Burden and Forecast of Early‐Onset Colorectal Cancer (1990–2038) in Five East Asian Populations: A Systematic Analysis Based on the GBD 2023 Study

Lili jin; Jiahao Tang; Chunyang Meng; Jianhua liao; Baoqing Liu

doi:10.1002/cam4.71905

. 2026 May 3;15(5):e71905. doi: 10.1002/cam4.71905

Burden and Forecast of Early‐Onset Colorectal Cancer (1990–2038) in Five East Asian Populations: A Systematic Analysis Based on the GBD 2023 Study

Lili jin ¹, Jiahao Tang ², Chunyang Meng ¹, Jianhua liao ¹, Baoqing Liu ^1,^✉

PMCID: PMC13136513 PMID: 42076788

ABSTRACT

Background

Early‐onset colorectal cancer (EO‐CRC) is increasing globally with substantial regional variation. We assessed epidemiological changes in EO‐CRC in five East Asian populations.

Methods

Using GBD 2023 data, we calculated age‐standardized incidence, prevalence, mortality, and DALY rates (ASIR, ASPR, ASMR, ASDR), counts, and average annual percent changes (AAPC). Decomposition, age‐period‐cohort (APC), and forecast analyses assessed trends and risk factor contributions to mortality.

Results

In 2023, these populations accounted for 25%–31% of global EO‐CRC cases. China had the highest absolute burden, and Taiwan (Province of China) had the highest ASR. From 1990 to 2023, North Korea had the highest ASIR increase (AAPC = 1.34%), while South Korea's ASMR declined most (AAPC = −2.58%). Males had a higher burden than females. Decomposition analysis showed epidemiological changes increased incidence outside China but generally reduced mortality except in North Korea, with effects stronger for deaths than incidence. APC analysis revealed accelerated risk with age; period effects varied: North Korea showed the largest relative risk increase (RR 0.93 → 1.32), and China showed a post‐2014 rebound. Projections to 2038 suggest continued rises in incidence and DALYs. Risk analysis identified low calcium intake as the main mortality driver in North Korea, and low milk, low whole grains, and high red meat intake in the other populations; high BMI and processed meat–related deaths also increased markedly.

Conclusions

EO‐CRC incidence is rising in East Asia, with China highest in absolute numbers and Taiwan in ASR; men are disproportionately affected. Burden and risk analyses reveal population‐specific effects. Interventions should target diet, screening, and sex‐ and population‐specific risk factors.

Keywords: DALYs, early‐onset colorectal cancer (EO‐CRC), five east Asian populations, GBD, incidence

1. Introduction

Colorectal cancer (CRC) is a common malignancy worldwide, ranking third in incidence and second in cancer‐related mortality [1]. EO‐CRC, defined as CRC diagnosed before age 50, has increased over recent decades in many regions [2] Compared with late‐onset CRC, EO‐CRC often shows aggressive pathological features, including poor differentiation, signet‐ring histology, and lymphovascular or perineural invasion [3] Many young patients present with metastases [4] and experience high recurrence and low 5‐year survival despite adjuvant chemotherapy [5] Most EO‐CRC cases lack hereditary or familial background, with lifestyle factors (diet, physical inactivity) and metabolic disorders (obesity) contributing to risk [6] Further epidemiological and risk factor studies are needed to inform effective prevention strategies.

Existing GBD studies on EO‐CRC primarily provide global or regional assessments, [7, 8] often overlooking differences between populations within the same region. Based on the 2021 GBD classification of 21 regions, East Asia—including China, Taiwan, and North Korea—had the highest EO‐CRC incidence and deaths, with the second‐highest ASIR increase [7]. Investigating the EO‐CRC burden across East Asian populations is therefore essential. China, Japan, North Korea, South Korea, and Taiwan (Province of China) together comprise roughly one‐fifth of the world's population [9] and share similar geography, culture, diet, and lifestyle. With EO‐CRC rising in recent years, understanding epidemiological patterns in these populations is crucial for clarifying regional dynamics and guiding targeted public health interventions.

This study aims to comprehensively characterize the epidemiology of EO‐CRC in East Asia, identify high‐risk populations and key risk factors, and project future disease burden trends to inform targeted prevention and control strategies. We aim to fill gaps in regional EO‐CRC research, provide data to guide health policy, and ultimately reduce its public health impact. The findings may also help optimize screening, improve early diagnosis, and support targeted lifestyle interventions.

2. Methods

2.1. Data Source

This study analyzed the burden of EO‐CRC among 15–49‐year‐olds in five East Asian populations (China, Japan, the Democratic People's Republic of Korea [DPRK], the Republic of Korea [ROK], and Taiwan [Province of China]) using data from the 2023 Global Burden of Disease (GBD 2023) study. We retrieved population‐specific EO‐CRC incidence, prevalence, mortality, and disability‐adjusted life years (DALYs), including counts and rates, as well as the proportion and rates of deaths attributable to key risk factors, from the GBD Results Tool (https://vizhub.healthdata.org/gbd‐results/) for 1990–2023. Only data for the 15–49 age group were extracted; Mongolia was excluded due to its small population and EO‐CRC burden.

2.2. ASR

Age‐standardized rates (ASR) of EC‐CRC were calculated to account for differences in population age structure. ASR per 100,000 population was computed using the formula:

ASR = \frac{\sum_{i} (a_{i} \times w_{i})}{\sum_{i} w_{i}} \times 100,000

where $a_{i}$ is the age‐specific rate for age group $i$ , and $w_{i}$ is the corresponding standard population weight [10].

2.3. Socio‐Demographic Index (SDI)

The SDI quantifies a population's development level by integrating fertility, education, and per capita income [11]. Pearson correlation coefficients (ρ) were calculated to assess associations between ASRs and SDI across the five East Asian populations, highlighting the influence of socioeconomic factors on EO‐CRC burden [12].

