Abstract
Background:
Digestive system cancers constitute a significant number of cancer cases, but their burden is not uniform. As Global Cancer Observatory (GLOBOCAN) 2022 has recently updated its estimates of cancer burden, we aimed to investigate the burden of six major digestive system cancers both worldwide and in China, along with geographical and temporal variations in cancer-specific incidence and mortality.
Methods:
We extracted data on primary cancers of the esophagus, stomach, colorectum, liver, pancreas, and gallbladder from the GLOBOCAN database for 2022. Age-standardized incidence and mortality rates were calculated and stratified by sex, country, region, and human development index (HDI). We used the 2022 revision of the World Population Prospects (United Nations) to obtain demographic data for various age groups in China from 1988 to 2012 and used the joinpoint model and the average annual percentage change (AAPC) to analyze cancer incidence trends in China.
Results:
In 2022, the estimated global incidence of digestive system cancers reached 4,905,882, with an estimated 3,324,774 cancer-related deaths. Colorectal cancer was most prevalent in terms of incidence and mortality. There was a significant correlation between the burden of gastrointestinal cancers and country HDI. From 1988 to 2012, the incidence of esophageal, gastric, and liver cancers declined in China, whereas colorectal and pancreatic cancer incidences continued to increase. By 2050, colorectal and liver cancers are projected to remain the leading cancer types in China in terms of incidence and mortality, respectively.
Conclusions:
Digestive system cancers remain a significant public health challenge globally and in China. Although progress has been made in the prevention and control of some cancers, the burden of digestive system cancers persists. The implementation of tertiary prevention strategies must be intensified to reduce the incidence and mortality of digestive system cancers, mitigating their impact on public health.
Keywords: Digestive system cancer, Incidence, Mortality, GLOBOCAN 2022, China, Global, Esophagus cancer, Stomach cancer, Colorectal cancer
Introduction
The epidemiology of cancer varies across different regions of the world, but digestive system cancers continue to pose a significant challenge to public health systems in most areas, and are a major contributor to the burden of cancer.[1] The main types of digestive system cancers include esophageal, gastric, liver, gallbladder, pancreatic, and colorectal cancers. For both sexes, colorectal cancer was the third most common cancer and the second leading cause of cancer-related deaths worldwide in 2022, with an estimated 20 million new cases and 9.7 million deaths.[2] Gastric and liver cancers, including intrahepatic bile duct cancer, ranked as the fifth and sixth leading causes of new cancer cases, respectively, and the fifth and third leading causes of cancer-related deaths.
Due to variations in lifestyle habits, environmental exposure, and disparities in healthcare systems across different regions, there are notable differences in cancer prevalence. The human development index (HDI), developed by the UN Development Program, is a composite statistic used to assess human progress and the overall well-being of countries.[3] It measures three key dimensions of human development: health, education, and income. Countries with different HDIs exhibit distinct profiles for common cancer types; nations in transition often experience a higher prevalence of infection-related cancers and a growing burden of cancers associated with Western lifestyles.[4]
Cancer is a leading cause of death in China. Among gastrointestinal malignancies, colorectal, liver, and gastric cancers rank second, fourth, and fifth in incidence, while liver, gastric, colorectal, and esophageal cancers rank second, third, fourth, and fifth in mortality.[5] Compared to 2016, except for liver and gallbladder cancers, incidences of the other four major gastrointestinal cancers have increased. In 2022, the age-standardized incidence rate (ASIR) for colorectal (20.10/105) and pancreatic cancers (4.44/105) in the world standard population (Segi’s et al[6] population) was higher than that in 2016 (18.05/105 for colorectal cancer and 4.36/105 for pancreatic cancer).[5,7] Given China’s large population, even slight changes in cancer incidence and mortality rates can lead to significant shifts in the national economic burden.[4] The Chinese government has implemented various measures to reduce the incidence and mortality rates of cancer; understanding trends in these rates for major cancers can help the country in making targeted changes to healthcare policies.
We utilized recently released data from Global Cancer Observatory (GLOBOCAN) 2022 to investigate the disease burden of six major digestive system cancers across different continents. We also assessed cancer epidemiology in areas with varying HDI levels. Focusing on China, we explored the incidence and mortality rates of the six digestive system cancers and sex-specific trends from 1988 to 2012 using a joinpoint regression analysis. Additionally, future trends in the estimated number of new gastrointestinal cancer-related cases and deaths in China from 2022 to 2050 were determined.
