Abstract
Background
Cervical cancer remains a major public health challenge in East Asia, with heterogeneous epidemiological patterns across countries. A comprehensive comparison of long-term trends and future trajectories is essential to inform region-specific prevention strategies.
Methods
Using data from the Global Burden of Disease 2021 study, we analyzed incidence, prevalence, disability-adjusted life years (DALYs), and mortality of cervical cancer among women aged 20–64 years in China, Japan, and South Korea from 1990 to 2021. Temporal trends were assessed using Joinpoint regression, and future burdens were projected through 2050 using established demographic and epidemiological modeling frameworks.
Results
Marked cross-country differences were observed. China exhibited sustained increases in incidence and prevalence over the past three decades, while mortality and DALYs declined only modestly. For example, the age-standardized incidence rate in China increased from 16.74 per 100,000 population in 1990 (95% CI: 13.04–21.14) to 19.76 per 100,000 population in 2021 (95% CI: 13.99–26.14). In contrast, Japan showed relatively stable incidence and mortality rates, accompanied by moderate increases in prevalence, reflecting prolonged survival. South Korea demonstrated consistent declines across incidence, mortality, and DALYs, representing the most pronounced improvement among the three countries. Future projections suggest that, without intensified prevention efforts, the cervical cancer burden in China will continue to rise, whereas Japan and South Korea are expected to maintain stable or declining trends.
Conclusions
The burden of cervical cancer in East Asia shows substantial divergence. China faces a growing challenge, while Japan and South Korea have achieved more effective disease control. These findings underscore the need for tailored prevention and control strategies adapted to national contexts.
Supplementary Information
The online version contains supplementary material available at 10.1007/s12672-026-04688-9.
Keywords: Cervical cancer, Incidence, Prevalence, Mortality, DALYs, Global Burden of Disease, East Asia, Age-period-cohort analysis
Introduction
Cervical cancer ranks as the fourth most common cancer among women and the fourth leading cause of cancer-related mortality [1], with approximately 660,000 new cases and 350,000 deaths [2]. Despite being highly preventable through human papillomavirus (HPV) vaccination and organized screening, cervical cancer continues to impose a disproportionate burden, particularly in Asia [3]. In fact, more than one-quarter of global cervical cancer cases in 2022 occurred in East Asia [4]. China bears the heaviest national burden of cervical cancer globally, with the highest number of incident cases reported worldwide [5].
Although several studies have examined cervical cancer burden at global or national levels, comparative analyses focusing on young and middle-aged women across East Asian countries remain limited. In particular, few studies have jointly assessed long-term trends and future projections using a consistent analytical framework. Therefore, this study aims to compare long-term trends and project future changes in the incidence, prevalence, mortality, and disability-adjusted life years (DALYs) of cervical cancer among women aged 20–64 years in China, Japan, and South Korea, using data from the Global Burden of Disease 2021 study. Understanding these divergent trends is essential for informing evidence-based cervical cancer prevention strategies, particularly in optimizing HPV vaccination coverage and strengthening organized screening programs among young and middle-aged women. Although several studies have examined cervical cancer incidence and mortality at global or national levels, comparative analyses focusing specifically on young and middle-aged women across East Asian countries remain limited. In particular, few studies have jointly evaluated long-term trends, demographic drivers, and future projections of cervical cancer burden using a consistent analytical framework.
Methods
Data sources
Data on cervical cancer burden were obtained from the GBD 2021, which provides annual estimates for 371 diseases and injuries in 204 countries and territories between 1990 and 2021 [6]. The present analysis focused on women aged 20–64 years in China, Japan, and Korea, representing the young and middle-aged working population. The study population was restricted to women aged 20–64 years to focus on young and middle-aged adults, corresponding broadly to reproductive and working-age populations. This age range captures the period of highest socioeconomic impact of cervical cancer while minimizing confounding effects related to pediatric cases and advanced-age comorbidities. Similar age-based stratifications have been adopted in previous epidemiological studies to assess disease burden among economically active populations. We extracted data on cervical cancer incidence, prevalence, mortality, and DALYs, including both absolute counts and age-standardized rates. Specifically, age-standardized incidence rates (ASIR), age-standardized mortality rates (ASMR), and age-standardized DALY rates (ASDR) were obtained. All data were downloaded as raw files from the Global Health Data Exchange (GHDx) database (https://vizhub.healthdata.org/gbd-results/) rather than extracted from the online visualization interface to ensure analytical reproducibility.