2.4. Joinpoint Regression Analysis

The Joinpoint regression model evaluates changes in incidence trends by identifying points where statistically significant shifts occur, providing a better fit than a single Poisson or time series regression line. The method determines the minimum number of joinpoints needed to assess temporal changes. In this study, a maximum of five joinpoints was allowed, and permutation tests were used to evaluate trend significance. Annual percent changes (AAPC) were calculated, and the statistical significance of trends across segments was assessed by comparing AAPC with zero, with p < 0.05 considered significant [13].

2.5. Age‐Period‐Cohort (APC) Analysis

The age–period–cohort (APC) model examines temporal trends in disease incidence or mortality by decomposing effects of age, period, and birth cohort. Due to the high linear dependence among these factors, independent estimation of each effect is challenging [14, 15]. To address this collinearity, we applied the parametrized APC method proposed by Carstensen, based on the Lexis diagram framework, [16] which decomposes estimable functions of age, period, and cohort. For GBD data, age groups were defined as 15–19, 20–24, …, 40–44 years, and periods were set in 5‐year intervals (1994–1998, 1999–2003, …, 2019–2023), with death counts and corresponding population numbers calculated for each age group. The APC model was fitted using a Poisson regression with the log of population as an offset. Analyses were conducted in R (version 4.4.2) to estimate age, period, and cohort effects.

2.6. Decomposition Analysis

Decomposition analysis was employed to assess the relative contributions of aging, epidemiological changes, and population growth to trends in EC incidence and mortality. This approach allows for the quantification of how each factor drives increases or decreases in disease burden, providing insights for more targeted public health strategies [17]. Specifically, the method calculates the effect of each component on overall trends, helping to disentangle the drivers of changes in EC burden.

2.7. Frontier Analysis

We constructed a Socio‐Demographic Index (SDI)‐based frontier model to estimate the theoretical minimum EO‐CRC ASR at each development level and quantify the gap between observed and optimal burden. Local weighted regression (LOESS, smoothing parameter = 0.3) combined with 1000 bootstrap samples was used to generate a robust frontier curve. The potential for improvement was assessed by calculating the absolute distance between observed ASRs and the frontier [18].

2.8. Bayesian Age‐Period‐Cohort (BAPC) Prediction

We applied a Bayesian BAPC model to analyze global EO‐CRC ASRs from 1990 to 2023 and project trends by age group through 2038. The model used historical ASR and population data with default weakly informative priors and INLA‐based parameter estimation, without standard MCMC convergence checks. Predictive accuracy was evaluated via backcasting, demonstrating minimal error. Outputs included ASR with 95% uncertainty intervals (UIs) for public health reference [19, 20].

2.9. Statistical Analysis

Descriptive statistics are presented as means with 95% uncertainty or confidence intervals (UI or CI), and p < 0.05 was considered statistically significant. Data processing and visualization were performed in R (version 4.4.2).

3. Results

3.1. Incidence of EO‐CRC in the Five East Asian Populations

Figure 1 shows the global distribution of the EO‐CRC burden in 2023, with East Asia identified as a relatively high‐burden region (Figure 1A–D). In 2023, the five East Asian populations had 58,648 (95% UI: 48,569–76,093) incident cases of early‐onset colorectal cancer (EO‐CRC), accounting for 27.33% of global cases, a 15.31% increase since 1990, with all populations' ASIRs exceeding the global level (Figure 2A, Table 1). The largest increase occurred in the DPRK, with 1226 cases (95% UI: 829–1656), a 122.5% rise since 1990; its ASIR was 8.23 per 100,000 (95% UI: 5.34–11.73) with an AAPC of 1.34%. China had the highest number of cases (48,144; 95% UI: 38,339–60,700), while Taiwan had the highest ASIR (17.24 per 100,000; 95% UI: 14.1–21.29) (Figure 2A). Data for other populations are shown in Table 1.

Age‐Standardized Rates of Incidence, Prevalence, Deaths and DALYs from 1990 to 2023, in early‐onset colorectal cancer (EO‐CRC) Across 204 countries. (A) Incidence. (B) Prevalence. (C) Mortality. (D) DALYs. DALYs Disability‐Adjusted Life Years.

(A) The Numbers and Age‐Standardized Rate of the Five Countries of East Asia Burden of early‐onset colorectal cancer (EO‐CRC). (B) Age‐standardized incidence rate (ASIR). (C) Age‐standardized Prevalence rate(ASPR). (D) Age‐standardized Deaths rate (ASMR).

TABLE 1.

Numbers and Age‐standardized rates (ASR) of the burden for early‐onset colorectal cancer (CO‐CRC) in 1990 and 2023, as well as the average annual percentage change (AAPC) from 1990 to 2023.