Methods
Study design
The current GLOBOCAN database provides estimates of cancer incidence and mortality by country, cancer site, and sex for 2022, and is available at the Global Cancer Observatory (https://gco.iarc.fr/today/home).[8] This database was utilized to perform a descriptive secondary analysis of the burden of six digestive system cancers (esophageal, gastric, liver, gallbladder, pancreatic, and colorectal cancers). To evaluate future cancer incidence and mortality in China, we obtained data from CANCER TOMORROW (https://gco.iarc.fr/tomorrow/en) up until 2050. Additionally, we obtained the 2022 revision of the World Population Prospects released by the United Nations.[9]
Technical information and participants
We extracted the number of new cases and deaths for the six digestive system cancers globally, across six continents as well as for individual countries, using codes from the International Classification of Diseases 10th Revision (ICD-10): esophagus (C15), stomach (C16), liver (C22, including intrahepatic bile ducts), gallbladder (C23), pancreas (C25), and colorectum (C18–21). Additionally, we categorized regions based on HDI levels (the cutoff points are <0.550, 0.550–0.699, 0.700–0.799, and ≥0.800 for low HDI, medium HDI, high HDI, and very high HDI, respectively)[10] and retrieved estimates of the ASIR and age-standardized mortality rate (ASMR) for these cancers.
Cancer data from GLOBOCAN 2022 and population estimates from the United Nations were utilized to estimate cancer profiles in China from 1988 to 2012. This period was chosen because the GLOBOCAN 2022 database provides continuous data on incidence and mortality rates in China only for these years. We extracted the number of new cases and deaths from the GLOBOCAN 2022 database separated by sex and by age, with age groups defined as under 50 years and 50 years and above. Segi’s world standard population was used for the age standardization of rates in the joinpoint regression analysis.[6,11]
Statistics
The estimated numbers of new cases and deaths, as well as the ASIR and ASMR of the six digestive system cancers, were described across 27 countries and regions within the 6 continents. The cancer burden in these regions was ranked based on the ASIRs and ASMRs. We then categorized world regions and countries into quartiles based on HDI and described the ASIR and ASMR of regions with different HDI levels.
For digestive system cancers in China, we utilized joinpoint regression to analyze the incidence and mortality trends stratified by gender or age.[12] To assess the magnitude and direction of trends from 1988 to 2012, we derived the average annual percentage change (AAPC) and the corresponding 95% confidence interval (CI). In the joinpoint regression stratified by gender, we segmented age data into groups every 10 years. The AAPC provides a geometrically weighted average of the annual percentage changes derived from joinpoint trend analysis, with weights assigned based on the length of each segment during the specified time interval. Joinpoint regression was performed using the Joinpoint Regression Program 5.1.0 (National Cancer Institute, USA). We used the projected data on cancer incidence and mortality from GLOBOCAN 2022, spanning 2022–2050, to assess the future burden of cancer.
Results
Global incidence distribution
In 2022, the estimated global incidence of digestive system cancers reached 4,905,882, constituting 24.6% of all new cancer cases worldwide [Table 1]. Colorectal cancer has a significantly higher incidence than other digestive system cancers, with an estimated 1,926,425 new cases and an ASIR of 18.4/100,000, ranking fourth among all newly diagnosed cancers globally. Following colorectal cancer, gastric cancer had the second highest incidence rate (9.2/100,000). Subsequent gastrointestinal cancer prevalence, in descending order, included liver (8.6/100,000), esophageal (5.0/100,000), pancreatic (4.7/100,000), and gallbladder cancers (1.2/100,000).
Table 1.
Estimated incidence of digestive system cancers for six continents in 2022.
| Continents | Cancer types | Rank | ||||||
|---|---|---|---|---|---|---|---|---|
| Esophagus | Colorectum | Pancreas | Stomach | Liver | Gallbladder | All | ||
| Worldwide | 511,054 | 1,926,425 | 510,992 | 968,784 | 866,136 | 122,491 | 4,905,882 | – |
| Asia | 382,892 | 966,399 | 232,537 | 691,791 | 607,361 | 88,112 | 2,969,092 | – |
| China | 224,012 | 517,106 | 118,672 | 358,672 | 367,657 | 31,132 | 1,617,251 | 1 |
| Japan | 19,926 | 145,756 | 47,627 | 126,724 | 41,388 | 10,814 | 392,235 | 2 |
