Trends and Drivers of Head and Neck Cancers in Older Adults Over 30 Years: A Population-Based Modelling Study

Abstract

Background

Head and neck cancers (HNCs) are a significant source of morbidity and contribute to severe functional impairments in older adults globally. Although largely preventable, inadequate mapping of their long-term epidemiological trends and determinants hinders the development of targeted prevention and rehabilitation strategies.

Methods

This study analyzed the global incidence and mortality of major HNCs, including nasopharyngeal cancer (NPC), lip and oral cavity cancer (LOCC), other pharyngeal cancer (OPC), and laryngeal cancer (LC) in older adults (60–89 years) from 1992 to 2021. Their temporal and future trends were assessed using Joinpoint regression BAPC models, respectively.

Results

Globally, 464,744 new cases and 303,207 deaths were reported among older adults in 2021. The long-term trends from 1992 to 2021 showed a slight increase in the age-standardized incidence rate (ASIR) and a significant decrease in the age-standardized mortality rate (ASMR). The global ASIR and ASMR for LOCC and OPC increased from 1992 to 2021. However, those for NPC and LC decreased. LOCC and LC were the most prevalent HNCs among older adults globally, followed by OPC and NPC. However, the burden of the four cancers varied across regions. The numbers of cases and deaths from the four HNCs are projected to continue increasing.

Conclusion

The global burden of head and neck cancers in older adults is increasing due to population growth and aging. This trend, particularly the notable rise in OPC, poses a significant challenge for countries with high and low-middle sociodemographic index scores, especially those in America and Europe. Tobacco and alcohol use remain the dominant modifiable risk factors. Addressing these factors is critical to reducing severe swallowing and communication impairments and mitigating the disproportionate burden borne by older adults.

Introduction

Head and neck cancer (HNC) is the sixth most common malignancy globally, and is responsible for more than 450,000 deaths annually. Its disease burden is significantly influenced by age, and is increasing due to the aging population.^1–5 The global incidence of HNCs has stabilized in recent years. However, their incidence and mortality rates among older adults continue to increase.^6–8 This trend is closely linked to the global demographic transition.⁹ United Nations data have been used to project that the global population of people older than 60 years will double to 2.1 billion by 2050, and this population will account for 80% of new cancer cases.¹⁰ However, the lack of systematic research on the epidemiologic characteristics, treatment patterns, and survival outcomes of older adults with HNCs has severely limited the development of precise prevention and treatment strategies.^11–13

Older patients with HNCs face unique clinical and social challenges. Survivors of cancers of the oral cavity, pharynx, nasosinus, salivary glands, and throat have impaired essential processes, that adversely affect vital activities such as breathing, mastication, salivation, deglutition, phonation, and sensory perception.^14–16 Physiologic decline, multiple comorbidities (such as cardiovascular disease and diabetes mellitus), and immune senescence significantly limit the use of standard treatment regimens, such as surgery, radiotherapy, and chemotherapy.^17,18 These limitations result in poorly tolerated treatments and increased risk of complications.^13,18,19 Social cognitive biases often result in the symptoms of older patients being mistaken for normal changes in aging, which delays diagnosis.^20,21 Existing GBD data analyses tend to focus on all age groups and lack in-depth stratification of older subgroups.^22,23 This has led to the neglect of disease heterogeneity (such as anatomical subtype distribution and risk factor differences) in this population. Historically, long-term tobacco use and heavy alcohol consumption have been established as the primary, traditional drivers of HNCs.^24,25 However, human papillomavirus (HPV) infection has increasingly emerged as a critical pathogenetic factor altering the global epidemiological landscape, notably driving the rising incidence of oropharyngeal cancers.²⁶ While widespread HPV vaccination is anticipated to significantly reduce the future burden of OPC in younger generations, its protective effect does not extend to the current older adult population, who remain highly susceptible.^27,28 Furthermore, dependable epidemiological research from several middle-income and low-income countries is also lacking.^29–32

To address these gaps, this study targets the core older demographic by specifically focusing on the age range of 60–89 years; individuals aged ≥90 years were excluded to minimize potential analytical biases arising from small sample sizes and less reliable cause-of-death registries in extreme longevity cohorts. Global estimates of the age-standardized incidence and death rates for four major head and neck cancers, including nasopharynx cancer (NPC), lip and oral cavity cancer (LOCC), other pharynx cancer (OPC), and larynx cancer (LC), for older adults over the past few decades can fill gaps in disease statistics. In-depth analyses of trends can enhance the understanding of the epidemiology of these diseases and promote medical practice. This will contribute to specific actions in response to the United Nations Decade of Action for Healthy Ageing.

The Global Burden of Disease, Injuries and Risk Factors Study (GBD) 2021 is a crucial resource for epidemiological investigations. This study uses GBD data to describe the burden of HNCs and analyze its trends in older adults. It also evaluates the current status of the disease in different regions and countries, highlights changes over time, and identifies age-specific risk factors (such as long-term tobacco exposure and alcohol intake). The findings of this study are expected to provide key evidence for optimizing early screening guidelines for HNC in older adults, developing age-adapted treatment guidelines, and achieving the global goal of healthy aging.

Method

Data Sources

This study focused on four major HNC subtypes—nasopharynx cancer (NPC), lip and oral cavity cancer (LOCC), larynx cancer (LC), and other pharynx cancer (OPC)—among older adults (aged 60–89 years), as defined by the Global Burden of Disease (GBD) study (eMethod 1). The mapping of these acronyms to GBD cause names, International Classification of Diseases, 11th Revision (ICD-11) codes, and GBD cause IDs is provided in eMethod 2. (https://icd.who.int/browse/2025-01/mms/en#1640200163). The statistics on the incidence, deaths, and disability-adjusted life years (DALYs) were obtained from the GBD study 2021 via the Global Health Statistics Exchange (GHDx) results tool. The GBD 2021 evaluated health loss attributable to 369 diseases, injuries, and disabilities and 87 risk factors across 204 countries and territories, positioning it as a vital resource for epidemiological research.³³ The study population comprised older adults aged 60–89 years.³⁴ The rates were expressed per 100,000 individuals, and the 95% uncertainty intervals (UIs) were determined based on the 2.5th– and 97.5th percentiles of 1,000 draws.³⁵ The sociodemographic index (SDI), which is an extensive evaluation of health-associated social and economic determinants, was computed using financial position, educational attainment, and fertility statistics for 204 countries and territories. All nations were classified into high, high-middle, middle, low-middle, and low quintiles based on the estimations.³⁶

Descriptive Analysis

This study elucidated the burden of four HNCs (NPC, LOCC, OPC, and LC) at the global, regional, and national levels. The age-standardized incidence (ASIRs) and age-standardized mortality rates (ASMRs) per 100,000 population were determined using the GBD standard population structure. The numbers of deaths and new cases, ASIR, and ASMR for the four HNCs were determined for the different sexes, age groups, SDI levels, regions, and countries for the period of 1992–2021. The older adults (aged 60 to 89 years) were categorized into six GBD age groups at 5-year intervals.³⁷ Their mean age (60–89 years) at incidence and mortality for the four HNCs was determined using the GBD-modeled incidence and mortality estimates. The average age of each age cohort was used to assign a distinct incidence/mortality age to each GBD age group. For example, the 60–64 age group was assigned an incidence/mortality age of 62 years. The ages of the different age groups within a given demographic were summed. This value was subsequently divided by the total number of cases and deaths within the same demographic to determine the average age at onset and death.³⁸ While assigning the midpoint (eg, 62 years for the 60–64 age group) assumes a symmetrical age distribution within each 5-year interval and may introduce minor calculation bias, this approach represents a standard demographic aggregation technique when individual-level exact ages are unavailable in grouped GBD data.