Data were derived from the Global Burden of Disease Study 2021, which synthesizes multiple data sources through standardized data quality control and modeling procedures. Mortality inputs for cervical cancer were primarily obtained from national vital registration systems, cancer registries, and verbal autopsy studies where applicable. To address incomplete coverage and underreporting, mortality data were adjusted using GBD’s cause-of-death ensemble modeling (CODEm) framework, which incorporates covariates related to health system performance and demographic structure. Non-specific and ill-defined causes of death were redistributed using established GBD algorithms. Detailed descriptions of data quality assessment, correction for underreporting, and estimation procedures have been published elsewhere and are available in the GBD 2021 methods documentation. The GBD 2021 framework employed the Bayesian meta-regression tool DisMod-MR 2.1 [7].
Estimation methods
To examine long-term temporal changes from 1990 to 2021, we applied Joinpoint regression models (Joinpoint Regression Program, version 4.9.1.0, US National Cancer Institute) [8]. The analysis allowed a maximum of five joinpoints, enabling detection of potential changes in temporal trends over the study period. Joinpoint models were fitted using log-linear regression, and the optimal number and location of joinpoints were determined through permutation tests with a significance level of 0.05. For each identified segment, the annual percentage change (APC) was estimated, and the average annual percentage change (AAPC) was calculated to summarize the overall trend across the entire period. Statistical significance of APC estimates was assessed using two-sided tests, and 95% confidence intervals were reported where applicable.
Age-specific patterns were analyzed using estimates for seven five-year age groups (20–24 through 60–64 years), enabling characterization of the distribution of cervical cancer burden across reproductive and working life stages. Changes in cervical cancer DALYs were decomposed into contributions from population growth, population aging, and epidemiological change following the standard GBD decomposition framework, which is conceptually based on the Das Gupta method [9].
Future cervical cancer burden from 2022 to 2050 was projected using a Bayesian age-period-cohort (BAPC) model [10]. Age, period, and cohort effects were specified as random effects to capture smooth temporal variation, while the overall intercept was modeled as a fixed effect. Second-order random walk priors were assigned to the age, period, and cohort components to penalize abrupt changes and ensure temporal smoothness. Model inference was performed using integrated nested Laplace approximation (INLA) [11], and posterior distributions were obtained accordingly. Weakly informative priors were adopted for precision parameters following standard BAPC applications in disease burden forecasting. Forecast results were summarized as posterior means with corresponding 95% credible intervals. The BAPC framework has been widely applied in long-term epidemiological projections because it balances robustness with an explicit representation of uncertainty.
Statistical analysis
All statistical analyses and data visualization were conducted using R software (version 4.2.2). Figures were generated with the ggplot2 package. Temporal trends were analyzed using the Joinpoint Regression Program (version 5.4.0.0, US National Cancer Institute). The BAPC projections were implemented in R using the BAPC and INLA packages. All analyses were conducted using annual data from 1990 to 2021, ensuring consistent temporal resolution across countries and indicators. Age-standardized rates, including age-standardized incidence rates, mortality rates, and DALY rates, were calculated using the GBD 2021 global age-standard population. This standardization approach was applied uniformly to all countries to facilitate valid cross-country and temporal comparisons.