| India | 70,637 | 70,038 | 13,661 | 64,611 | 38,703 | 21,780 | 279,430 | 4 |
| Republic of Korea | 2437 | 29,560 | 8891 | 29,267 | 14,791 | 3264 | 88,210 | 10 |
| Indonesia | 1382 | 35,676 | 5734 | 3852 | 23,805 | 627 | 71,076 | 12 |
| Viet Nam | 3686 | 16,835 | 1251 | 16,277 | 24,502 | 293 | 62,844 | 13 |
| Thailand | 3333 | 20,173 | 3314 | 4089 | 27,936 | 1823 | 60,668 | 14 |
| Turkey | 1339 | 21,718 | 8636 | 12,773 | 5039 | 792 | 50,297 | 15 |
| Europe | 53,513 | 538,262 | 146,477 | 135,610 | 88,871 | 12,670 | 975,403 | – |
| Russian Federation | 9345 | 83,693 | 21,842 | 38,883 | 11,748 | 2137 | 167,648 | 5 |
| Germany | 7310 | 62,544 | 21,869 | 14,088 | 9959 | 1661 | 117,431 | 7 |
| Italy | 2479 | 54,784 | 15,710 | 13,501 | 11,886 | 1171 | 99,531 | 8 |
| France | 4942 | 51,636 | 15,895 | 7673 | 12,172 | 636 | 92,954 | 9 |
| UK | 9601 | 49,429 | 11,351 | 6034 | 8223 | 1343 | 85,981 | 11 |
| North America | 21,888 | 183,973 | 67,089 | 29,675 | 48,485 | 5229 | 356,339 | – |
| United States of America | 18,747 | 160,186 | 60,127 | 25,554 | 43,492 | 4719 | 312,825 | 3 |
| Canada | 3136 | 23,725 | 6939 | 4113 | 4974 | 510 | 43,397 | 16 |
| Latin America and the Caribbean | 20,366 | 145,120 | 41,032 | 74,379 | 42,769 | 10,434 | 334,100 | – |
| Brazil | 10,985 | 60,118 | 14,670 | 23,021 | 13,599 | 2249 | 124,642 | 6 |
| Mexico | 1433 | 16,082 | 5822 | 9516 | 8603 | 1292 | 42,748 | 18 |
| Argentina | 2142 | 15,863 | 5554 | 4460 | 2504 | 810 | 26,873 | 19 |
| Colombia | 1019 | 11,163 | 2812 | 8938 | 2591 | 669 | 27,192 | 21 |
| Peru | 370 | 4943 | 1807 | 6380 | 2068 | 1100 | 16,668 | 23 |
| Africa | 29,965 | 70,428 | 18,993 | 33,352 | 73,844 | 5512 | 232,094 | – |
| Egypt | 1543 | 5940 | 3349 | 3285 | 27,946 | 787 | 36,910 | 17 |
| South Africa | 3312 | 7338 | 2779 | 1919 | 2650 | 359 | 18,357 | 22 |
| Nigeria | 567 | 8114 | 1344 | 1857 | 4382 | 245 | 16,509 | 24 |
| Ethiopia | 1494 | 6551 | 944 | 2394 | 2798 | 413 | 14,594 | 25 |
| Morocco | 433 | 5306 | 1229 | 2355 | 1112 | 530 | 10,965 | 26 |
| Oceania | 2430 | 22,243 | 4864 | 3977 | 4806 | 534 | 38,854 | – |
| Australia | 1755 | 17,088 | 3988 | 2837 | 3333 | 370 | 29,371 | 20 |
| New Zealand | 396 | 4070 | 661 | 497 | 382 | 73 | 6079 | 27 |
–: Not available.
Within the domain of gastrointestinal malignancies, Asia has emerged as the predominant contributor, accounting for 60.5% of new global gastrointestinal cancer cases. Subsequent continental distributions delineated Europe, North America, Latin America, and Africa contributing to 19.9%, 7.3%, 6.8%, and 4.7%, respectively; Oceania had the lowest incidence, with 38,854 new cases. Colorectal cancer has emerged as the most prevalent digestive system neoplasm in Asia, Europe, North America, Latin America, and Oceania; in contrast, Africa exhibits a distinct epidemiological profile, with liver cancer being the most common. Gallbladder cancer consistently had the lowest incidence rates across all six continents.
When examining specific countries, the burden of gastrointestinal tumors in China was particularly severe. In 2022, the estimated number of new cases reached 1,617,251, significantly surpassing that in other nations. In contrast, New Zealand demonstrated effective control of gastrointestinal cancer burden, with the incidence of nearly all digestive system cancers (excluding colorectal cancer) remaining below 1000 cases for each type.
A robust socioeconomic correlation was evident between the incidence of digestive system cancers and mean national HDI values [Figure 1]. Colorectal and pancreatic cancers were significantly associated with HDI. As the HDI increased, incidence rates increased, with rates in high-HDI countries being nearly five times higher than those in low-HDI countries. In countries with very high HDI, the ASIR of pancreatic cancer was 7.9/100,000 person-years, while in countries with low HDI, it was only 1.4/100,000; in contrast, the incidence rates of gastric and liver cancer in very high-HDI countries were slightly lower than those in high-HDI countries but remained higher than those in medium- and low-HDI countries. The incidence rate of esophageal cancer was lowest in very high-HDI countries, and was even lower than that in low-HDI countries, despite decreasing from high- to low-HDI countries. The incidence of gallbladder cancer showed relatively minor variations across countries with different HDI levels, with slightly higher rates in countries with medium HDIs.
Figure 1.
Estimated incidence (A) and mortality (B) of digestive system cancers globally in 2022 according to human develop index. HDI: human development index.
