Prostate cancer in the context of population health: Risk determinants and perspectives on early diagnosis

Prostate cancer represents a serious public health problem that significantly affects morbidity and mortality of the male population worldwide. It is one of the most common malignant diseases in men and its incidence has been steadily increasing in recent decades (Berenguer et al., 2023). This trend is related not only to population aging and increasing life expectancy, but also to improvements in diagnostic methods, widespread use of the prostate-specific antigen (PSA) test, and growing awareness of preventive check-ups (Rawla, 2019; Culp et al., 2020).

Prostate cancer often has a slow and asymptomatic course, which complicates its early diagnosis. In many cases, it is diagnosed only at an advanced stage, which negatively affects patient prognosis and quality of life (Wilson et al., 2022). Despite technological advances in diagnostics and treatment, the identification of risk groups, effective design of screening strategies, and promotion of a healthy lifestyle as a key element of primary prevention remain priorities.

From a public health perspective, it is essential to view prostate cancer as a disease with multifactorial etiopathogenesis, in which genetic, hormonal, behavioral, and environmental factors intersect. Analysis of these determinants enables a better understanding of the causes of regional differences in incidence and mortality, thereby creating the basis for the development of effective preventive and intervention measures (EAU, 2023).

Epidemiology of prostate cancer worldwide and in Slovakia

In terms of global epidemiology, prostate cancer is among the most frequently diagnosed malignant tumors in men. According to data from the International Agency for Research on Cancer (IARC), more than 1.4 million new cases and approximately 375,000 deaths were recorded worldwide in 2020, with the disease accounting for about 14% of all new cancer diagnoses in men. In recent decades, its incidence has been increasing, linked to demographic aging, wider use of the PSA test, and improved diagnostics (Culp et al., 2020). Regional differences in incidence and mortality are pronounced. The highest incidence rates have long been recorded in high-income countries, primarily in North America, Western and Northern Europe, and Australia, where incidence ranges from 100 to 130 cases per 100,000 men (WHO, 2022). Conversely, in developing regions, especially sub-Saharan Africa and Southeast Asia, incidence is significantly lower, but mortality is relatively higher, reflecting inequalities in access to healthcare and early diagnosis (WHO, 2022; OECD, 2023).

In Europe, the highest incidence rates have long been recorded in Nordic and Western European countries (Sweden, Norway, Finland, Belgium, the Netherlands), which also have the lowest mortality due to well-developed prevention programs and a long tradition of PSA testing (EAU, 2023). Central and Eastern European countries — including Slovakia, the Czech Republic, Poland, and Hungary — show lower incidence but higher mortality, pointing to later diagnosis and differences in access to treatment (Berenguer et al., 2023; OECD, 2023).

In Slovakia, prostate cancer is among the three most common oncological diseases in men, along with lung cancer and colorectal carcinoma. According to data from the National Health Information Center (NCZI), incidence reaches approximately 130 cases per 100,000 men, while mortality remains above the European Union average. The highest incidence is recorded in the age group over 65 years. Regional differences are pronounced; higher incidence is observed in the Bratislava and Trnava regions, while higher mortality is seen in the Banská Bystrica and Prešov regions. These indicators confirm the need for a more targeted approach to prevention, screening, and improved accessibility of diagnostic methods so that the disease can be detected in earlier, treatable stages (NCZI, 2024).

Risk factors for prostate cancer

The etiology of prostate cancer is complex and involves a set of genetic, hormonal, behavioral, nutritional, and environmental factors. It is a multifactorial disease in which individual risk determinants interact with one another. From a public health perspective, risk factors for prostate cancer can be divided into modifiable and non-modifiable risk determinants. Understanding both groups of determinants is crucial for developing effective prevention strategies and risk-based approaches in screening (Rawla, 2019).