Measure	Location	1990		2023		1990–2023 AAPC
		All‐ages cases	ASR 100,000 people	All‐ages cases	ASR 100,000 people	1990–2023 AAPC
		n (95% UI)	n (95% UI)	n (95% UI)	n (95% UI)	n (95% CI)
	Five East Aisa Countries	50,861 (40,976,64,264)		58,648 (48,569,76,093)
Incidence	Global	115,189 (101,896,128,537)	4.84 (4.26,5.4)	214,616 (186,592,246,218)	5.14 (4.4,5.91)	0.18 (0.08, 0.29)
	China	40,595 (32,950,46,663)	6.99 (5.43,8.52)	48,144 (38,339,60,700)	6.04 (4.49,7.96)	−0.41 (−0.74, −0.08)
	Democratic People's Republic of Korea	551 (392,772)	5.33 (3.68,7.72)	1226 (829,1656)	8.23 (5.34,11.73)	1.34 (1.17, 1.50)
	Japan	6953 (6293,7650)	9.04 (8.13,10.01)	6671 (5621,7857)	10.05 (8.33,11.99)	0.27 (−0.24, 0.78)
	Republic of Korea	1426 (1162,1684)	6.35 (4.97,7.78)	2122 (1714,2815)	6.79 (5.18,9.21)	0.12 (−0.14, 0.38)
	Taiwan (Province of China)	1336 (1179,1495)	13.26 (11.48,15.11)	2485 (2066,3065)	17.24 (14.1,21.29)	0.86 (0.48, 1.24)
	Five East Aisa Countries	253,440 (204,961,297,228)		380,863 (299,317,460,863)
Prevalence	Global	606,868 (535,552,693,265)	25.58 (22.33,29.39)	1,251,050 (1,046,042,1,440,721)	29.94 (25.09,34.74)	0.49 (0.37, 0.61)
	China	188,933 (148,339,223,093)	32.58 (25.18,39.59)	294,121 (229,210,353,678)	36.92 (27.58,47.14)	0.43 (0.13, 0.72)
	Democratic People's Republic of Korea	2841 (1973,3969)	27.42 (18.69,39.35)	6897 (4676,9372)	46.4 (30.28,67.21)	1.64 (1.52, 1.76)
	Japan	46,372 (41,511,51,875)	60.17 (53.55,67.38)	48,027 (39,648,57,754)	72.26 (58.3,88.18)	0.51 (−0.01, 1.03)
	Republic of Korea	7335 (5977,8913)	32.63 (25.58,40.34)	14,599 (11,908,18,712)	46.56 (35.58,61.49)	1.04 (0.85, 1.24)
	Taiwan (Province of China)	7959 (6861,9178)	78.99 (66.77,92.34)	17,219 (13,875,21,347)	119.72 (95.57,149.57)	1.32 (0.92, 1.72)
	Five East Aisa Countries	30,629 (25,059,35,989)		22,752 (18,971,27,323)
Deaths	Global	64,421 (57,703,71,503)	2.7 (2.37,3.02)	93,099 (82,015,105,608)	2.23 (1.93,2.57)	−0.56 (−0.63, −0.48)
	China	26,532 (21,436,31,384)	4.58 (3.57,5.59)	19,616 (16,250,23,645)	2.46 (1.9,3.17)	−1.82 (−2.08, −1.56)
	Democratic People's Republic of Korea	333 (239,478)	3.22 (2.25,4.67)	589 (410,801)	3.93 (2.58,5.59)	0.62 (0.52, 0.72)
	Japan	2336 (2159,2520)	3.05 (2.81,3.3)	1431 (1312,1557)	2.14 (1.95,2.36)	−1.12 (−1.55, −0.69)
	Republic of Korea	837 (679,976)	3.74 (2.96,4.45)	500 (437,630)	1.59 (1.28,2.01)	−2.58 (−2.97, −2.19)
	Taiwan (Province of China)	591 (546,631)	5.86 (5.27,6.46)	616 (562,690)	4.22 (3.73,4.81)	−0.95 (−1.33, −0.57)
	Five East Aisa Countries	1,618,196 (1,324,740,1,885,825)		1,129,087 (950,488,1,354,500)
DALYs (Disability‐Adjusted Life Years)	Global	3,337,151 (2,982,790,3,711,643)	137.49 (119.89,154.17)	4,686,080 (4,120,541,5,300,384)	112.65 (97.62,129.5)	−0.58 (−0.65, −0.51)
	China	1,412,579 (1,143,710,1,685,144)	237.51 (183.75,290.67)	972,521 (814,499,1,171,073)	124.36 (96.52,159.95)	−1.89 (−2.16, −1.63)
	Democratic People's Republic of Korea	17,043 (12,139,24,425)	164.15 (115.06,238.45)	29,630 (20,747,40,335)	199.72 (130.91,284.07)	0.61 (0.51, 0.71)
	Japan	114,843 (106,069,123,883)	152.31 (140.16,164.95)	71,161 (65,302,77,541)	109.8 (100.02,121.47)	−1.04 (−1.44, −0.63)
	Republic of Korea	42,144 (33,957,49,133)	184.75 (145.68,220.61)	24,959 (21,910,31,105)	81.09 (65.59,103.05)	−2.48 (−2.84, −2.12)
	Taiwan (Province of China)	31,187 (28,865,33,240)	301.97 (270.89,333.17)	30,816 (28,030,34,445)	216.79 (191.23,247.16)	−0.96 (−1.32, −0.60)

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3.2. Prevalence of EO‐CRC in the Five East Asian Populations

In 2023, the five East Asian populations had 380,863 prevalent EO‐CRC cases (95% UI: 299,317–460,863), accounting for 30.44% of global cases, a 50.28% increase since 1990, with ASPR above the global level (Figure 2B, Table 1). The DPRK showed the largest increase, rising 142.77% to 6897 cases, with ASPR increasing from 27.42 to 46.40/100,000 (AAPC +1.64%). China had the highest number of cases (294,121), while Taiwan had the highest ASPR (119.72/100,000). All five populations exhibited rising ASPR trends (Figure 2B, Table 1).

3.3. Deaths of EO‐CRC in the Five East Asian Populations

In 2023, the five East Asian populations had 22,752 EO‐CRC deaths (95% UI: 18,971–27,323), accounting for 24.44% of global deaths, a 25.72% decrease since 1990 (Figure 2C, Table 1). The ROK experienced the largest decline, with 500 deaths (−40.26%) and ASMR falling from 3.74 to 1.59/100,000 (AAPC –2.58%). The DPRK was the only population with a rising ASMR (AAPC +0.62%). China had the highest number of deaths (19,616), while Taiwan had the highest ASMR (4.22/100,000). Other data for the populations are shown in Table 1.