Results
Burden of cervical cancer in 2021
In 2021, the burden of cervical cancer among women aged 20–64 years differed markedly across China, Japan, and Korea (Table 1). China bore the largest burden across all four indicators, with over 100,000 incident cases, approximately 667,000 prevalent cases, and more than 1.14 million DALYs, substantially exceeding those observed in Japan and Korea. The ASIR in China was 19.8 per 100,000, accompanied by an ASMR of 5.1 per 100,000. Japan exhibited a substantially lower absolute burden, with fewer than 8000 incident cases and approximately 64,000 DALYs in 2021. Despite this, Japan showed an ASIR (19.6 per 100,000) comparable to that of China, while mortality and DALY rates remained lower. Korea consistently demonstrated the smallest burden, with approximately 2400 incident cases, 480 deaths, and 20,000 DALYs. Its ASMR (2.2 per 100,000) and DALY rate (100.1 per 100,000) were the lowest among the three countries.
Table 1.
The incidence, prevalence, DALYs and death cases for Cervical cancer across the middle-aged and young population, as well as the age-standardized rates, were analyzed for China, Japan and Korea in the years 1990 and 2021
| Location | Measures | 1990 | 2021 | 1990–2021 AAPC | ||
|---|---|---|---|---|---|---|
| All-ages cases (95% CI) | ASR (95% CI) | All-ages cases (95% CI) | ASR (95% CI) | |||
| China | Incidence | 46679.32 (36299.63 to 59017.04) | 16.74 (13.04 to 21.14) | 101614.66 (71801.52 to 134220.45) | 19.76 (13.99 to 26.14) | 0.644 (0.585 to 0.704) |
| Prevalence | 219641.03 (169567.74 to 279083.63) | 75.51 (58.42 to 95.87) | 666999.72 (472372.59 to 883553.37) | 133.62 (94.79 to 177.06) | 1.905 (1.797 to 1.976) | |
| DALYs | 914830.66 (715495.80 to 1154550.02) | 332.79 (260.74 to 419.44) | 1144778.63 (813731.08 to 1518931.64) | 213.51 (151.93 to 283.47) | −1.389 (−1.465 to −1.332) | |
| Deaths | 21782.59 (17097.34 to 27373.90) | 8.12 (6.38 to 10.19) | 28533.54 (20329.18 to 37853.32) | 5.14 (3.67 to 6.82) | −1.436 (−1.51 to −1.378) | |
| Japan | Incidence | 5996.58 (5383.21 to 6698.91) | 13.79 (12.33 to 15.46) | 7770.08 (6573.24 to 9077.99) | 19.56 (16.47 to 22.96) | 1.123 (0.908 to 1.326) |
| Prevalence | 42908.64 (38102.90 to 48371.09) | 100.20 (88.70 to 113.19) | 59029.40 (48732.96 to 69986.83) | 151.52 (125.03 to 179.97) | 1.315 (1.142 to 1.468) | |
| DALYs | 61988.51 (59100.61 to 64719.27) | 138.39 (131.97 to 144.56) | 64443.51 (60828.14 to 67781.56) | 150.98 (142.60 to 158.96) | 0.262 (0.143 to 0.379) | |
| Deaths | 1528.58 (1460.51 to 1589.90) | 3.32 (3.17 to 3.45) | 1541.62 (1459.37 to 1613.40) | 3.43 (3.26 to 3.59) | 0.1 (−0.014 to 0.213) | |
| Korea | Incidence | 2705.27 (1921.05 to 3661.47) | 23.09 (16.46 to 31.13) | 2423.44 (1605.11 to 3557.65) | 13.06 (8.56 to 19.36) | −1.794 (−1.885 to −1.713) |
| Prevalence | 16704.10 (11327.53 to 23440.01) | 139.36 (94.59 to 195.24) | 18292.77 (11999.12 to 27125.26) | 101.09 (65.71 to 150.90) | −0.999 (−1.093 to −0.911) | |
| DALYs | 40406.64 (29347.29 to 53377.64) | 351.34 (255.86 to 462.68) | 20121.31 (14003.79 to 28852.23) | 100.08 (68.97 to 144.14) | −3.953 (−4.018 to −3.894) | |
| Deaths | 951.50 (697.14 to 1248.90) | 8.47 (6.22 to 11.09) | 479.98 (334.86 to 684.66) | 2.23 (1.55 to 3.20) | −4.222 (−4.276 to −4.166) | |
Trends of cervical cancer burden from 1990 to 2021
From 1990 to 2021, temporal trends in cervical cancer burden showed pronounced cross-country heterogeneity (Fig. 1). In China, incidence and prevalence exhibited statistically significant increasing trends, with accelerated growth during the early 2000s, followed by more gradual increases thereafter. In contrast, mortality and DALYs showed overall declining trends, although the magnitude of reduction was modest relative to the rise in new cases. Japan experienced gradual increases in incidence and prevalence, particularly from the mid-1990s to early 2010s, while mortality and DALY rates remained largely stable over the three decades, indicating improvements in survival rather than reductions in disease occurrence. In Korea, all four indicators demonstrated statistically significant declining trends, with particularly steep reductions in mortality and DALYs from the late 1990s onward, reflecting sustained improvements in disease control.