Modifiable risk factors

Among the most significant modifiable factors are nutritional habits, body weight, level of physical activity, smoking, and exposure to environmental carcinogens. Nutrition plays a fundamental role in the etiopathogenesis of prostate cancer. Epidemiological and experimental studies show that a diet high in animal fats, red and processed meat, as well as excessive consumption of dairy products with high calcium content, may increase the risk of developing the disease. These foods stimulate androgen signaling, increase levels of insulin-like growth factor (IGF-1), and lead to increased production of reactive oxygen species, which damage prostate cell DNA and promote malignant transformation (Wilson et al., 2022).

Conversely, a diet rich in antioxidants, plant polyphenols, and phytochemicals is associated with a lower risk of prostate carcinogenesis. Lycopene, present especially in tomatoes and tomato products, acts as a powerful antioxidant that inhibits lipid peroxidation and modulates androgen receptor activity (Puah et al., 2021). Isoflavones found in soy products act as phytoestrogens that regulate the cell cycle, promote apoptosis, and inhibit angiogenesis. Catechins from green tea, particularly epigallocatechin gallate (EGCG), exhibit chemopreventive effects through neutralization of free radicals and suppression of inflammatory processes in prostate tissue (Musial et al., 2020). Similarly, sulforaphane from cruciferous vegetables influences the expression of detoxification pathway enzymes and suppresses cell proliferation (Berenguer et al., 2023).

Vitamin D also plays an important role; adequate levels contribute to the regulation of cell differentiation and inhibition of inflammatory processes. Vitamin D deficiency is associated with an increased risk of more aggressive forms of the disease, while excessive calcium intake may reduce this effect (Grant et al., 2020). Obesity and metabolic syndrome are additional significant factors that affect both the risk and course of the disease. In obese men, hormonal changes occur, particularly a decrease in androgen levels and an increase in estrogens, as well as hyperinsulinemia and elevated IGF-1 levels. These mechanisms promote prostate cell proliferation and reduce apoptosis, thereby creating an environment favorable to tumor growth (Wilson et al., 2022).

Smoking is associated with an unfavorable prognosis and higher mortality in patients with prostate cancer. Carcinogens contained in tobacco smoke, such as polycyclic aromatic hydrocarbons and aromatic amines, lead to oxidative DNA damage and promote mutational processes. Long-term smoking is associated with an increased risk of metastatic forms of the disease and recurrence after treatment (Wilson et al., 2022). Environmental risks include especially long-term exposure to pesticides, heavy metals (cadmium, lead), endocrine disruptors, and chemicals in agriculture and industry (Vietri et al., 2021; WHO, 2022).

From a prevention perspective, it is therefore essential to promote a healthy lifestyle — a varied plant-based diet, regular physical activity, maintaining appropriate body weight, and limiting alcohol and tobacco consumption. The World Health Organization estimates that up to 30–50% of all cancer cases could be prevented through lifestyle changes and reduction of exposure to risk factors (WHO, 2022).

Non-modifiable risk factors

Non-modifiable risk factors include primarily age, family history, genetic predisposition, and ethnic origin. Age is the most significant determinant, as the incidence of prostate cancer rises exponentially after the age of fifty and most cases are diagnosed at older ages (Culp et al., 2020). This increase is related to the accumulation of somatic mutations, hormonal changes, and a decline in the efficiency of DNA repair mechanisms (Rawla, 2019).

Family history significantly increases the risk of the disease. Men who have a first-degree relative (father, brother, or son) with prostate cancer have approximately two to three times the risk of developing the disease compared to the general population (Rawla, 2019; Vietri et al., 2021). It is estimated that familial forms of prostate cancer account for approximately 20% of all cases, while hereditary forms with an identified gene mutation account for 5 to 15%. The most common mutations include BRCA1, BRCA2, HOXB13, CHEK2, ATM, and genes associated with Lynch syndrome (MLH1, MSH2, MSH6, PMS2). These genetic changes are related to defects in DNA repair mechanisms, genomic instability, and a higher risk of aggressive forms of the disease (Vietri et al., 2021).