3.4. DALYs Of EO‐CRC in the Five East Asian Populations

In 2023, EO‐CRC DALYs in the five East Asian populations totaled 1,129,087 (95% UI: 950,488–1,354,500), accounting for 24.09% of global DALYs, a 30.23% decrease since 1990 (Figure 2D, Table 1). The ROK showed the largest decline, with 24,959 DALYs (−40.78%) and ASDR dropping from 184.75 to 81.09/100,000 (AAPC –2.48%). The DPRK was the only population with a rising ASDR (AAPC +0.61%). China had the highest DALYs (972,521), while Taiwan had the highest ASDR (216.79/100,000). Other data for the populations are shown in Table 1.

3.5. Descriptive Analysis by Gender and Age

Between 1990 and 2023, the EO‐CRC burden was consistently higher in males than in females across the five East Asian populations (Figure S1A–E; Table S1). In 2023, male ASIRs in China, the DPRK, Taiwan, Japan, and the ROK were 2.70‐, 1.92‐, 1.66‐, 1.32‐, and 1.17‐fold those of females, respectively, while male ASMRs were 2.41‐, 1.99‐, 1.76‐, 1.21‐, and 1.08‐fold higher. Trends in ASPR and ASDR mirrored those of ASIR and ASMR.

Regarding age patterns, EO‐CRC in East Asia exhibited a uniform age effect from 1990 to 2023, with burden increasing with age, indicating a cumulative age effect (Figure S2; Table S2). The burden in individuals aged 40–49 was markedly higher than in those aged 30–39 (Figure S2; Table S2). In China, the DPRK, Taiwan, Japan, and the ROK, ASIRs in the 40–49 age group were 5.39‐, 3.29‐, 3.21‐, 2.89‐, and 2.69‐fold higher than in the 30–39 group (Figure S2A), while ASMRs were 2.61‐, 3.13‐, 3.26‐, 3.55‐, and 3.68‐fold higher (Figure S2C). ASPR and ASDR showed similar age gradients (Figure S2B,D).

3.6. Age‐Peroid‐Cohort (APC) Analysis

Figure 3 presents the APC analysis of ASIR of EO‐CRC across the five East Asian populations. The age effect increased progressively with age (Figure 3A). Period effects declined most sharply in China (RR: 1.37 → 0.86) but rebounded after 2014–2018; the DPRK showed the strongest increase (RR: 0.93 → 1.32), while Japan and ROK increased slightly, and Taiwan showed a modest decline (Figure 3B). Cohort effects decreased most in China but increased among cohorts born after 1999; the largest increase was observed in the DPRK (RR: 0.67 → 1.43), with mild increases in Japan, ROK, and Taiwan (Figure 3C).

Age–period–cohort (APC) analysis of early‐onset colorectal cancer (EO‐CRC) in five East Asian populations. Panels (A–C) show age‐standardized incidence rates (ASIR): (A) longitudinal age curve, (B) period effect, and (C) cohort effect. Panels (D–F) show age‐standardized mortality rates (ASMR): (D) longitudinal age curve, (E) period effect, and (F) cohort effect.

For ASMR, APC analysis indicated that the age effect increased progressively in all populations (Figure 3D). Period and cohort effects increased in the DPRK but declined in other populations, with the greatest decreases observed in China and the ROK (Figure 3E,F).

3.7. Joinpoint Analysis

Joinpoint regression (1991–2022) showed that ASIR and ASPR in the five East Asian populations were consistently higher than global levels (Figure S2). In China, ASIR exhibited a biphasic pattern from 1991 to 2021 (AAPC = −0.41), with a significant decline during 2007–2014 (2007–2010 APC = −4.40; 2010–2014 APC = −2.63; p < 0.05), followed by an upward trend after 2014, particularly during 2020–2023 (APC = 5.18; p < 0.05) (Figure S2A). ASPR showed a similar pattern (Figure S2B). Globally, ASIR and ASPR also declined initially and increased after 2014. China's ASMR (AAPC = −1.82) and ASDR (AAPC = −1.89) declined overall but rose markedly during 2020–2023 (Figure S2C,D). Except for ROK, the other four East Asian populations and the global level showed an evident post‐2020 increase in ASR (APC > 0), possibly related to screening suspension during COVID‐19 and subsequent catch‐up diagnoses after healthcare services resumed [21].

3.8. Correlation Analysis Between ASR and SDI in Five East Asian Populations

In the five East Asian populations, ASIR and ASPR were positively correlated with SDI (r = 0.44 and 0.58, p < 0.001) (Figure S4A,B), whereas ASMR and ASDR were negatively correlated, exhibiting an inverse N‐shaped trend; both declined when SDI exceeded 0.75 (r = −0.28, p < 0.001) (Figure S4C,D).

3.9. Decomposition Analysis

In the five East Asian populations (excluding DPRK), population factors consistently suppressed the growth of early‐onset colorectal cancer (EO‐CRC) incidence (Figure 4A–E), whereas aging promoted its increase across all populations. The impact of epidemiological changes on EO‐CRC incidence varied by population: it was inhibitory in China (−84.43%, Figure 4A) but positive in Taiwan (42.78%), Japan (227.87%), ROK (15.99%), and DPRK (+54.06%) (Figure 4B–E, Table S3).

At the Five Countries of East Asia, changes in early‐onset colorectal cancer (EO‐CRC) Incidence as influenced by factors such as population growth, aging, and epidemiological change. (A) China, (B) Taiwan (Province of China), (C) Japan, (D) ROK, (E) DPRK.

For EO‐CRC deaths, the effect of epidemiological changes differed from that on incidence. Except for DPRK (+35.25%), epidemiological changes in China (−206.76%), Taiwan (Province of China, −758.17%), Japan (−73.39%), and ROK (−173.78%) significantly reduced the mortality burden (Figure S5A–E, Table S3), with the negative effect on deaths exceeding the positive effect on incidence. Additionally, population factors suppressed EO‐CRC mortality in the four populations (excluding DPRK), whereas aging consistently increased deaths across all five populations.

3.10. Frontier Analysis

Frontier analysis for 2023 indicated that EO‐CRC ASRs in the five East Asian populations have substantial potential for improvement compared with populations with similar SDI, particularly Taiwan (Province of China), which exhibited the highest potential (Figure S6A–D).