Trend Analysis

We performed Joinpoint regression analysis (Joinpoint Software version 5.4.0, National Cancer Institute) to examine the temporal trends of the incidence and mortality of HNCs from 1992 to 2021. This analysis identifies significant change points (joinpoints) in the data to model targeted trends. We calculated the Annual Percent Change (APC) and its 95% confidence interval (CI) for each segment between the joinpoints. The Average Annual Percent Change (AAPC), a weighted average of the APCs, was computed to summarize the overall trend across the entire period. Trends were classified as increasing or decreasing if the 95% CI of the APC or AAPC did not include zero or stable if otherwise. A detailed description of the Joinpoint model configuration and fitting criteria is provided in eMethod 3.^39,40 We categorized the global trends of incidence and deaths based on sex, age group, and SDI quintiles. We also presented the patterns at the regional and national levels. The approaches for determining the AAPC and APC described earlier were used to accomplish these tasks.

Decomposition Analysis

Decomposition analysis was conducted to elucidate the contributions of demographic and epidemiologic factors to the variations in the new and death cases of four HNCs over the past 30 year. The analysis accounted for the population count, age distribution, and epidemiologic shifts for each country.⁴¹ The number of cases in each region was determined using the following formula:

where incidence ay, py, ey represents the incidence count influenced by age distribution, population count, and incidence in year y; ai, y represents the percentage of persons within age group i among the n age groups in year y; py is the general population in year y; and ei, y represents the incidence for age group i in year y. The impact of each component on variations in the number of cases was determined by modifying one variable while maintaining the others. The approach for estimating mortality was the same as that for estimating incidence.

Risk Factor Analysis

The GBD 2021 database provides a comprehensive assessment of the impact of risk factor exposures on specific health outcomes.^42,43 This study summarizes the secondary risk factors for HNC, alcohol, and tobacco. The estimates for the DALYs attributable to alcohol and tobacco use were obtained directly from the Global Burden of Disease Study 2021 (GBD 2021). They were derived using the GBD comparative risk assessment framework, which calculates the population-attributable fractions. The population-attributable fraction represents the proportional reduction in the disease burden that would occur if exposure to a risk factor were reduced to a theoretical minimum risk exposure level. The exposure-response relationships for alcohol and tobacco with each cancer site were characterized using smooth spline models within a meta-regression framework in the GBD modeling. The number of knots (or the equivalent degrees of freedom) is the key parameter for the spline fit and controls the flexibility of the curve to fit the data.^28,44 Importantly, while other risk factors—such as human papillomavirus (HPV) infection, betel nut chewing, and occupational exposures—are critical drivers of HNC pathogenesis, they were not comprehensively quantified for all four HNC anatomical subtypes in the GBD 2021 framework. Therefore, our risk factor analysis is strictly limited to tobacco and alcohol, which represents a structural limitation of the available global dataset.

Predictive Analysis

We projected the future disease burden from 2022 to 2040 using the Bayesian age-period-cohort (BAPC) model.^45,46 To ensure epidemiological plausibility, the BAPC model applies second-order random walk (RW2) priors, assuming that age, period, and cohort effects evolve smoothly over time. The projections’ 95% uncertainty intervals similarly incorporate both sampling and modeling uncertainties. The model was validated by withholding the most recent data (training on data from 1992 to 2017 and predicting the data from 2018 to 2021). The low mean absolute percentage error (MAPE < 0.1) indicated good predictive performance. The final model, which was fitted to the entire dataset (1992–2021), was used to generate projections through 2040. All estimates are reported as 95% uncertainty intervals. A detailed description of the model specification, priors, and validation is provided in eMethod 4.⁴⁷

Results

Global Trends

There were 508445 incident cases and and 303,207 deaths from the four major HNCs among older adults globally in 2021 (Table 1) The global ASIR increased from 1992 to 2021 (AAPC of 0.07), while the ASMR decreased (AAPC of −0.55). The mean age at both diagnosis and death for this cohort increased slightly over the study period. (Table 1). Notably, the disease burden was highly subtype-dependent. However, their long-term trajectories diverged significantly: while the incidence and mortality rates for NPC and LC decreased substantially between 1992 and 2021, those for LOCC and OPC exhibited concerning continuous increases (Tables 1–3, S1–S4; and Figures 1–3).

Table 1.