Global mortality distribution
Table 2 shows the epidemiological data on the mortality of digestive system cancers within diverse geographic regions spanning six continents, with an estimated 3,324,774 cancer-related deaths reported in 2022. Colorectal cancer was the primary cause of mortality within the digestive system cancer spectrum, contributing to 27.2% of all global cancer deaths; it was the third leading cause of all cancer-related deaths, with an ASMR of 8.1/100,000. Liver cancer, accounting for 22.8% of gastrointestinal cancer-related deaths, followed by gastric (19.9%), pancreatic (14.1%), esophageal (13.4%), and gallbladder cancers (2.7%).
Table 2.
Estimated mortality of digestive system cancers for six continents in 2022.
| Continents | Cancer types | Rank | ||||||
|---|---|---|---|---|---|---|---|---|
| Esophagus | Colorectum | Pancreas | Stomach | Liver | Gallbladder | All | ||
| Worldwide | 445,391 | 904,019 | 467,409 | 660,175 | 758,725 | 89,055 | 3,324,774 | – |
| Asia | 329,803 | 462,252 | 212,243 | 462,606 | 530,928 | 66,821 | 2,064,653 | – |
| China | 187,467 | 240,010 | 106,295 | 260,372 | 316,544 | 24,543 | 1,135,231 | 1 |
| India | 66,410 | 40,993 | 12,759 | 57,727 | 36,953 | 16,407 | 231,249 | 2 |
| Japan | 12,161 | 60,473 | 43,265 | 43,807 | 26,420 | 7252 | 193,378 | 3 |
| Indonesia | 1330 | 19,255 | 5833 | 3242 | 23,383 | 432 | 53,475 | 11 |
| Viet Nam | 3470 | 8454 | 1226 | 13,264 | 23,333 | 209 | 49,956 | 12 |
| Thailand | 3097 | 10,158 | 3280 | 3070 | 27,143 | 1285 | 48,033 | 13 |
| Republic of Korea | 1521 | 11,595 | 7582 | 8517 | 12,595 | 2091 | 43,901 | 14 |
| Turkey | 1134 | 11,698 | 8415 | 10,457 | 4929 | 504 | 37,137 | 16 |
| Europe | 47,212 | 247,842 | 138,644 | 95,431 | 79,091 | 8203 | 616,423 | – |
| Russian Federation | 8359 | 41,447 | 20,672 | 27,306 | 11,377 | 1321 | 110,482 | 5 |
| Germany | 6399 | 26,544 | 21,292 | 8729 | 8712 | 1057 | 72,733 | 7 |
| Italy | 2094 | 24,188 | 14,903 | 9885 | 9606 | 743 | 61,419 | 8 |
| France | 4304 | 21,218 | 14,669 | 4963 | 10,478 | 270 | 55,902 | 9 |
| UK | 8595 | 22,868 | 10,769 | 4232 | 7326 | 787 | 54,577 | 10 |
| North America | 19,116 | 66,155 | 56,044 | 13,367 | 35,075 | 2453 | 192,210 | – |
| United States of America | 16,469 | 54,614 | 49,491 | 10,976 | 30,931 | 2136 | 164,617 | 4 |
| Canada | 2642 | 11,521 | 6534 | 2391 | 4130 | 317 | 27,535 | 18 |
| Latin America and the Caribbean | 18,895 | 73,647 | 38,319 | 57,895 | 39,351 | 7047 | 235,154 | – |
| Brazil | 10,393 | 28,884 | 14,294 | 18,138 | 13,041 | 1458 | 86,208 | 6 |
| Mexico | 1271 | 8283 | 5267 | 7226 | 7673 | 844 | 30,564 | 17 |
| Argentina | 1967 | 8800 | 5097 | 3379 | 2147 | 528 | 21,918 | 19 |
| Colombia | 924 | 5640 | 2573 | 6901 | 2396 | 519 | 18,953 | 20 |
| Peru | 332 | 2527 | 1628 | 4767 | 1809 | 647 | 11,710 | 25 |
| Africa | 28,276 | 46,087 | 17,770 | 28,730 | 70,315 | 4198 | 195,376 | – |
| Egypt | 1510 | 3096 | 3186 | 2469 | 26,971 | 578 | 37,810 | 15 |
| South Africa | 3025 | 4591 | 2360 | 1622 | 2401 | 182 | 14,181 | 22 |
| Nigeria | 540 | 5912 | 1283 | 1599 | 4252 | 222 | 13,808 | 23 |
| Ethiopia | 1422 | 4863 | 842 | 2212 | 2683 | 375 | 12,397 | 24 |
| Morocco | 415 | 2892 | 1181 | 2075 | 1047 | 373 | 7983 | 26 |
| Oceania | 2089 | 8036 | 4389 | 2146 | 3965 | 333 | 20,958 | – |
| Australia | 1526 | 5715 | 3552 | 1335 | 2591 | 194 | 14,913 | 21 |
| New Zealand | 302 | 1704 | 628 | 304 | 336 | 63 | 3337 | 27 |
–: Not available.