3.11. Bayesian Age‐Period‐Cohort (BAPC) Prediction Analysis

Based on BAPC projections, the incidence and prevalence of EO‐CRC in all five East Asian populations are expected to increase through 2038 (Figure 5A,B). By 2038, ASIRs (per 100,000) are projected to reach 9.33 in China, 16.59 in Japan, 8.33 in ROK, 11.69 in DPRK, and 22.34 in Taiwan (Province of China), representing increases of 53.96%, 67.41%, 24.33%, 42.39%, and 5.32% compared with 2023, respectively (Figure 6A). Age‐standardized prevalence rates (ASPR) are also projected to rise across all five populations (Figure 5B; Tables S4–S8).

Trends and Forecasts of the burden of early‐onset colorectal cancer (EO‐CRC) across Five Countries of East Asia, Until 2038. (A) ASR of Incidence. (B) ASR of Prevalence. (C) ASR of Deaths. (D) ASR of DALYs. ASR: Age‐standardized rate, DALYs: Disability‐Adjusted Life Years.

Proportional contributions (%) of 11 risk factors to deaths from early‐onset colorectal cancer (EO‐CRC) in five East Asian populations. (A) Attributable fractions for 1990 and 2023. (B) Changes in Attributable Fractions (1990–2023).

DALYs and age‐standardized DALY rates (ASDR) are likewise projected to increase by 2038 (Figure 5D; Tables S3–S7), with ASDR rising to 141.62 in China, 185.43 in Japan, 95.18 in ROK, 256.90 in DPRK, and 271.40 in Taiwan (Province of China), corresponding to increases of 13.86%, 69.14%, 17.83%, 28.77%, and 76.13%, respectively. Projections of ASMR indicate declining trends in ROK and Taiwan (Province of China) from 2023 to 2038, whereas China, Japan, and DPRK show increasing trends; notably, despite declining crude mortality in Japan, its ASMR is projected to rise. Overall, these upward projections indicate a growing EO‐CRC burden in East Asia (Figure 5C; Tables S4–S8).

3.12. Analysis of Attributable Risk Factors

We analyzed 11 EO‐CRC attributable risk factors globally and in the five East Asian populations from 1990 to 2023. In 2023, the proportional contribution (%) showed that EO‐CRC deaths in China, Japan, ROK, and Taiwan were mainly driven by diet low in milk, diet low in whole grains, and diet high in red meat (Figure 6A). In DPRK, diet low in calcium (21.7%) was the predominant factor, markedly higher than in other populations and steadily increasing since 1990. Sex‐specific analysis indicated greater attribution to smoking and high alcohol use in males, and to diet low in calcium, diet low in milk, and low physical activity in females (Figure S7).

From 1990 to 2023, the mortality contribution of high body‐mass index increased markedly in all five East Asian populations (Figure 6B). In China, deaths attributable to diet high in processed meat (+198.6%), high body‐mass index (+95.8%), and smoking (+33.6%) rose substantially; in Japan, diet high in processed meat (+65%), high body‐mass index (+49.5%), and diet low in fiber (+54.4%) increased; in Taiwan (Province of China), diet high in processed meat (+117.7%), high body‐mass index (+119.8%), and high fasting plasma glucose (+88.2%) rose notably; in ROK, diet high in processed meat (+146.3%), high body‐mass index (+103.1%), and diet low in fiber (+47.8%) increased; in DPRK, high body‐mass index (+119.1%), diet low in fiber (+44.2%), and diet low in calcium (+36.9%) rose. Except for China, smoking‐ and alcohol‐attributable deaths declined in the other populations, whereas in China they increased.

Analysis of age‐standardized mortality rates (ASR) further confirmed these structural differences (Figure S8). In China, Japan, ROK, and Taiwan, the highest ASRs were attributable to a diet high in red meat, a diet low in milk, and a diet low in whole grains. In 2023, Taiwan and DPRK showed markedly higher mortality from these three dietary factors than the other populations, indicating a greater impact of a diet high in red meat, a diet low in milk, and a diet low in whole grains on EO‐CRC in these populations. Moreover, DPRK had the highest ASR for deaths attributable to a diet low in calcium (0.68 per 100,000) in East Asia, with an increasing trend, highlighting the severe contribution of low calcium to EO‐CRC mortality in DPRK.

4. Discussion

This study systematically analyzed the burden of EO‐CRC in the five East Asian populations from 1990 to 2023. Frontier analysis indicated that, compared with populations of similar SDI, EO‐CRC in East Asia still has substantial potential for improvement in prevention and control. In 2023, the region had 380,863 prevalent cases and 22,752 deaths, with China accounting for the highest number of cases and deaths, while Taiwan (Province of China) had the highest ASIR. Notably, although overall prevalence continues to rise across East Asia, deaths and ASMR declined in all populations except DPRK. SDI correlation analysis showed that when SDI exceeded 0.75, ASMR decreased markedly across the five populations, consistent with the 2021 global GBD results [22] likely reflecting improvements in healthcare, increased screening coverage, and better early diagnosis and treatment outcomes.

East Asian populations exhibit consistently high risk for colorectal cancer. Risk analysis indicates that the primary EO‐CRC–related factors in these populations are diet low in milk, diet low in whole grains, and diet high in red meat, whereas in DPRK, diet low in calcium predominates, differing markedly from Western populations [23]. Despite rapid economic development in East Asia over the past 30 years, dairy intake remains generally low, likely due to high lactose intolerance and the longstanding cultural practice of substituting soy milk for cow's milk [24, 25]. Milk consumption has been confirmed as a protective factor against colorectal cancer [26]. Decomposition analysis showed that epidemiological changes had a positive effect on EO‐CRC in all populations except China, suggesting increased exposure to risk factors among young East Asians. Over the past three decades, dietary patterns in East Asia have gradually Westernized, with increased consumption of red and processed meats, rising obesity rates, and decreased occupational physical activity due to rapid urbanization [27, 28]. These lifestyle and dietary factors are well‐established contributors to colorectal cancer risk, [29] and risk analysis indicates that deaths attributable to them have increased markedly, especially from processed meat intake and obesity. Collectively, these factors have driven the rising incidence of EO‐CRC in East Asia.