Ethnic and racial differences are also significant. Men of African and Caribbean origin have higher incidence and mortality compared to men of European origin, while the lowest incidence is observed in Asian populations (Taitt et al., 2018). These differences can be explained by genetic variations, hormonal profiles, as well as inequalities in access to healthcare, level of screening, and differences in lifestyle. Genetic polymorphisms, particularly in the chromosome 8q24 region, have been identified as significant risk loci associated with an increased likelihood of developing prostate cancer. These variants are more frequently present in populations of African and European origin and represent an important direction for future research on genetic predisposition (Vietri et al., 2021).

Overall, it can be stated that risk factors for prostate cancer form a complex system of interacting biological, genetic, and behavioral determinants. Identifying and influencing modifiable factors is of fundamental importance for primary prevention, while understanding non-modifiable determinants enables more effective risk stratification and more targeted design of screening and diagnostic programs (EAU, 2023).

Screening and diagnostic procedures for prostate cancer

Secondary prevention of prostate cancer, i.e., early identification of the disease through screening, represents one of the key pillars of mortality reduction (EAU, 2023). The goal of screening is to identify tumors in early, clinically localized stages that are treatable with a high success rate. Nevertheless, the question of the effectiveness and optimal form of screening remains a subject of long-standing debate, as there are differences between countries in recommendations and the extent of implementation (Wei et al., 2023).

The basic tool for screening is the determination of serum PSA levels, which has been used since the late 1980s (Martorana et al., 2024). PSA values correlate with prostate volume and can be elevated not only in malignant diseases but also in benign conditions, such as benign prostatic hyperplasia or prostatitis. Therefore, although the test has high sensitivity, its specificity is relatively low, leading to the risk of false positive results, overdiagnosis, and treatment of clinically insignificant tumors. This phenomenon has not only medical but also psychological and economic consequences (Liu et al., 2025).

For these reasons, an individualized or risk-based approach to screening has been gaining ground in recent years. Modern recommendations emphasize the need to consider age, family history, genetic predisposition, ethnic origin, and overall health status when deciding on PSA testing. Men at increased risk (e.g., those with a family history of prostate cancer or carriers of a BRCA2 mutation) are recommended to start testing at around age 45, while for men at average risk, individual decision-making is appropriate between the ages of 50 and 69 (EAU, 2023). Testing intervals should be adjusted according to previous PSA results (Carlsson et al., 2020).

In the case of elevated PSA levels, further examinations are necessary to improve diagnostic specificity. Multiparametric magnetic resonance imaging (mpMRI) is currently considered the standard in pre-biopsy assessment of patients with suspected prostate cancer. This method allows better localization of suspicious lesions and helps reduce the number of unnecessary biopsies. The combination of mpMRI with systematic and targeted biopsy sampling significantly increases diagnostic accuracy and reduces the risk of missing clinically significant tumors (Stabile et al., 2020).

In addition to imaging methods, new biomarkers are increasingly being used in diagnostics to enable better risk stratification and decision-making on the need for biopsy. Among the most commonly used are the Prostate Health Index (PHI), the 4Kscore test, the PCA3 (Prostate Cancer Antigen 3) test in urine, and the newer SelectMDx. These tools combine molecular and clinical indicators and improve the ability to distinguish between low-risk and high-risk forms of the disease (Liu et al., 2025). The use of so-called liquid biopsies, which monitor circulating tumor DNA or RNA in the blood, is also being investigated in the experimental phase and could bring less invasive and more dynamic disease monitoring in the future (Udager et al., 2018).

Another important step in optimizing diagnostics is risk stratification and so-called active surveillance. This approach is applied particularly in men with low-risk, slowly progressing tumors for whom immediate treatment is not necessary. The patient is regularly monitored through PSA tests, mpMRI, and repeat biopsies. Active surveillance helps avoid overtreatment, which could lead to unnecessary complications such as incontinence or erectile dysfunction, without compromising overall survival (Liu et al., 2025).