The mortality rates of digestive system tumors in Asia far exceeded those in other regions, constituting 62.1% of global deaths, and China had the highest mortality burden in Asia. Mortality trends related to digestive system cancers in Europe, North America, Latin America, and Oceania aligned with the global pattern of incidence, with colorectal cancer remaining the leading cause of mortality among all digestive system tumors. Liver cancer had the highest mortality rate in Asia and Africa, while gallbladder cancer had the lowest mortality rate across all continents.
The mortality patterns of different digestive system cancers across varying HDI levels also mirrored the incidence trends. Colorectal and pancreatic cancers exhibited higher mortality rates in high-HDI countries than in countries with other HDI levels. Gastric and liver cancers mortality rates were highest in high-HDI countries, especially for liver cancer, which obviously surpassed rates for other HDI levels with an ASMR of 10.7/100,000. The mortality rate of gallbladder cancer subtly fluctuated across differing HDI levels, with slightly elevated rates in countries with medium HDIs.
Incidence trends by sex and by age in China
The incidence trends, segmented by gender and age group, are displayed in Tables 3 and 4, respectively, as determined from the joinpoint regression analysis. Overall, the incidence rates of esophageal, gastric, and liver cancers declined from 1988 to 2012, with AAPCs and corresponding 95% CIs of −5.00% (−5.26% to −4.76%), −3.77% (−4.14% to −3.50%), and −2.74% (−2.93% to −2.55%), respectively. Over the past two decades, esophageal cancer experienced the most substantial incidence decline, followed by gastric and liver cancers. Incidence rates of gastric and liver cancers showed relatively minor differences between males and females. However, a faster decline in esophageal cancer incidence was observed in females (AAPC: −5.28%, 95% CI: −5.83% to −4.79%) compared with males (AAPC: −3.51%, 95% CI: −4.06% to −3.18%). In contrast, incidences (both sexes) of colorectal cancer (AAPC: 1.15%, 95% CI: 1.05%–1.27%) and pancreatic cancer (AAPC: 1.14%, 95% CI: 0.73%–1.47%) have steadily increased. The incidence rate of colorectal cancer has significantly increased among males (AAPC: 1.44%, 95% CI: 1.26%–1.66%) compared with females (AAPC: 0.82%, 95% CI: 0.69%–0.98%).
Table 3.
Average annual percent change of age-standardized incidence of digestive system cancers in China, 1988–2012 (%).
| Caner sites | Male | Female | All | |||
|---|---|---|---|---|---|---|
| AAPC | 95% CI | AAPC | 95% CI | AAPC | 95% CI | |
| Esophagus | –3.51 | –4.06 to –3.18 | –5.28 | –5.83 to –4.79 | –3.78 | –4.12 to –3.47 |
| Colorectum | 1.44 | 1.26 to 1.66 | 0.82 | 0.69 to 0.98 | 1.15 | 1.05 to 1.27 |
| Pancreas | 1.04 | 0.58 to 1.43 | 1.18 | 0.83 to 1.60 | 1.14 | 0.73 to 1.47 |
| Stomach | –2.97 | –3.34 to –2.61 | –2.99 | –3.28 to –2.58 | –2.89 | –3.19 to –2.59 |
| Liver | –1.83 | –2.02 to –1.64 | –2.22 | –2.54 to –1.82 | –1.87 | –2.18 to –1.56 |
| Gallbladder | –0.09 | –0.43 to 0.72 | 0.26 | –0.54 to 1.32 | 0.11 | –0.31 to 0.61 |
AAPC: Annual average percentage change; CI: Confidence interval.
Table 4.
Average annual percent change of age-standardized incidence of digestive system cancers in China by age, 1988–2012 (%).
| Caner sites | Patients <50 years | Patients ≥50 years | All | |||
|---|---|---|---|---|---|---|
| AAPC | 95% CI | AAPC | 95% CI | AAPC | 95% CI | |
| Esophagus | –3.02 | –4.14 to –2.03 | –4.29 | –4.62 to –3.97 | –3.78 | –4.12 to –3.47 |
| Colorectum | –1.04 | –1.51 to –0.60 | 0.80 | 0.69 to 0.93 | 1.15 | 1.05 to 1.27 |
| Pancreas | –0.82 | –2.44 to 0.61 | 0.73 | 0.35 to 1.08 | 1.14 | 0.73 to 1.47 |
| Stomach | –4.28 | –4.95 to –3.79 | –3.43 | –3.71 to –3.15 | –2.89 | –3.19 to –2.59 |
| Liver | –3.55 | –4.17 to –3.11 | –2.29 | –2.56 to –2.03 | –1.87 | –2.18 to –1.56 |
| Gallbladder | –1.00 | –2.65 to 0.70 | –0.27 | –0.70 to 0.22 | 0.11 | –0.31 to 0.61 |
AAPC: Annual average percentage change; CI: Confidence interval.