Fig. 1.
Temporal trends in cervical cancer burden among women aged 20–64 years in China, Japan, and Korea, 1990–2021. A Age-standardized incidence rate (ASIR) per 100,000 population; B Age-standardized prevalence rate (ASPR) per 100,000 population; C Age-standardized disability-adjusted life years (ASDR) per 100,000 population; D Age-standardized mortality rate (ASMR) per 100,000 population
Comparative analysis of cervical cancer burden among China, Japan, and Korea
Comparative analysis highlighted a clear divergence in cervical cancer trajectories across East Asia (Figs. 2, 3, 4). Between 1990 and 2021, China experienced more than a twofold increase in incidence and a threefold increase in prevalence, accompanied by substantial rises in deaths and DALYs. Japan showed modest increases in incidence and prevalence, while deaths and DALYs remained largely unchanged over time. In contrast, Korea achieved a marked overall reduction, with deaths decreasing by approximately 50% and DALYs nearly halved over the study period.
Fig. 2.
Age-specific burden of cervical cancer in China, Japan, and Korea, 2021. Values are expressed as the absolute number of cases within each 5-year age group among women aged 20–64 years
Fig. 3.
Age-specific burden of cervical cancer in China, Japan, and Korea, 1990. Values are expressed as the absolute number of cases within each 5-year age group among women aged 20–64 years
Fig. 4.
Comparison of cervical cancer burden in China, Japan, and Korea, 1990–2021
Age-specific patterns of cervical cancer burden
Age-specific analyses revealed distinct but broadly consistent patterns across countries (Fig. 5). In China, the cervical cancer burden shifted toward older age groups over time. While incidence and DALYs peaked among women aged 35–44 years in 1990, the highest burden in 2021 was observed among those aged 40–54 years. Mortality became increasingly concentrated in women aged 50–59 years. In Japan, incidence and prevalence consistently peaked among women aged 40–49 years, with only minor temporal shifts. Mortality and DALYs remained relatively stable across age groups. Korea demonstrated uniform reductions across nearly all age groups, with particularly pronounced declines among women aged 30–54 years, resulting in a compressed age distribution of burden by 2021.
Fig. 5.
Comparison of age-specific cervical cancer burden in China, Japan, and Korea, 1990 and 2021
Decomposition of cervical cancer burden changes
Decomposition analysis identified distinct drivers of cervical cancer burden across countries (Fig. 6). In China, increases in deaths and DALYs were primarily driven by population aging and population growth, while epidemiological improvements partially offset these demographic pressures. For incidence and prevalence, both demographic changes and adverse epidemiological trends contributed to the net increase. In Japan, the overall burden remained relatively stable due to offsetting effects. Population aging exerted upward pressure, which was largely counterbalanced by population decline and modest epidemiological improvements. In contrast, Korea’s substantial reduction in burden was driven predominantly by favorable epidemiological changes, which outweighed the effects of aging and population growth across all four indicators.
Fig. 6.