In the Slovak context, there is currently no national prostate cancer screening program. PSA testing is carried out as part of preventive check-ups with a general practitioner or urologist (NCZI, 2024). However, the participation rate of men in these check-ups is low, which significantly affects the timeliness of diagnosis. In the future, it would therefore be desirable to introduce a more systematic, risk-based screening that would specifically target at-risk population groups (EAU, 2023).

Overall, current developments in prostate cancer diagnostics are moving toward a more precise, personalized approach that combines biomarkers, imaging methods, and genetic information. Such a comprehensive model makes it possible to reduce the risk of overdiagnosis, improve patient selection for treatment, while maintaining high survival rates. For public health, this approach represents a path toward more efficient use of resources, rationalization of care, and improvement of quality of life for patients with this disease (EAU, 2023).

Discussion

Current scientific knowledge confirms that prostate cancer has a multifactorial nature, with modifiable lifestyle factors playing a fundamental role. A recent meta-analysis by Ziglioli et al. (2023) demonstrated that obesity, low physical activity, and smoking significantly increase the risk of developing and progressing the disease. Similarly, a large cohort study by Pagadala et al. (2024) confirmed that men with a higher healthy lifestyle score had up to 40% lower risk of developing advanced prostate cancer. These findings confirm that primary prevention through lifestyle modification represents a key public health tool in reducing the risk of the disease.

Nutritional factors remain an important area of research. More recent reviews emphasize the negative impact of excessive consumption of red meat, animal fats, and dairy products with high calcium content, while increased intake of plant foods, antioxidants, and vitamin D has a protective effect (Bossio et al., 2024). These conclusions build on earlier study results and confirm that changes in dietary habits can significantly contribute to the prevention of prostate cancer, especially in older age groups (Wilson et al., 2022; Grant et al., 2020).

Significant progress has also been made in the area of screening and diagnostics. A systematic review by Kawada et al. (2023) showed that new liquid biomarkers such as PHI, 4Kscore, and SelectMDx improve the differentiation of clinically significant tumors and enable a reduction in unnecessary biopsies. Similar studies by Tayo et al. (2024) and Farooqui et al. (2024) confirm that the combination of molecular markers and multiparametric magnetic resonance imaging increases diagnostic specificity. These approaches, in line with EAU recommendations (2023), support the introduction of personalized, risk-based screening that takes into account genetic predisposition, age, and the patient's overall health status.

Overall, it can be stated that the latest research confirms the need for an integrated approach combining primary prevention, healthy lifestyle, and modern diagnostic tools. Such a model makes it possible to reduce the burden of prostate cancer, improve the efficiency of healthcare, and contribute to the long-term sustainability of public health systems.

Conclusion

Prostate cancer remains one of the most significant oncological diseases in men, and its rising incidence requires a coordinated public health approach. The disease results from a complex interaction of genetic, hormonal, behavioral, and environmental factors, with a large portion of the risk being modifiable through lifestyle. Promoting healthy nutrition, physical activity, maintaining appropriate body weight, and limiting smoking represent the fundamental pillars of primary prevention. Equally important is early diagnosis through risk-based screening, which enables reduced mortality and improved quality of life for patients. Increasing awareness among the male population, equitable access to specialized care, and the development of modern diagnostic technologies are essential steps toward more effective management of this disease in both the Slovak and global context.

Authors: MUDr. Michaela Uhrinová Vukušičová prof. MUDr. Kvetoslava Rimárová, CSc. Mgr. Simona Miškárová MVDr. Martina Hrubovčák Tejová This work is supported by grant KEGA 001UPJŠ-4/2024 Implementation of Multimedia Technologies in the Teaching of Preventive Interventions in Medical and Non-Medical Fields.

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