There was a notable difference in the incidence trends of gastrointestinal cancers between the population aged 50 years and above and those below 50 years. Colorectal cancer (AAPC: 0.80%, 95% CI: 0.69%–0.93%) and pancreatic cancer (AAPC: 0.73%, 95% CI: 0.35%–1.08%) have shown an increasing trend from 1988 to 2012 among those aged 50 years and above, while other cancers have exhibited a decline. For the population below 50 years old, the incidence rates of all cancers have been declining.
Predictions of future incidence and mortality in China
Figure 2 illustrates projected changes in the incidence and mortality of digestive system cancers in China until 2050. By 2050, the number of new colorectal cancer cases is projected to increase to 869,000, remaining the leading digestive system cancer in terms of incidence, representing approximately 11.9% of all cancer cases in China. The number of new cases of gastric cancer is expected to surpass that of liver cancer, reaching 619,000, positioning it as the second most common digestive system cancer. Liver cancer had the slowest projected growth rate among digestive system cancers, with an incidence rate of 52.17%. Although gallbladder cancer had a lower incidence rate, its incidence growth rate was remarkably high at 90.35%.
Figure 2.
Estimated increase in the number of new cases (A) and deaths (B) of digestive system cancers in China, 2022–2050.
In terms of mortality, liver cancer was projected to remain the leading cause of gastrointestinal cancer deaths in 2050, with a projected mortality of 514,000 individuals; however, it exhibited the smallest growth rate with an increase of 62.15%. Gastric cancer was the second leading cause of mortality, followed by colorectal cancer, with projected mortalities of 513,000 and 498,000, respectively. There is expected to be a significant increase in colorectal cancer mortality, reaching a rate of 107.5%; similarly, the projected mortality rate of gallbladder cancer steeply increased, reaching 106.12%, although its contribution to cancer-related deaths in China remained relatively low (1.05%).
Discussion
Our study offers a comprehensive and contemporary analysis of the global and Chinese landscapes of digestive system cancers in 2022, illuminating the disparities observed across various geographical, socioeconomic, and temporal dimensions. Digestive system cancers remain a serious global public health concern, constituting approximately one-third of all cancer incidences and mortality burdens.
Among the six digestive system cancers studied, colorectal cancer had the most severe burden in terms of both incidence and mortality, accounting for approximately 40% of all new cases and 30% of all deaths; additionally, it holds the top position for both incidence and mortality in the majority of continents. The incidence and mortality of colorectal cancer were higher in countries with higher HDI levels, largely influenced by the lifestyle and dietary habits prevalent in these countries such as high-fat diets, excessive red meat consumption, sedentary behavior, smoking, and drinking.[13–16] Encouragingly, due to the adoption of healthier lifestyles and the widespread promotion of colorectal cancer screening in recent years, developed countries have witnessed a decline in the incidence of colorectal cancer.[17–18]
Liver cancer is another tumor of significant concern. While colorectal cancer imposes a substantial burden on most regions, liver cancer stands out as the digestive system cancer with the highest incidence and mortality rates in Africa; it was also the leading cause of death due to digestive system tumors in Asia. Although the etiological factors for liver cancer may vary across regions, chronic hepatitis B and C infections and exposure to aflatoxins are among the primary risk factors in areas with low to medium levels of development.[19,20] Unlike colorectal cancer, the incidence and mortality of liver cancer across countries did not increase with increasing HDI levels. In both very high- and low-HDI settings, the age-standardized incidence and mortality rates of liver cancer were not as high as those in countries with high HDIs. In countries with high HDIs experiencing rapid social and economic development, significant changes in various cancer epidemiological trends are more likely to occur.[21] Population aging, along with the prevalence of conditions such as obesity, diabetes, and hypertension, exacerbates the incidence and progression of liver cancer, especially when traditional risk factors remain uncontrolled.[22,23]
With increasing economic and societal development in China, significant changes in the lifestyle and population structure have occurred over the past three decades. These changes have led to notable shifts in the incidence and mortality rates of digestive system cancers. From 1988 to 2012, there was a declining trend in the incidence rates of digestive system cancers such as gastric, esophageal, and liver cancers. The decline in the incidence of esophageal cancer was particularly significant, with a nearly 30% decrease in the number of new cases, which was more pronounced in females. Esophageal cancer is associated with lifestyle and dietary habits; factors such as smoking, excessive alcohol consumption, and consumption of hot beverages and foods are known to increase the incidence of esophageal cancer.[24–27] The difference in the incidence of esophageal cancer between men and women is primarily attributed to factors such as male exposure to risk factors such as smoking and alcohol consumption, as well as physiological differences between sexes. Effective preventative measures targeting high-risk factors and the successful implementation of screening programs for esophageal cancer may be the main reasons for the recent decline in its incidence in China.[28,29] In contrast, colorectal and pancreatic cancers incidences in China have increased annually over the past two decades and were expected to reach alarming levels by 2022 (especially among individuals aged 50 years and above), accounting for half of all new gastrointestinal cases in Asia and highlighting the need for focused attention and intervention. It is anticipated that by 2050, colorectal cancer will continue to have the highest burden of all gastrointestinal tumors in China, with a steep increase in mortality rates. This indicates that efforts should focus on primary prevention, screening, early detection, and treatment. Although the mortality rate of liver cancer is increasing slowly, it is expected to remain the leading cause of death among digestive system cancers in China owing to its large current mortality base. Currently, gallbladder cancer does not impose a high burden on gastrointestinal cancer incidence and mortality in China; however, both rates are rapidly increasing, warranting attention.
