cases in LMICs present with metastatic disease due to delayed diagnosis. Androgen deprivation therapy remains the most impactful treatment for metastatic prostate cancer in resource-limited settings. Surgical orchiectomy provides a durable, cost-effective alternative to long-term medical castration. Docetaxel and androgen receptor pathway inhibitors improve survival but remain inaccessible to many patients. Diagnostic staging in LMICs relies on risk-stratified, symptom-directed approaches rather than advanced imaging. Health system reforms improve access, continuity of care, and affordability for metastatic prostate cancer. Most prostate cancer cases in LMICs present with metastatic disease due to delayed diagnosis. Androgen deprivation therapy remains the most impactful treatment for metastatic prostate cancer in resource-limited settings. Surgical orchiectomy provides a durable, cost-effective alternative to long-term medical castration. Docetaxel and androgen receptor pathway inhibitors improve survival but remain inaccessible to many patients. Diagnostic staging in LMICs relies on risk-stratified, symptom-directed approaches rather than advanced imaging. Health system reforms improve access, continuity of care, and affordability for metastatic prostate cancer.