Incidence and Death of Head and Neck Cancer from 1992 to 2021

	Incidence						Deaths
	1992		2021		1992–2021		1992		2021		1992–2021
	Case Number (95%UI)	Rate (per 100,000)	Case number (95%UI)	Rate (per 100,000)	AAPC (95% CI)	P	Case number (95%UI)	Rate (per 100,000)	Case Number (95%UI)	Rate (per 100,000)	AAPC (95% CI)	P
Global	235,416 (220,879 to 249,300)	46.76 (43.79 to 49.53)	508,445 (464,744 to 549,064)	47.75 (3.59 to 51.57)	0.07 (0.04 to 0.1)	<0.001	167,200 (155,148 to 179,390)	33.58 (31.17 to 36.02)	303,207 (275,432 to 329,516)	28.63 (25.98 to 31.11)	−0.55 (−0.58 to −0.53)	<0.001
Sex
Male	175,986 (164,413 to 188,557)	77.44 (72.23 to 82.99)	373,811 (338,603. to 408,485)	75.60 (68.40 to 82.59)	−0.08 (−0.11 to −0.06)	<0.001	126,004 (116,146 to 137,212)	56.68 (52.19 to 61.69)	222,527 (202,507 to 248,456)	46.16 (41.45 to 50.84)	−0.71 (−0.73 to −0.69)	<0.001
Female	59,430 (53,070 to 64,743)	21.70 (19.37 to 23.65)	134,634 (117,230 to 150,870)	23.60 (20.55 to 26.45)	0.29 (0.25 to 0.32)	<0.001	41,196 (36,022 to 45,752)	15.11 (13.21 to 16.79)	77,780 (67,172 to 88,857)	13.63 (11.77 to 15.57)	−0.35 (−0.38 to −0.32)	<0.001
Age group
60–64	72,368 (68,523 to 76,654)	43.52 (41.21to 46.09)	131,345 (121,275 to 141,590)	41.04 (37.89 to 44.24)	−0.23 (−0.27 to −0.18)	<0.001	47,640 (44,486 to 51,311)	28.65 (26.75 to 30.85)	70,942 (64,843 to 77,164)	22.17 (20.26 to 24.11)	−0.86 (−0.9 to −0.81)	<0.001
65–69	62,833 (59,260 to 66,478)	47.86 (45.14 to 50.66)	130,084 (120,119 to 140,631)	47.16 (43.55to50.98)	−0.07 (−0.13 to −0.02)	<0.001	42,417 (39,461 to 45,567)	32.31 (30.06 to 34.71)	72,772 (66,531 to 79,131)	26.38 (24.12 to 28.69)	−0.72 (−0.77 to −0.68)	<0.001
70–74	44,976 (42,266 to 47,479)	49.21 (46.24 to 51.94)	106,824 (98,710 to 115,216)	51.90 (47.96 to 55.97)	0.18 (0.16 to 0.2)	<0.001	32,359 (30,075 to 34,637)	35.40 (32.90 to 37.89)	62,978 (57,639 to 68,473)	30.60 (28.00 to 33.27)	−0.51 (−0.55 to −0.47)	<0.001
75–79	29,796 (27,928 to 31,488)	48.25 (45.23 to 50.99)	69,006 (63,103 to 74,475)	52.32 (47.85 to 56.47)	0.3 (0.27 to 0.33)	<0.001	22,773 (21,173 to 24,255)	36.88 (34.29 to 39.28)	44,037 (403,011 to 47,760)	33.39 (30.56 to 36.21)	−0.32 (−0.35 to −0.29)	<0.001
80–84	17,388 (15,790 to 18,518)	46.36 (42.10 to 49.37)	44,786 (39,415 to 48,264)	51.14 (45.00 to 55.11)	0.35 (0.29 to 0.4)	<0.001	14,738 (13,447 to 14,782)	39.29 (35.85 to 42.08)	32,343 (28,867 to 34,997)	36.92 (32.96 to 39.96)	−0.2 (−0.23 to −0.17)	<0.001
85–89	8056 (7112 to 8683)	48.63 (42.94 to 52.42)	26,399 (22,121 to 28,889)	57.74 (48.38 to 63.18)	0.6 (0.55 to 0.64)	<0.001	7272 (6505 to 7838)	43.90 (39.27 to 47.32)	20,134 (17,250 to 21,992)	44.04 (37.73 to 48.10)	0.02 (−0.05 to 0.08)	<0.001
Mean age	69.47		75.49		–		70.10		71.24		–
World region
Africa	7729 (6672 to 8739)	23.3 (20.09 to 26.38)	16,824 (14,349 to 19,377)	23.92 (20.46 to 27.47)	0.09 (0.08 to 0.11)	<0.001	7166 (6190 to 8129)	22.09 (19.06 to 25.09)	14,172 (12,083 to 16,337)	20.7 (17.72 to 23.78)	−0.22 (−0.23 to −0.21)	<0.001
America	42,687 (40,321 to 44,440)	53.92 (50.91 to 56.14)	77,715 (72,092 to 81,741)	45.64 (42.3 to 48.02)	−0.59 (−0.63 to −0.55)	<0.001	20,197 (19,116 to 20,981)	25.51 (24.13 to 26.51)	32,666 (30,224 to 34,470)	19.25 (17.8 to 20.32)	−0.99 (−1.05 to −0.94)	<0.001
Asia	112,196 (100,763 to 124,378)	45.18 (40.52 to 50.05)	302,530 (266,653 to 337,668)	49.08 (43.23 to 54.76)	0.28 (0.24 to 0.35)	<0.001	95,884 (85,470 to 107,112)	39.37 (35.06 to 43.96)	204,699 (180,701 to 228,505)	33.51 (29.58 to 37.4)	−0.54 (−0.56 to −0.51)	<0.001
Europe	72,270 (68,173 to 76,326)	51.96 (49.01 to 54.89)	110,586 (101,598 to 118,927)	55.24 (50.9 to 59.36)	0.19 (0.15 to 0.23)	<0.001	43,559 (41,346 to 45,614)	31.33 (29.73 to 32.81)	51,193 (47,132 to 54,807)	25.21 (23.29 to 26.97)	−0.76 (−0.79 to −0.72)	<0.001
SDI
Low SDI	10,649 (8652 to 12,855)	40.21 (32.68 to 48.51)	23,992 (19,788 to 28,745)	43.55 (35.95 to 52.09)	0.33 (0.28 to 0.38)	<0.001	10,014 (8148 to 12,115)	38.72 (31.51 to 46.83)	21,046 (17,357.86 to 25,205.34)	39.07 (32.28 to 46.71)	0.07 (0.01 to 0.13)	0.03
Low-middle SDI	37,385 (31,822 to 43,659)	51.31 (43.6 to 59.92)	97,839 (84,968 to 111,604)	58.34 (50.66 to 66.55)	0.47 (0.4 to 0.53)	<0.001	34,386 (29,176 to 40,330)	48.17 (40.8 to 56.49)	81,568 (70,834 to 93,308)	49.48 (42.96 to 56.6)	0.1 (0.05 to 0.15)	<0.001
Middle SDI	49,059 (44,569 to 53,701)	39.37 (35.73 to 43.08)	132,821 (116,775 to 150,067)	41.05 (36.06 to 46.35)	0.16 (0.13 to 0.19)	<0.001	43,407 (39,330 to 47,616)	35.68 (32.31 to 39.12)	90,597 (80,112 to 101,855)	28.45 (25.14 to 31.97)	−0.79 (−0.83 to −0.75)	<0.001
High-middle SDI	60,463 (56,041 to 65,268)	45.87 (42.44 to 49.55)	107,721 (94,737 to 121,448)	42.84 (37.67 to 48.29)	−0.21 (−0.27 to −0.14)	<0.001	44,038 (40,628 to 47,847)	33.95 (31.26 to 36.92)	58,174 (51,365 to 65,489)	23.24 (20.51 to 26.15)	−1.35 (−1.4 to −1.3)	<0.001
High SDI	77,588 (73,030 to 81,557)	53.27 (50.16 to 56)	145,571 (132,889 to 15,5454)	55.01 (50.44 to 58.67)	0.12 (0.08 to 0.15)	<0.001	35,149 (33,046to 36,862)	23.99 (22.57 to 25.17)	51,513 (46,870 to 54,978)	19.08 (17.45 to 20.34)	−0.79 (−0.82 to −0.76)	<0.001

Abbreviations: AAPC, average annual percentage change; UI, uncertainty interval; CIs, Confidence Intervals.

Table 2.