Decomposition of changes in cervical cancer DALYs and deaths among women aged 20–64 years in China, Japan, and Korea, 1990–2021
Future projections of cervical cancer burden to 2050
Projections to 2050 suggest continued divergence in cervical cancer burden across the three countries (Fig. 7 and Table S1). In China, age-standardized incidence and prevalence rates are projected to increase modestly, while absolute case numbers gradually decline due to demographic transitions. Mortality and DALYs are projected to decrease substantially over the projection period. Japan is expected to experience relatively stable incidence and prevalence rates, accompanied by gradual declines in mortality and DALYs. Korea is projected to maintain continued reductions in mortality and disability burden, despite a modest increase in prevalence rates driven by population aging.
Fig. 7.
Bayesian age-period-cohort projections of cervical cancer burden in China, Japan, and Korea from 1990 to 2050
Discussion
This study provides a comprehensive comparative assessment of cervical cancer burden among women aged 20–64 years in China, Japan, and Korea using data from the GBD 2021 study. By examining incidence, prevalence, mortality, and DALYs from 1990 to 2021 and projecting future trends to 2050, we identified pronounced heterogeneity in epidemiological trajectories across East Asia. Overall, China continues to bear the heaviest burden with rising incidence and prevalence, Japan shows relative stability in mortality despite increasing incidence, and Korea has achieved sustained reductions across most indicators. These divergent patterns reflect differences in demographic dynamics, prevention coverage, and health system performance in this critical working-age population.
Our findings indicate that cervical cancer incidence and prevalence among Chinese women aged 20–64 years increased substantially over the past three decades, while mortality declined only modestly. This pattern is consistent with recent national and global analyses showing that China remains one of the countries with the largest absolute cervical cancer burden worldwide and that case numbers continue to rise despite some improvements in survival [5]. The observed divergence between increasing detection and limited mortality reduction likely reflects expanded diagnostic activity combined with delayed or uneven implementation of effective prevention strategies. Although China launched a national cervical cancer screening program in 2009, overall coverage remains below international benchmarks. Available evidence suggests that lifetime screening participation is still limited, particularly in rural and underserved areas [12]. Implementation assessments further indicate that cytology-based screening and visual inspection methods remain dominant in many regions, both of which are constrained by shortages of trained personnel and variability in diagnostic quality [12, 13]. In contrast, high-risk HPV testing has demonstrated superior sensitivity for detecting CIN2+/CIN3+ lesions in large multicenter randomized trials conducted in China, supporting its potential role as a primary screening modality [14]. Taken together, these factors help explain why epidemiological improvements have not yet translated into a net reduction in burden. National reviews consistently emphasize that without substantial scale-up of HPV vaccination and wider adoption of high-performance screening, China is unlikely to achieve cervical cancer elimination targets within the expected timeframe [15]. Projections based on GLOBOCAN 2022 similarly suggest that, under current trajectories, both cases and deaths in China will continue to increase markedly by mid-century [4].
Japan exhibited a distinctive pattern characterized by gradually increasing incidence and largely stable mortality among women aged 20–64 years. This finding aligns with longitudinal analyses reporting that cervical cancer incidence has risen since the early 2000s, particularly among younger cohorts, while mortality has remained relatively unchanged over the past two decades [16]. Such stability in mortality suggests that detection and treatment have partially offset rising incidence. Screening participation remains limited: national data indicate that coverage has stagnated at approximately 40% since the 1990s, one of the lowest rates among high-income countries [17], with clear socioeconomic gradients in uptake [18]. Survey-based studies consistently identify psychological and social barriers as major deterrents to participation [19]. HPV coverage has also likely contributed to Japan’s trajectory. After the 2013 suspension of proactive governmental recommendations, uptake fell from >70% to <1%, leaving several birth cohorts largely unvaccinated [20]. Project substantial excess cervical cancer cases and deaths attributable to this coverage gap [21]. Although recommendations and catch-up vaccination were resumed in 2022 and vaccine effectiveness has been supported by observational evidence [22–24], the resulting cohort effect may continue to sustain incidence in the coming decades, highlighting the need to rebuild vaccination and strengthen high-performance screening.