This study found that ASR of EO‐CRC was higher in males than in females across the five East Asian populations, consistent with previous reports [30]. The elevated male risk may be partly due to a higher prevalence of alcohol consumption [31] and smoking, [32] with risk analysis indicating greater male‐attributable deaths from these factors. Biological factors also contribute: estrogen modulates immune responses, reduces inflammation, and maintains a beneficial gut microbiota, thereby lowering EO‐CRC risk in young females [33]. Collectively, these factors result in a higher EO‐CRC burden in males. Age trends were consistent across all five populations, showing a cumulative age effect, suggesting that in East Asian countries with well‐developed healthcare, screening for EO‐CRC could reasonably begin at age 40 to improve early detection.

This study found that EO‐CRC in China exhibited a “two‐phase” trend, declining from 1990 to 2014 and rising sharply thereafter. The initial decline may partly reflect rapid expansion of cancer registries and early data quality fluctuations between 2000 and 2015; [34] although GBD 2023 has corrected for potential biases by incorporating higher‐quality data and model adjustments, [35] this trend should be interpreted cautiously. Decomposition analysis indicated that epidemiological changes overall suppressed EO‐CRC incidence, suggesting that the early ASR decline may relate to population characteristics and baseline risk exposure. Rapid economic growth since the 1990s [36] improved nutritional status, particularly calcium intake (mean 350–370 mg/d in 2012), [37] which may have buffered early risk (an additional ~300 mg/d can reduce CRC risk by ~8%) [38]. From the mid‐2010s, EO‐CRC incidence rebounded. APC analysis showed that despite an overall declining period effect, incidence risk increased after 2014–2018. Considering the temporal increase in red and processed meat consumption since the 1990s [39] and a 10–14 year latency, [40] the health impact became evident in the mid‐to‐late 2010s. Concurrent declines in physical activity and rising obesity likely contributed to the upward trend. Risk attribution analysis indicated that deaths related to processed meat intake and high BMI increased steadily from 1990 to 2023, while smoking‐ and alcohol‐related burdens rose slightly, suggesting lifestyle and metabolic factors as key drivers of EO‐CRC. Decomposition further showed that epidemiological changes suppressed deaths more than incidence, implying that reduced mortality reflects improved healthcare access, early diagnosis, and treatment rather than lower risk exposure. Overall, these findings highlight the need for dietary optimization and metabolic interventions to mitigate EO‐CRC risk among young populations in China.

This study showed rising ASIR of EO‐CRC in Japan, ROK, and Taiwan, while ASMR declined steadily, with the largest decrease observed in ROK. Decomposition analysis indicated that epidemiological changes positively influenced incidence but suppressed deaths in these populations, suggesting that in settings with relatively high healthcare accessibility, [41] improvements in early detection and treatment have played a key role in reducing mortality. Risk attribution analysis revealed marked increases in deaths attributable to high BMI and high processed meat intake in Japan, ROK, and Taiwan, with Taiwan also showing a prominent rise in deaths related to high fasting plasma glucose, indicating that adverse metabolic and dietary exposures among young East Asians may be driving continued EO‐CRC incidence. Notably, Taiwan has persistently had the highest ASIR and ASMR in East Asia. Despite broadly similar CRC screening policies, dietary habits, and economic development across Taiwan, ROK, and Japan, [41] the reasons for Taiwan's higher EO‐CRC incidence remain unclear, potentially involving lifestyle, environmental factors, population characteristics, or gene–environment interactions, but direct evidence is lacking and warrants further study. Additionally, in Taiwan, deaths attributable to diet low in milk, diet low in whole grains, and diet high in red meat remain high, highlighting the need for targeted dietary and metabolic interventions.

This study found that DPRK is the only East Asian population with continuously rising EO‐CRC ASIR and ASMR during the study period. Decomposition analysis indicated the strongest positive impact of epidemiological changes, while AAPC analysis showed the largest increases in period‐ and cohort‐specific incidence and mortality risk. These trends likely reflect persistent malnutrition, worsening high‐risk dietary exposures, and extremely limited screening and treatment access in DPRK. Unlike other East Asian populations, deaths attributable to low calcium were highest in DPRK and continued to rise, with the corresponding ASR markedly exceeding that of other populations, highlighting the severity of calcium deficiency. Limited evidence suggests chronic undernutrition among DPRK children and defectors, including multiple micronutrient and calcium deficiencies [42, 43]. Risk analysis also showed a rapid rise in high BMI–related deaths, indicating a dual burden of “undernutrition + increasing obesity,” a pattern common in low‐ to middle‐SDI countries [44, 45]. At the same time, DPRK lacks systematic EO‐CRC screening and early diagnosis capacity, whereas Fecal Occult Blood Test (FOBT) and colonoscopy have been shown to significantly reduce CRC mortality in 40–50‐year‐olds [46, 47]. The combination of accumulated high‐risk exposures and absent screening likely increases late‐stage diagnoses, driving sustained ASMR rises. Overall, DPRK exhibits a “dual nutritional burden + screening gap + treatment gap” pattern, producing an EO‐CRC trajectory markedly different from other East Asian populations.