Incidence of Head and Neck Cancers from 1992 to 2021

		Incidence
		1992		2021		1992–2021
		Case Number (95%UI)	Rate (per 100,000)	Case Number (95%UI)	Rate (per 100,000)	AAPC (95CI)	P
Larynx cancer	Global	77,795 (73,394 to 82,011.68)	15.35 (14.46 to 16.19)	131,390 (121,342 to 142,128)	12.30 (11.35 to 13.31)	−0.76 (−0.85 to −0.68)	<0.001
	Sex
	Male	67,534 (63,792 to 71,542)	29.70 (27.99 to 31.49)	112,577 (103,396 to 122,280)	22.74 (20.84 to 24.70)	−0.91 (−0.99 to −0.83)	<0.001
	Female	10,262 (8558 to 11,235)	3.73 (3.11 to 4.08)	18,813 (15,629 to 21,994)	3.30 (2.74 to 3.85)	−0.41 (−0.52 to −0.30)	<0.001
	SDI
	Low SDI	3191 (2536 to 3955)	11.98 (9.50 to 14.85)	5926 (4987 to 6980)	10.68 (8.98 to 12.57)	−0.35 (−0.48 to −0.21)	<0.001
	Low-middle SDI	10,042 (8437 to 11,981)	13.77 (11.55 to 16.42)	21,665 (19,164 to 24,794)	12.85 (11.36 to 14.72)	−0.19 (−0.50 to 0.12)	0.223
	Middle SDI	14,532 (13,189 to 15,830)	11.67 (10.57 to 12.70)	35,587 (31,427 to 40,364)	10.96 (9.67 to 12.42)	−0.20 (−0.36 to −0.04)	0.013
	High-middle SDI	23,833 (22,468 to 25,299)	17.92 (16.86 to 19.05)	33,972 (30,096 to 38,096)	13.48 (11.94 to 15.12)	−0.96 (−1.18 to −0.74)	<0.001
	High SDI	26,086 (24,669 to 27,376)	17.97 (17.00 to 18.86)	34,070 (31,372 to 36,191)	12.99 (12.00 to 13.79)	−1.15 (−1.29 to −1.02)	<0.001
Lip and oral cavity cancer	Global	97,491 (92,105 to 102,093)	19.64 (18.50 to 20.58)	240,933 (219,329 to 258,377)	22.75 (20.68 to 24.40)	0.51 (0.44 to 0.59)	<0.001
	Sex
	Male	63,813 (60,104 to 67,592)	28.60 (26.88 to 30.30)	154,687 (138,866 to 168,207)	31.60 (28.35 to 34.36)	0.36 (0.27 to 0.44)	<0.001
	Female	33,678 (30,961 to 35,915)	12.37 (11.35 to 13.19)	86,246 (76,297 to 93,944)	15.12 (13.37 to 16.47)	0.70 (0.60 to 0.80)	<0.001
	SDI
	Low SDI	4830 (4077. to 5591)	18.66 (15.75 to 21.62)	12,008 (10,047 to 14,142)	22.19 (18.56 to 26.10)	0.64 (0.53 to 0.75)	<0.001
	Low-middle SDI	17,977 (15,694 to 20,414)	25.10 (21.84 to 28.52)	50,867 (44,078 to 57,553)	30.68 (26.59 to 34.71)	0.72 (0.58 to 0.86)	<0.001
	Middle SDI	18,004 (16,612 to 19,406)	14.77 (13.59 to 15.93)	62,527 (55,196 to 69,848)	19.51 (17.21 to 21.79)	0.97 (0.84 to 1.10)	<0.001
	High-middle SDI	20,898 (19,635 to 22,131)	16.11 (15.10 to 17.08)	44,956 (40,025 to 49,683)	17.96 (15.98 to 19.84)	0.41 (0.15 to 0.66)	0.002
	High SDI	35,676 (33,477 to 37,491)	24.35 (22.86 to 25.59)	70,367 (63,681 to 75,133)	26.20 (23.85 to 27.92)	0.26 (0.15 to 0.37)	<0.001
Nasopharynx cancer	Global	26,732 (24,198 to 29,476)	5.24 (4.75 to 5.78)	40,963 (35,745 to 46,880)	3.82 (3.34 to 4.37)	−1.10 (−0.94 to −1.25)	<0.001
	Sex
	Male	18,069 (15,848 to 20,663)	7.81 (6.85 to 8.92)	29,819 (25,295 to 35,335)	5.96 (5.06 to 7.05)	−0.95 (−1.09 to −0.81)	<0.001
	Female	8663 (7577 to 9829)	3.14 (2.74 to 3.56)	11,144 (9520 to 12,955)	1.95 (1.67 to 2.27)	−1.65 (−1.85 to −1.45)	<0.001
	SDI
	Low SDI	1113 (894 to 1353)	4.05 (3.25 to 4.93)	1840 (1490 to 2272)	3.25 (2.64 to 4.01)	−0.73 (−1.02 to −0.44)	<0.001
	Low-middle SDI	2970 (2500 to 3485)	3.97 (3.34 to 4.66)	5590 (4931 to 6411)	3.28 (2.89 to 3.76)	−0.61 (−0.92 to −0.30)	<0.001
	Middle SDI	10,581 (9334 to 11,924)	8.30 (7.32 to 9.34)	15,799 (13,413 to 18,586)	4.83 (4.10 to 5.67)	−1.87 (−2.00 to −1.73)	<0.001
	High-middle SDI	8647 (7319 to 10,268)	6.57 (5.56 to 7.80)	12,877 (10,181 to 16,244)	5.10 (4.04 to 6.43)	−0.92 (−1.21 to −0.63)	<0.001
	High SDI	3409 (3205 to 3600)	2.36 (2.22 to 2.49)	4835 (4333 to 5318)	1.86 (1.67 to 2.04)	−0.84 (−1.02 to −0.66)	<0.001
Other pharynx cancer	Global	33,398 (31,182 to 35,719)	6.52 (6.08 to 6.97)	95,159 (88,328 to 101,679)	8.87 (8.23 to 9.48)	1.08 (0.9 to 1.25)	<0.001
	Sex
	Male	26,570 (24,670 to 28,760)	11.34 (10.53 to 12.28)	76,727 (71,046 to 82,663)	15.30 (14.15 to 16.49)	1.04 (0.83 to 1.24)	<0.001
	Female	6828 (5973 to 7764)	2.48 (2.16 to 2.82)	18,432 (15,784 to 21,977)	3.23 (2.77 to 3.85)	0.93 (0.69 to 1.16)	<0.001
	SDI
	Low SDI	1515 (1146 to 1955)	5.52 (4.17 to 7.11)	4218 (3263 to 5350)	7.44 (5.76 to 9.42)	1.03 (0.76 to 1.30)	<0.001
	Low-middle SDI	6397 (5192 to 7779)	8.48 (6.87 to 10.32)	19,718 (16,795 to 22,846)	11.52 (9.81 to 13.36)	1.07 (0.60 to 1.53)	<0.001
	Middle SDI	5943 (5434 to 6542)	4.64 (4.24 to 5.11)	18,908 (16,739 to 21,268)	5.75 (5.09 to 6.46)	0.77 (0.54 to 1.00)	<0.001
	High-middle SDI	7085 (6619 to 7570)	5.26 (4.91 to 5.63)	15,916 (14,435 to 17,425)	6.30 (5.71 to 6.90)	0.51 (0.24 to 0.79)	<0.001
	High SDI	12,418 (11,678 to 13,090)	8.59 (8.08 to 9.06)	36,300 (33,503 to 38,812)	13.96 (12.92 to 14.92)	1.71 (1.46 to 1.96)	<0.001

Abbreviations: AAPC, average annual percentage change; UI, uncertainty interval; CIs, Confidence Intervals.