In contrast, Korea exhibited the most favorable cervical cancer profile, with age-standardized incidence and mortality declining steadily from 1990 to 2021, consistent with national registry data [25, 26]. These reductions cannot be attributed solely to a lower baseline disease prevalence, as declines were observed across multiple age groups and persisted after age standardization. Importantly, the mortality and DALY reductions among women aged ≥40 years are unlikely to be directly related to HPV vaccination, since Korea’s national immunization program was introduced in 2016 and initially targeted pre-adolescent girls. Instead, the short-term burden reduction is more plausibly explained by long-standing high participation in organized cervical cancer screening, which approached 70% coverage by 2020 [27]. Meanwhile, the rapid scale-up of HPV vaccination has achieved high coverage in younger cohorts [28] and is expected to contribute increasingly to future incidence reduction as these cohorts age. Together, these findings indicate that Korea’s declining burden reflects effective screening in the short term and expanding vaccination benefits in the long term, rather than inherently lower background risk.
Taken together, the three countries represent different stages of cervical cancer control in East Asia. China remains in an expansion phase, where demographic pressures and incomplete prevention coverage continue to drive increases in burden. Japan occupies a transitional stage, with stable mortality but rising incidence reflecting gaps in screening and historical vaccination disruption. Korea exemplifies a consolidated prevention model, in which coordinated vaccination and screening have produced measurable epidemiological gains. This study highlights pronounced cross-country disparities in cervical cancer burden among working-age women in East Asia. Scaling up HPV vaccination, strengthening screening coverage, and ensuring timely treatment remain central to reducing disease burden and advancing toward cervical cancer elimination across the region.
Limitations
This study has several limitations that warrant careful consideration. First, our analysis is based on modeled estimates from the GBD 2021 study rather than raw primary registry data. GBD 2021 synthesizes heterogeneous inputs (including cancer registries and vital registration systems) using standardized modeling frameworks such as DisMod-MR 2.1 to ensure internal consistency across epidemiologic quantities. Nevertheless, the validity of country-level estimates ultimately depends on the completeness, timeliness, and coding quality of the underlying data sources, which may vary across China, Japan, and Korea and can introduce under-ascertainment or misclassification. A key indicator of this uncertainty is the 95% uncertainty interval (UI) provided with all GBD estimates; the width of these intervals in our Results reflects the combined impact of input-data sparsity, potential measurement error, and model uncertainty, and should be considered when interpreting cross-country differences and temporal changes. In addition, cause-of-death inputs may be affected by the use of non-specific or intermediate codes, and although GBD applies systematic redistribution and other correction procedures, residual error may persist and could differ by setting. Second, our analyses were conducted at the national level, which may mask meaningful subnational heterogeneity. Cervical cancer burden is known to be shaped by geographically and socioeconomically patterned access to screening, diagnosis, and treatment; therefore, national aggregates may underestimate within-country inequalities and dilute signals that are critical for policy targeting. Third, future projections using BAPC modeling inherently assume that historical patterns and latent temporal structures remain broadly informative for the forecast horizon. While the approach explicitly quantifies predictive uncertainty through posterior distributions, it cannot fully anticipate abrupt structural breaks, such as rapid expansions in HPV vaccination coverage, major screening policy reforms, or disruptive health-system shocks. Finally, this study is primarily descriptive and comparative. We did not integrate time-varying risk-factor or programmatic indicators into a causal framework; therefore, observed associations between country trajectories and prevention strategies should be interpreted as contextual consistency rather than causal attribution. Future work linking GBD estimates with high-resolution national registry data and program metrics, and conducting subnational and equity-stratified analyses, would strengthen causal inference and improve policy relevance.
Supplementary Information
Author contributions
X.Z conceived the idea, designed the study, and drafted the manuscript. K.Y.B and X.Y.T coded the statistical analysis, figures, and appendix. All authors have read and approved the final manuscript.
Funding
No Funding.
Data availability
Data from the Global Burden of Disease 2021 (https://vizhub.healthdata.org/gbd-results/) are available to researchers following a successful registration and application process.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Supplementary Materials
Data Availability Statement
Data from the Global Burden of Disease 2021 (https://vizhub.healthdata.org/gbd-results/) are available to researchers following a successful registration and application process.