Although GLOBOCAN provides comprehensive estimates of cancer incidence, mortality, and trends across various regions, our study had some limitations. The estimation of the incidence and mortality rates is subject to bias owing to variations in the coverage and quality of cancer registration systems across different countries and regions. Additionally, owing to the lack of data reported by GLOBOCAN, the AAPC for the mortality rates of digestive system cancers in China could not be estimated.
Overall, this study comprehensively analyzed the incidence and mortality rates of digestive system cancers both globally and in China. Although recent efforts in the prevention and control of digestive system cancers have made some progress, the burden remains substantial both globally and in China. It is imperative to strengthen the implementation of tertiary prevention strategies targeting key types of digestive system cancers to reduce the burden of incidence and mortality.
Footnotes
Yueyang Zhou and Kai Song contributed equally to this work.
How to cite this article: Zhou YY, Song K, Chen YQ, Zhang YL, Dai M, Wu D, Chen HD. Burden of six major types of digestive system cancers globally and in China. Chin Med J 2024;137:1957–1964. doi: 10.1097/CM9.0000000000003225
References
- 1.Arnold M Abnet CC Neale RE Vignat J Giovannucci EL McGlynn KA, et al. Global burden of 5 major types of gastrointestinal cancer. Gastroenterology 2020;159:335–349.e15. doi: 10.1053/j.gastro.2020.02.068. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Bray F Laversanne M Sung H Ferlay J Siegel RL Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2024;74:229–263. doi: 10.3322/caac.21834. [DOI] [PubMed] [Google Scholar]
- 3.Cullen J, Schwartz MD, Lawrence WF, Selby JV, Mandelblatt JS. Short-term impact of cancer prevention and screening activities on quality of life. J Clin Oncol 2004;22:943–952. doi: 10.1200/JCO.2004.05.191. [DOI] [PubMed] [Google Scholar]
- 4.Xia C, Dong X, Li H, Cao M, Sun D, He S, Yang F, Yan X, Zhang S, Li N, Chen W. Cancer statistics in China and United States, 2022: profiles, trends, and determinants. Chin Med J 2022;135:584–590. doi: 10.1097/CM9.0000000000002108. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Han B Zheng R Zeng H Wang S Sun K Chen R, et al. Cancer incidence and mortality in China, 2022. J Natl Cancer Cent 2024;4:47–53. doi: 10.1016/j.jncc.2024.01.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Segi M, Fujisaku S, Kurihara M. Geographical observation on cancer mortality by selected sites on the basis of standardised death rate. Gan 1957;48:219–225. [PubMed] [Google Scholar]
- 7.Zheng R Zhang S Zeng H Wang S Sun K Chen R, et al. Cancer incidence and mortality in China, 2016. J Natl Cancer Cent 2022;2:1–9. doi: 10.1016/j.jncc.2022.02.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Ferlay JEM Lam F Laversanne M Colombet M Mery L Piñeros M, et al. Global cancer observatory: Cancer today. Lyon, France: International Agency for Research on Cancer, 2024. [Google Scholar]
- 9.Division UNDoEaSAP . World Urbanization Prospects: The 2022 Revision, 2024. Available from: https://population.un.org/wpp/. [Last accessed on 2024 April 22].