Table 3.

Mortality of Head and Neck Cancers from 1992 to 2021

		Mortality
		1992		2021		1992–2021
		Case Number (95%UI)	Rate (per 100,000)	Case Number (95%UI)	Rate (per 100,000)	AAPC (95% CI)	P
Larynx cancer	Global	65,028 (57,242 to 76,745)	11.22 (10.44 to 11.97)	80,507 (74,184 to 87,206)	7.60 (6.99 to 8.23)	−1.33 (−1.43 to −1.22)	<0.001
	Sex
	Male	48,582 (45,417 to 52,102)	22.05 (20.57 to 23.66)	69,048 (63,496 to 75,175)	14.21 (13.05 to 15.47)	−1.50 (−1.59 to −1.41)	<0.001
	Female	7337 (5795 to 8208)	2.68 (2.12 to 3.00)	11,460 (9287 to 13,710)	2.01 (1.63 to 2.40)	−1.00 (−1.17 to −0.84)	<0.001
	SDI
	Low SDI	3168 (2523 to 3917)	12.20 (9.70 to 15.10)	5586 (4713 to 6557)	10.32 (8.70 to 12.12)	−0.55 (−0.71 to −0.39)	<0.001
	Low-middle SDI	9768 (8191 to 11,680)	13.71 (11.48 to 16.39)	19,279 (16,985 to 22,182)	11.68 (10.28 to 13.44)	−0.56 (−0.93 to −0.19)	0.003
	Middle SDI	13,042 (11,822 to 14,186)	10.80 (9.78 to 11.74)	24,603 (21,918 to 27,592)	7.74 (6.89 to 8.68)	−1.14 (−1.29 to −0.98)	<0.001
	High-middle SDI	17,604 (16,587 to 18,744)	13.50 (12.69 to 14.40)	18,766 (16,807 to 20,823)	7.49 (6.71 to 8.32)	−2.01 (−2.28 to −1.74)	<0.001
	High SDI	12,248 (11,590 to 12,824)	8.35 (7.90 to 8.74)	1214 (11,183 to 12,913)	4.51 (4.16 to 4.78)	−2.12 (−2.23 to −2.01)	<0.001
Lip and oral cavity cancer	Global	58,695 (55,095 to 62,093)	11.96 (11.20 to 12.65)	126,865 (114,590 to 136,814)	12.04 (10.68 to 12.99)	0.03 (−0.05 to 0.10)	0.497
	Sex
	Male	38,923 (36,261 to 41,884)	17.78 (16.54 to 19.13)	82,122 (72,590 to 90,084)	16.94 (14.99 to 18.57)	−0.17 (−0.28 to −0.05)	0.005
	Female	19,771 (18,018 to 21,344)	7.30 (6.65 to 7.89)	44,743 (39,538 to 49,302)	7.84 (6.93 to 8.64)	0.25 (0.14 to 0.35)	<0.001
	SDI
	Low SDI	4133 (3516 to 4782)	16.45 (13.99 to 19.06)	9485 (7957 to 11,137)	18.01 (15.13 to 21.12)	0.33 (0.20 to 0.45)	<0.001
	Low-middle SDI	15,080 (13,156 to 17,153)	21.57 (18.75 to 24.55)	38,100 (33,050 to 43,097)	23.45 (20.34 to 26.52)	0.31 (0.10 to 0.52)	0.004
	Middle SDI	13,635 (12,556 to 14,710)	11.52 (10.59 to 12.44)	36,951 (32,813 to 41,079)	11.73 (10.40 to 13.04)	0.07 (−0.09 to 0.22)	0.391
	High-middle SDI	12,072 (11,391 to 12,685)	9.47 (8.91 to 9.97)	20,269 (18,146 to 22,266)	8.13 (7.27 to 8.93)	−0.51 (−0.85 to −0.17)	0.003
	High SDI	13,705 (12,846 to 14,310)	9.32 (8.74 to 9.73)	21,946 (19,804 to 23,321)	8.03 (7.30 to 8.52)	−0.51 (−0.73 to −0.30)	<0.001
Nasopharynx cancer	Global	27,578 (24,982 to 30,436)	5.46 (4.95 to 6.03)	36,427 (32,240 to 41,096)	3.42 (3.02 to 3.86)	−1.61 (−1.74 to −1.48)	<0.001
	Sex
	Male	18,481 (16,216 to 21,133)	8.13 (7.13 to 9.28)	25,879 (22,398 to 30,176)	5.24 (4.54 to 6.10)	−1.52 (−1.68 to −1.36)	<0.001
	Female	9098 (7974 to 10,309)	3.31 (2.90 to 3.75)	10,548 (9109 to 12,115)	1.85 (1.60 to 2.12)	−2.03 (−2.25 to −1.81)	<0.001
	SDI
	Low SDI	1194 (960 to 1450)	4.42 (3.55 to 5.37)	1982 (1602 to 2452)	3.56 (2.88 to 4.39)	−0.74 (−0.95 to −0.53)	<0.001
	Low-middle SDI	3190 (2687 to 3745)	4.33 (3.65 to 5.09)	6010 (5301 to 6890)	3.57 (3.15 to 4.09)	−0.62 (−0.92 to −0.32)	<0.001
	Middle SDI	11,144 (9842 to 12,567)	8.90 (7.87 to 10.02)	14,302 (12,305 to 16,600)	4.44 (3.81 to 5.14)	−2.40 (−2.54 to −2.27)	<0.001
	High-middle SDI	8953 (7619 to 10,615)	6.89 (5.86 to 8.16)	10,149 (8253 to 12,581)	4.04 (3.29 to 5.00)	−1.90 (−2.21 to −1.58)	<0.001
	High SDI	3084 (2893 to 3265)	2.12 (1.99 to 2.25)	3962 (3536 to 4366)	1.49 (1.33 to 1.64)	−1.24 (−1.43 to −1.05)	<0.001
Other pharynx cancer	Global	25,008 (22,996 to 27,189)	4.93 (4.53 to 5.36)	59,407 (54,417 to 64,401)	5.57 (5.10 to 6.04)	0.42 (0.28 to 0.55)	<0.001
	Sex
	Male	20,018 (18,251 to 22,092)	8.72 (7.95 to 9.62)	48,377 (44,023 to 53,021)	9.77 (8.88 to 10.70)	0.39 (0.25 to 0.52)	<0.001
	Female	4991 (4236 to 5892)	1.82 (1.55 to 2.15)	11,030 (9239 to 13,730)	1.93 (1.61 to 2.41)	0.22 (0.04 to 0.40)	0.014
	SDI
	Low SDI	1519 (1150to 1966)	5.64 (4.28 to 7.30)	3993 (3086 to 5059)	7.18 (5.56 to 9.08)	0.84 (0.56 to 1.12)	<0.001
	Low-middle SDI	6348 (5142 to 7751)	8.56 (6.92 to 10.46)	18,179 (15,498 to 21,139)	10.79 (9.20 to 12.55)	0.80 (0.41 to 1.20)	<0.001
	Middle SDI	5587 (5111 to 6153)	4.46 (4.07 to 4.91)	14,741 (13,076 to 16,584)	4.54 (4.03 to 5.11)	0.08 (−0.05 to 0.22)	0.22
	High-middle SDI	5410 (5030 to 5803)	4.09 (3.80 to 4.39)	8991 (8159 to 9820)	3.57 (3.24 to 3.90)	−0.48 (−0.89 to −0.07)	0.023
	High SDI	6112 (5718 to 6463)	4.21 (3.93 to 4.45)	13,441 (12,347 to 14,379)	5.06 (4.66 to 5.41)	0.59 (0.38 to 0.81)	<0.001