Based on projections, the EO‐CRC burden in East Asia is expected to further increase by 2038, highlighting the need for tailored prevention and control strategies. Dietary interventions should focus on reducing red and processed meat intake while increasing consumption of fiber, fruits, vegetables, and milk. Health education, promotion of physical activity, and weight management programs are essential, particularly to mitigate metabolic risk among young populations. In China, Japan, ROK, and Taiwan, expanding CRC screening coverage—especially for those over 40 in Taiwan, which has the highest incidence—can facilitate early detection and treatment, reducing mortality. In DPRK, improving nutrition by increasing calcium, fiber, and dairy intake, strengthening basic healthcare services, expanding screening, and enhancing public awareness of early diagnosis and treatment are critical. Sex‐specific differences should also be addressed, as males face higher incidence and mortality, warranting targeted interventions. Overall, comprehensive public health strategies, combined with international collaboration and improved screening and treatment capacity, are needed to effectively reduce the EO‐CRC burden in East Asia.

The limitations of this study are as follows. First, although we systematically analyzed multiple East Asian populations, differences in cancer registry coverage and data quality may affect the completeness and accuracy of estimates. In particular, data for the DPRK in GBD 2023 are largely model‐based with limited primary surveillance data, resulting in greater uncertainty; therefore, conclusions regarding EO‐CRC incidence and mortality trends in DPRK should be interpreted cautiously. Second, in the BAPC projections, some estimates showed wide UIs, such as the age‐standardized incidence rate in Japan, indicating substantial variability. This uncertainty may arise from historical data fluctuations, model assumptions, and unpredictable future factors, potentially limiting the precision of burden projections. These uncertainties should be considered when interpreting results and informing public health strategies. Third, projections were based primarily on historical trends and did not fully account for potential major public health interventions, such as expanded screening coverage, changes in screening initiation age, updated dietary guidelines, or other policy changes. In addition, the COVID‐19 pandemic may have influenced EO‐CRC trends through disruptions in screening, healthcare access, and diagnostic delays. However, its independent impact could not be quantified in this study, and related trend changes should be interpreted with caution. Finally, although the APC model and Bayesian projections provide valuable insights into EO‐CRC trends in East Asia, future studies incorporating more high‐quality longitudinal data and comprehensive intervention assessments are needed to better characterize disease burden dynamics and support public health policymaking.

5. Conclusion

This study systematically analyzed the burden and risk factors of early‐onset colorectal cancer (EO‐CRC) in East Asia from 1990 to 2023. Overall, ASIR increased across the region, with China showing a slight early decline but rising after 2014. The increase in EO‐CRC incidence may be related to rising processed meat consumption and obesity rates in East Asia. Except for DPRK, ASMR declined regionally, likely reflecting improved healthcare access, early diagnosis, and treatment. EO‐CRC mortality was mainly driven by diet (low milk, low whole grains, and high red meat), while low calcium was the dominant risk factor in DPRK. Males exhibited higher incidence and mortality than females. China had the highest case counts, Taiwan the highest ASR, and DPRK showed a persistent upward trend. Projections suggest EO‐CRC burden will continue to increase. Public health strategies should focus on optimizing diet, controlling obesity and metabolic risks, expanding screening coverage, targeting high‐risk populations, and strengthening health education and international collaboration.

Author Contributions

B. Liu designed the study, wrote the original draft, and secured funding. L. Jin contributed to data analysis, manuscript review and editing, project administration, and supervision. J. Tang assisted with manuscript review and editing. C. Meng and J. Liao conducted the statistical analyses. All authors reviewed and approved the final manuscript.

Funding

This work was supported by Zhejiang Provincial Traditional Chinese Medicine Science and Technology Project (2024ZL231).

Ethics Statement

Our research involved a secondary evaluation of the publicly accessible GBD Study dataset, without primary data collection. Hence, no ethical approval was necessary.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Figure S1: Gender‐Stratified Number and Age‐Standardized Rate of early‐onset colorectal cancer (EO‐CRC) Burden in Five East Asian Countries(A) China; (B) Japan; (C) Taiwan (Province of China); (D) Republic of Korea; (E) Democratic People's Republic of Korea.

Figure S2: The Numbers and Rates of early‐onset colorectal cancer (EO‐CRC) in 1990 and 2023, stratified by age groups (20–29, 30–39, and 40–49 years), are shown for five East Asian countries/regions across four indicators: (A) Incidence, (B) Prevalence, (C) Deaths, and (D) Disability‐adjusted life years (DALYs).

Figure S3: APC for ASIR, ASPR, ASMR, and ASDR of EOCRC across Five Countries of East Asia between 1990 and 2023. An asterisk (*) denotes statistical significance at the p < 0.05. (A) ASR of incidence (ASIR). (B) ASR of prevalecne (ASPR). (C) ASR of deaths (ASMR). (D) ASR of DALYs. ASR: age‐standardied rate.

Figure S4: Burden of early‐onset colorectal cancer (EO‐CRC) Across Five Countries of East Asia by SDI. (A) ASR of incidence. (B) ASR of prevalecne. (C) ASR of deaths. (D) ASR of DALYs. ASR: age‐standardied rate, SDI Socio‐Demographic Index.

Figure S5: At the Five Countries of East Asia, changes in early‐onset colorectal cancer (EO‐CRC) Mortality as influenced by factors such as population growth, aging, and epidemiological change. (A)China, (B) Taiwan (Province of China), (C) Japan, (D) ROK, (E) DPRK.

Figure S6: Frontier analysis, shown by the solid black lines, examines how the Socio Demographic Index (SDI) relates to the Age‐Standardized Rate (ASR) in terms of incidence (A), prevalence (B), Mortality (C) and DALYs (D) with regard to early‐onset colorectal cancer (EO‐CRC). In graphs A–D, each dot stands for a particular country or territory in 2023.

Figure S7: Sex‐specific proportional contributions (%) of 11 risk factors to mortality from early onset colorectal cancer (EO‐CRC) in five East Asian countries.

Figure S8: Age‐standardized mortality rates (ASMR) attributable to 11 risk factors for early‐onset colorectal cancer (EO‐CRC) in five East Asian countries between 1990 and 2023.