- 10.United Nations Development Programme . Human Development Report 2023-24: Breaking the gridlock: Reimagining cooperation in a polarized world. New York, 2024. Available from: https://hdr.undp.org/content/human-development-report-2023-24. [Last accessed on 2024 April 11]. [Google Scholar]
- 11.Bray F, Guilloux A, Sankila R, Parkin DM. Practical implications of imposing a new world standard population. Cancer Causes Control 2002;13:175–182. doi: 10.1023/a:1014344519276. [DOI] [PubMed] [Google Scholar]
- 12.Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med 2000;19:335–351. doi: 10.1002/(sici)1097-0258(20000215)19:3<335:aid-sim336>3.0.co;2-z. [DOI] [PubMed] [Google Scholar]
- 13.Rawla P, Sunkara T, Barsouk A. Epidemiology of colorectal cancer: Incidence, mortality, survival, and risk factors. Prz Gastroenterol 2019;14:89–103. doi: 10.5114/pg.2018.81072. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Thanikachalam K, Khan G. Colorectal cancer and nutrition. Nutrients 2019;11:164. doi: 10.3390/nu11010164. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Lynch BM. Sedentary behavior and cancer: A systematic review of the literature and proposed biological mechanisms. Cancer Epidemiol Biomarkers Prev 2010;19:2691–2709. doi: 10.1158/1055-9965.Epi-10-0815. [DOI] [PubMed] [Google Scholar]
- 16.Parajuli R, Bjerkaas E, Tverdal A, Le Marchand L, Weiderpass E, Gram IT. Cigarette smoking and colorectal cancer mortality among 602,242 Norwegian males and females. Clin Epidemiol 2014;6:137–145. doi: 10.2147/clep.S58722. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Edwards BK Ward E Kohler BA Eheman C Zauber AG Anderson RN, et al. Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 2010;116:544–573. doi: 10.1002/cncr.24760. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Murphy CC, Sandler RS, Sanoff HK, Yang YC, Lund JL, Baron JA. Decrease in incidence of colorectal cancer among individuals 50 years or older after recommendations for population-based screening. Clin Gastroenterol Hepatol 2017;15:903–909.e6. doi: 10.1016/j.cgh.2016.08.037. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Okeke E Davwar PM Roberts L Sartorius K Spearman W Malu A, et al. Epidemiology of liver cancer in Africa: Current and future trends. Semin Liver Dis 2020;40:111–123. doi: 10.1055/s-0039-3399566. [DOI] [PubMed] [Google Scholar]
- 20.Singal AG, El-Serag HB. Hepatocellular carcinoma from epidemiology to prevention: Translating knowledge into practice. Clin Gastroenterol Hepatol 2015;13:2140–2151. doi: 10.1016/j.cgh.2015.08.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.DeSantis CE, Bray F, Ferlay J, Lortet-Tieulent J, Anderson BO, Jemal A. International variation in female breast cancer incidence and mortality rates. Cancer Epidemiol Biomarkers Prev 2015;24:1495–1506. doi: 10.1158/1055-9965.Epi-15-0535. [DOI] [PubMed] [Google Scholar]
- 22.Hwang SY, Yu SJ, Lee JH, Kim HY, Kim YJ. Reduction of oxidative stress attenuates lipoapoptosis exacerbated by hypoxia in human hepatocytes. Int J Mol Sci 2015;16:3323–3334. doi: 10.3390/ijms16023323. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Fuchs A Samovski D Smith GI Cifarelli V Farabi SS Yoshino J, et al. Associations among adipose tissue immunology, inflammation, exosomes and insulin sensitivity in people with obesity and nonalcoholic fatty liver disease. Gastroenterology 2021;161:968–981.e12. doi: 10.1053/j.gastro.2021.05.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Castellsagué X, Muñoz N, De Stefani E, Victora CG, Castelletto R, Rolón PA. Influence of mate drinking, hot beverages and diet on esophageal cancer risk in South America. Int J Cancer 2000;88:658–664. doi: 10.1002/1097-0215(20001115)88:4<658:aid-ijc22>3.0.co;2-t. [DOI] [PubMed] [Google Scholar]
- 25.Hung HC, Huang MC, Lee JM, Wu DC, Hsu HK, Wu MT. Association between diet and esophageal cancer in Taiwan. J Gastroenterol Hepatol 2004;19:632–637. doi: 10.1111/j.1440-1746.2004.03346.x. [DOI] [PubMed] [Google Scholar]
- 26.Wang JM, Xu B, Rao JY, Shen HB, Xue HC, Jiang QW. Diet habits, alcohol drinking, tobacco smoking, green tea drinking, and the risk of esophageal squamous cell carcinoma in the Chinese population. Eur J Gastroenterol Hepatol 2007;19:171–176. doi: 10.1097/MEG.0b013e32800ff77a. [DOI] [PubMed] [Google Scholar]
- 27.Kamangar F, Chow WH, Abnet CC, Dawsey SM. Environmental causes of esophageal cancer. Gastroenterol Clin North Am 2009;38:27–57,vii. doi: 10.1016/j.gtc.2009.01.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Wei WQ Chen ZF He YT Feng H Hou J Lin DM, et al. Long-term follow-up of a community assignment, one-time endoscopic screening study of esophageal cancer in China. J Clin Oncol 2015;33:1951–1957. doi: 10.1200/jco.2014.58.0423. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Wang GQ Abnet CC Shen Q Lewin KJ Sun XD Roth MJ, et al. Histological precursors of oesophageal squamous cell carcinoma: Results from a 13 year prospective follow up study in a high risk population. Gut 2005;54:187–192. doi: 10.1136/gut.2004.046631. [DOI] [PMC free article] [PubMed] [Google Scholar]