Abbreviations: AAPC, average annual percentage change; UI, uncertainty interval; CIs, Confidence Intervals.

Figure 1.

The global burden of head and neck cancers among older adults (60–89 years), 1992–2021. The figure presents the age-standardized rates and counts for incidence and mortality of four head and neck cancers (A) nasopharynx cancer (NPC), lip and oral cavity cancer (LOCC), other pharynx cancer (OPC), and larynx cancer (LC) combined. (A) Trends in the age-standardized incidence rate (ASIR) per 100,000 population. (B) Trends in the number of new cases. (C) Trends in the age-standardized mortality rate (ASMR) per 100,000 population. (D) Trends in the number of deaths. Shaded areas represent the 95% uncertainty intervals. Data source: Global Burden of Disease Study 2021. Solid lines represent the point estimates. Shaded areas represent the 95% uncertainty intervals (UIs).

Figure 2.

Global trends in the incidence of head and neck cancers among older adults (60–89 years) from 1992 to 2021, analyzed by joinpoint regression. Trends are presented for (A) nasopharynx cancer (NPC), (B) lip and oral cavity cancer (LOCC), (C) other pharynx cancer (OPC), and (D) larynx cancer (LC). The solid line segments represent the fitted trends from the joinpoint model, with each uniquely colored segment indicating a period of distinct annual percent change (APC). The years identified as significant joinpoints are marked with lines and labeled.

Figure 3.

Global trends in the mortality of head and neck cancers among older adults (60–89 years) from 1992 to 2021, analyzed by joinpoint regression. Trends are presented for (A) nasopharynx cancer (NPC), (B) lip and oral cavity cancer (LOCC), (C) other pharynx cancer (OPC), and (D) larynx cancer (LC). The solid line segments represent the fitted trends from the joinpoint model, with each uniquely colored segment indicating a period of distinct annual percent change (APC). The years identified as significant joinpoints are marked with lines and labeled.

Global Trends by Sex

The global burden of these four HNCs is greater in older males than in older females. However, their temporal trajectories diverged significantly over the 30-year period. The ASIR for older men decreased (AAPC:-0.08) but increased for older women (AAPC: 0.29). The ASMR decreased for both older men and older women, but the decrease was more pronounced for the former (Tables 1–3).

The increase in LOCC incidence has been more pronounced in females (AAPC: 0.70) than in males (AAPC: 0.36). The LOCC mortality rate increased for females (AAPC: 0.25) but decreased for males (AAPC:- 0.17).

The increases in the incidence and mortality rates for men (AAPCs: 1.04 and 0.39, respectively) were significantly higher than those for women (AAPCs: 0.93 and 0.22, respectively) for OPC. For cancers with declining trends (NPC and LC), both sexes experienced reductions, though the incidence and mortality of LC decreased much more rapidly in men. Detailed joinpoint inflection years by gender are provided in Table S5. (Tables 2 and 3).

Joinpoint regression analysis revealed certain years marked by significant changes in the global death and incidence rates based on gender (Table S5).

Global Trends by Age Group

The ASIR and ASMR for the four HNCs increased with age, indicating a higher disease burden in the older age groups (Table 1). The highest incidences of NPC and LOCC were observed in the 65–69 years (4.23) and 85–89 years (35.15) age groups, respectively. The highest incidences of OPC and LC were observed in the 70–74 years age group (OPC, 9.81; LC, 13.69). The mortality rates for these four HNCs were highest among the individuals aged 85–89 years (NPC, 4.17; LOCC, 22.91; OPC, 6.17; LC, 10.78). For these four HNCs, both the incidence and mortality rates became more pronounced with age if there was an increasing trend, and less pronounced with age if there was a decreasing trend (Tables S1 and S2, Figures S1 and S2).

Joinpoint regression analysis revealed specific years marked by substantial shifts in global incidence and death rates by age (Table S6).

Global Trends by SDI Quintiles

The disease burden exhibited distinct socioeconomic patterns. In 2021, high and high-middle SDI regions reported the highest ASIRs across all four cancer types (eg, OPC and LOCC in high-SDI; NPC and LC in high-middle SDI). However, the highest ASMRs were predominantly concentrated in low-middle and middle SDI regions, highlighting a critical disparity between cancer incidence and survival outcomes. The greatest reductions in the incidence and mortality of LC (incidence, AAPC: −1.15; mortality, AAPC: −2.12) and NPC (incidence, AAPC:-1.87; mortality, AAPC:-2.40) were observed in the high-SDI and middle-SDI regions, respectively, between 1992 and 2021. The fastest increasing trends in the ASIR and ASMR were observed in the high (AAPC: 1.71) and low (AAPC: 0.84) SDI regions, respectively. The fastest increasing trends in the incidence and mortality of LOCC (AAPCs: 0.97 and 0.33, respectively) were observed in the middle and low SDI regions (Tables 2 and 3).

Joinpoint regression analysis identified the years with the most significant changes in the global incidence and mortality rates by SDI quintile (Table S7).