CAM4-15-e71905-s002.pdf^{(11.7MB, pdf)}

Table S1: Numbers and Age‐standardized rates (ASR) of the burden for early‐onset colorectal cancer (EO‐CRC) by Sex in 1990 and 2023, as well as the average annual percentage change (AAPC) from 1990 to 2023.

Table S2: The counts, rates and AAPC of Burden for early‐onset colorectal cancer (EO‐CRC) in 1990 and 2023, by age groups(20–29,30–39 and 40–49 years), during 1990–2023.

Table S3: Changes in Incidence and Deaths number according to population‐level determinants and causes from 1990 to 2023.

Table S4: Age‐standardized rates of early‐onset colorectal cancer (EO‐CRC) burden in China, 1990–2023, and predictions up to 2038.

Table S5: Age‐standardized rates of early‐onset colorectal cancer (EO‐CRC) burden in Japan, 1990–2023, and predictions up to 2036.

Table S6: Age‐standardized rates of early‐onset colorectal cancer (EO‐CRC) burden in Taiwan(Province of China), 1990–2023, and predictions up to 2036.

Table S7: Age‐standardized rates of early‐onset colorectal cancer (EO‐CRC) burden in South Korea, 1990–2023, and predictions up to 2036.

Table S8: Age‐standardized rates of early‐onset colorectal cancer (EO‐CRC) burden in North Korea, 1990–2023, and predictions up to 2036.

CAM4-15-e71905-s001.docx^{(136.8KB, docx)}

Acknowledgements

Our thanks go out to the members of our research center for the inspiring conversations that took place.

Data Availability Statement

The data were obtained from the publicly available GBD database and can be accessed at https://vizhub.healthdata.org/gbd‐results/. The GBD encourages collaborators to publish regional analyses without a formal application, requiring only simple registration. Jiahao Tang is a GBD collaborator, and this study has been duly registered with the GBD.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Figure S7: Sex‐specific proportional contributions (%) of 11 risk factors to mortality from early onset colorectal cancer (EO‐CRC) in five East Asian countries.

Figure S8: Age‐standardized mortality rates (ASMR) attributable to 11 risk factors for early‐onset colorectal cancer (EO‐CRC) in five East Asian countries between 1990 and 2023.

CAM4-15-e71905-s002.pdf^{(11.7MB, pdf)}

Table S2: The counts, rates and AAPC of Burden for early‐onset colorectal cancer (EO‐CRC) in 1990 and 2023, by age groups(20–29,30–39 and 40–49 years), during 1990–2023.

Table S3: Changes in Incidence and Deaths number according to population‐level determinants and causes from 1990 to 2023.

Table S4: Age‐standardized rates of early‐onset colorectal cancer (EO‐CRC) burden in China, 1990–2023, and predictions up to 2038.

Table S5: Age‐standardized rates of early‐onset colorectal cancer (EO‐CRC) burden in Japan, 1990–2023, and predictions up to 2036.

Table S6: Age‐standardized rates of early‐onset colorectal cancer (EO‐CRC) burden in Taiwan(Province of China), 1990–2023, and predictions up to 2036.

Table S7: Age‐standardized rates of early‐onset colorectal cancer (EO‐CRC) burden in South Korea, 1990–2023, and predictions up to 2036.

Table S8: Age‐standardized rates of early‐onset colorectal cancer (EO‐CRC) burden in North Korea, 1990–2023, and predictions up to 2036.

CAM4-15-e71905-s001.docx^{(136.8KB, docx)}

Data Availability Statement

[cam471905-bib-0001] 1. Bray F., Laversanne M., Sung H., et al., “Global Cancer Statistics 2022: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries,” CA: A Cancer Journal for Clinicians 74, no. 3 (2024): 229–263. [DOI] [PubMed] [Google Scholar]

[cam471905-bib-0002] 2. The Lancet Gastroenterology Hepatology , “The Rise in Early‐Onset Colorectal Cancer: Now a Global Issue,” Lancet Gastroenterology & Hepatology 10, no. 2 (2025): 95. [DOI] [PubMed] [Google Scholar]

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PERMALINK

Burden and Forecast of Early‐Onset Colorectal Cancer (1990–2038) in Five East Asian Populations: A Systematic Analysis Based on the GBD 2023 Study

Lili jin

Jiahao Tang

Chunyang Meng

Jianhua liao

Baoqing Liu

ABSTRACT

Background

Methods

Results

Conclusions

1. Introduction

2. Methods

2.1. Data Source

2.2. ASR

2.3. Socio‐Demographic Index (SDI)

2.4. Joinpoint Regression Analysis

2.5. Age‐Period‐Cohort (APC) Analysis

2.6. Decomposition Analysis

2.7. Frontier Analysis

2.8. Bayesian Age‐Period‐Cohort (BAPC) Prediction

2.9. Statistical Analysis

3. Results

3.1. Incidence of EO‐CRC in the Five East Asian Populations

FIGURE 1.

FIGURE 2.

TABLE 1.

3.2. Prevalence of EO‐CRC in the Five East Asian Populations

3.3. Deaths of EO‐CRC in the Five East Asian Populations

3.4. DALYs Of EO‐CRC in the Five East Asian Populations

3.5. Descriptive Analysis by Gender and Age

3.6. Age‐Peroid‐Cohort (APC) Analysis

FIGURE 3.

3.7. Joinpoint Analysis

3.8. Correlation Analysis Between ASR and SDI in Five East Asian Populations

3.9. Decomposition Analysis

FIGURE 4.

3.10. Frontier Analysis

3.11. Bayesian Age‐Period‐Cohort (BAPC) Prediction Analysis

FIGURE 5.

FIGURE 6.

3.12. Analysis of Attributable Risk Factors

4. Discussion

5. Conclusion

Author Contributions

Funding

Ethics Statement

Consent

Conflicts of Interest

Supporting information

Acknowledgements

Data Availability Statement

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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