Regional Trends

The regional burden of the four HNCs exhibited distinct geographical patterns in 2021. Europe had the highest ASIR and ASMR for both OPC and LC. Asia had the highest ASIR and ASMR for NPC and LOCC. The most substantial reductions in the ASIR and ASMR of NPC were observed in Asia (incidence, AAPC: −1.59; mortality, −2.21) between 1992 and 2021. The most notable increases in the ASIR (AAPC: 0.98) and ASMR (AAPC: 0.17) for LOCC were observed in Asia. The most notable decreases in the ASIR (AAPC: −0.55) and ASMR (AAPC: −0.81) were observed in America. The greatest increases in the ASIR and ASMR for OPC were observed in Europe (incidence, AAPC: 1.79; mortality, 0.68). The ASMR for OPC is increasing globally, but it has decreased significantly in America (AAPC: −0.24). The ASIR of LC decreased the most in the Americas (AAPC: −1.22) and Europe (AAPC: −1.83).

The notable inflection points for the incidence and mortality of the four HNCs in the four world regions from 1992 to 2021 were also identified using joinpoint regression analysis (Figures S5 and S6, Table S8).

National Trend

The ASIRs and ASMRs for the four HNCs in older adults varied considerably across the 204 countries and territories (Figures 4 and 5, S3 and S4). When analyzing age-standardized rates, Malaysia and Palau reported the highest ASIRs and ASMRs for NPC and LOCC, respectively. In contrast, European nations, specifically Hungary and Monaco, experienced the peak rates for OPC and LC. However, when evaluating the absolute burden—which is heavily influenced by demographic size—China and India emerged as the most affected nations. China reported the highest absolute number of incident cases and deaths for NPC and LC, whereas India accounted for the vast majority of cases and deaths for LOCC and OPC. The greatest substantial increases in the estimated ASIR and ASMR for LOCC and OPC were observed in Cabo Verde (Tables S9–S20).

Figure 4.

Global spatial distribution of the average annual percent change (AAPC) in the incidence of head and neck cancers among older adults (60–89 years), 1992–2021. World maps depict the country-level AAPC trends for: (A) Nasopharynx cancer (NPC), (B) Lip and oral cavity cancer (LOCC), (C) Other pharynx cancer (OPC), (D) Larynx cancer (LC). The color gradient represents the magnitude and direction (increasing or decreasing) of the AAPC over the study period. The color gradient represents the magnitude and direction of the AAPC. Countries shaded in grey indicate where data were not available.

Figure 5.

Global spatial distribution of the average annual percent change (AAPC) in the mortality of head and neck cancers among older adults (60–89 years), 1992–2021. World maps depict the country-level AAPC trends for: (A) Nasopharynx cancer (NPC), (B) Lip and oral cavity cancer (LOCC), (C) Other pharynx cancer (OPC), (D) Larynx cancer (LC). The color gradient represents the magnitude and direction (increasing or decreasing) of the AAPC over the study period. The color gradient represents the magnitude and direction of the AAPC. Countries shaded in grey indicate where data were not available.

The notable inflection points for the incidence and deaths of the four HNCs across 204 countries from 1992 to 2021 were identified using joinpoint regression analysis (Figures S5 and S6, Tables S16–S19).

The numbers of cases and deaths have significantly increased globally over the past 30 years. Decomposition analyses revealed the relative effects of population aging, population growth, and variations in the incidence and mortality of the four HNCs across different locations. Population growth was the main factor responsible for the increase in the numbers of cases and deaths from four HNCs between 1992 and 2021 (Figures 6 and S7, Tables S21–S23). The numbers of cases and deaths from LOCC were most affected by ageing. The impact of aging on HNCs was more pronounced in the Western Pacific region (Figure S7).

Figure 6.

Decomposition analysis of the changes in incidence and mortality of head and neck cancers among older adults (60–89 years) from 1992 to 2021. The analysis quantifies the contributions of three factors to the total change in case numbers: epidemiological change (yellow bars), population aging (green bars), and population growth (dark blue bars). Results are shown at the global level and by Socio-demographic Index (SDI) quintiles. (A–D) Decomposition of the change in incidence cases for (A) nasopharynx cancer (NPC), (B) lip and oral cavity cancer (LOCC), (C) other pharynx cancer (OPC), and (D) larynx cancer (LC). (E–H) Decomposition of the change in death cases for (E) nasopharynx cancer (NPC), (F) lip and oral cavity cancer (LOCC), (G) other pharynx cancer (OPC), and (H) larynx cancer (LC).

Analysis of Risk Factors

The DALYs attributable to alcohol use and smoking for NPC, LOCC, and LC decreased over the study period (Figure 7). However, the DALYs for OPC in the low-middle SDI region increased, although the uncertainty intervals for this trend should be noted. The DALYs for HNCs were positively associated with higher SDI. They increased for laryngeal cancer with higher SDI before decreasing at an SDI of 0.8 (Figures S8–11 and Table S24).

Figure 7.

Trends in disability-adjusted life years (DALYs) attributable to alcohol use and tobacco smoking among older adults (60–89 years) at the global level, 1992–2021. Data are from the GBD 2021 comparative risk assessment framework. (A) Nasopharynx cancer (NPC). (B) Lip and oral cavity cancer (LOCC). (C) Other pharynx cancer (OPC); note the high uncertainty associated with the upward trend in low-middle SDI regions. (D) Larynx cancer (LC). Solid lines represent the temporal trends of attributable DALYs. Shaded areas represent the 95% uncertainty intervals (UIs).

Predictions of Incidence and Deaths

The new cases and deaths from the four HNCs are projected to increase for both females and males until 2040 (Figures S12 and S13). Our projections indicate that the number of new cases of NPC, LOCC, OPC, and LC will be 69,346 (5247–135,107), 443,193 (190,045–696,341), 166,646 (35,757–297,535), and 206,283 (94,270–318,296), respectively, by 2040. The corresponding numbers of deaths will be 57,868 (5425–111,424), 219,177 (98,848–339,505), 102,090 (30,826–173,354), and 116,694 (54,149–179,239), respectively (Table S25). The age-standardized incidence for NPC (AAPC: 0.07), LOCC (AAPC: 0.36), and OPC (AAPC: 0.83) are projected to increase, but that for LC (AAPC:-0.12) is projected to decrease until 2040. The ASMRs for LOCC (AAPC: 0.15) and OPC (AAPC: 0.60) are expected to increase, but those for NPC (AAPC:-0.18) and LC (AAPC:-0.35) are expected to decrease until 2040.

Discussion

This study involved a thorough assessment of the incidence and mortality rate of NPC, LOCC, OPC and LC among older adults (aged 60–89 years). It also investigated heir temporal trends, risk factors, and global predictions and performed decomposition analyses. Our findings are largely consistent with recent large-scale global cancer estimates and epidemiological analyses. GLOBOCAN 2022 reported approximately 20.0 million new cancer cases and 9.7 million cancer and cancer deaths worldwide in 2022, highlighting the continuous rise of the global cancer burden and the key role that demographic growth and population ageing play in determining future cancer control priorities.¹ The IARC/WHO Global Cancer Observatory also offers an independent external reference for the burden of major HNC-related cancer sites, noting a heavy global burden of lip and oral cavity cancer, nasopharyngeal cancer, laryngeal cancer, and oropharyngeal cancer in 2022. These estimates are mostly in line with what we observed: LOCC and LC are still major sources of HNC burden in older adults, while NPC and pharyngeal cancers have clear geographic clustering traits. Specifically, GLOBOCAN 2022 found Asia contributed to most of the global NPC cases and deaths, which matches our conclusion that Asia and China face a notably high NPC burden. A large 2019 GBD analysis covering adult lip, oral, and pharyngeal cancers across 204 countries and regions also found obvious inequalities linked to region, country and SDI, alongside the considerable impact of tobacco and alcohol-related risk factors.⁴⁸ Our study does not conflict with existing large-scale research results; it actually expands on these observations by focusing specifically on adults aged 60–89 years with the GBD 2021 framework, proving that population growth and ageing keep pushing up the absolute HNC burden in older age groups, and may add more difficulty to prevention work, treatment scheme formulation and functional rehabilitation. The key findings are as follows. First, the global age standardized incidence and mortality rates of NPCs and LCs in older adults decreased between 1992 to 2021. However, those of lip and oral cavity and oropharyngeal cancers increased. These trends, which are consistent with those reported in previous studies, varied over time and across regions.^49,50 Secondly, the decreases in the age-standardized incidence and mortality rate of these cancers became less apparent with age, whereas the increases became more apparent. Third, the effect of smoking on DALYs for these cancers decreased over time, but the effect of alcohol use increased annually in low and low-middle SDI areas. Fourth, the numbers of cases and deaths are projected to increase from 2022 to 2040. These temporal patterns highlight the substantial disease burden of HNCs on older adults globally. The total burden is likely to increase, which will present a considerable challenges related to their control and treatment in the coming decades.

The functional impact of HNCs on older adults is multifaceted and profound. It extends beyond physical pain to include severe functional limitations that define quality of life.^51,52 The head and neck region contains vital organs responsible for breathing, eating (chewing and swallowing), vocalization, taste, smell, and hearing. Tumors in this region can cause symptoms such as dysphagia, hoarseness, and odynophagia, which severely affect daily living and nutritional status.⁵³ The increasing global burden of LOCC and OPC identified in our study indicates that more older adults will face these devastating functional sequelae. The treatment—whether surgery, radiotherapy, or chemotherapy—can exacerbate these issues, and cause long-term dysphagia, xerostomia, and dysphonia. There are particularly debilitating in an older adults who may already be experiencing age-related functional decline.^54,55 These physical impairments, coupled with the psychological distress from disfigurement, altered body image, and social stigma, create a heavy burden for survivors.⁵⁶ The evolution of surgical techniques offers a paradigm shift towards mitigating this functional burden. The advent of transoral robotic surgery (TORS) has improved the preservation of swallowing and speech functions in patients with oropharyngeal cancer relative to traditional open surgery or radiotherapy. Guarino et al comprehensively summarized the favorable functional outcomes of TORS for oropharyngeal squamous cell carcinoma, including the promising rates of swallowing preservation and a rapid recovery of intelligible speech, in a recent systematic review.⁵⁷ This underscores a critical clinical imperative. Our epidemiologic findings not only call for strengthened primary prevention and highlight the need to integrate functional preservation as a central goal in treatment planning for older patients with HNCs. Ensuring the global accessibility of advancements in function-preserving therapies such as TORS is paramount to improving the survival and quality of life of the growing population of older adults with HNCs.

Alcohol and tobacco use are significant risk factors for HNC and are associated with the prognosis of the disease.⁵⁸ Regional cancerization refer to the development of various primary and secondary malignancies in the mucous membranes of the upper aerodigestive tract due to repeated exposure to the carcinogenic effects of alcohol consumption and/or smoking. The risk of developing squamous cell carcinoma of the head and neck doubles with tobacco use and heavy tobacco use further increases the risk. Tobacco contains carcinogens, which increase the risk of HNCs. This includes the use of smokeless tobacco (such as cigarette smoke and the betel nut) and smoking tobacco (such as cigars, cigarettes, and the electronic cigarettes).⁵⁹ The inadequate control of tobacco is likely contributing to the increase in the disease burden. Approximately 80% of the 1.3 billion smokers worldwide live in low- and middle-income countries, where the rates of tobacco-related morbidity and mortality are highest.⁶⁰ The incidence and mortality rates for these cancers in older adults were relatively high in low- and low-middle SDI regions, especially in countries where tobacco use is prevalent, such as India, Pakistan, Bangladesh, Nepal, Sri Lanka, and other South-Central Asian countries. The WHO Member States ratified the WHO Framework Convention on Tobacco Control in 2003. Its effective implementation likely to contributed to the reduction of the burden of HNC after 2003. The WHO released the eighth report on the global tobacco products pandemic in 2021, The report detailed country initiatives to enforce the Framework Convention on Tobacco Control. These are collectively known as MPOWER measures and include tobacco surveillance and prevention, promotion of cessation actions, and raising tobacco taxes.⁶¹ Governments in low-income and lower-middle-income countries should respond favorably to the MPOWER measures. The WHO recently released the first clinical guidelines on smoking cessation for adults. These should be adopted and implemented by health-care providers, policymakers and stakeholders globally to promote cessation, improve the health of the millions of people who need to quit, and reduce morbidity and mortality from HNCs.⁶² IOur study also showed that the disease burden of HNCs attributable to alcohol use in older adults increased annually in low and low-middle SDI areas, especially for LOCC and OPC. This finding is consistent with that of a previous study.⁶³ The Global Action Plan on Alcohol 2022–2030, approved by WHO Member States, seeks to mitigate the global illness burden attributable to alcohol by implementing effective, evidence-based solutions at the national, regional, and global levels. Achieving this objective requires action at the global, regional, and national levels to address alcohol consumption levels, patterns, and environments, and broader social determinants of health. It also requires the implementation of high-impact, cost-effective interventions.⁶⁴

Our study revealed notable divergences in temporal trends between older men and women, which can be partly explained by differential exposure and shifting patterns. The steeper declines in LC incidence and mortality among men than among women, may reflect the historical differences in tobacco and alcohol consumption. Men had higher exposure levels and are now benefiting more from the larger relative reductions due to public health interventions.^65–67 The rising incidence of LOCC in women, despite the stabilization or decline in rates in men in some regions, is a concerning trend that warrants attention. This may be linked to the narrowing gender gap in smoking and drinking behaviors and potential sex-specific biological susceptibilities.^68–71 The disproportionate burden of OPC in men, and its rapid increase strongly indicate the dominant role of human papillomavirus (HPV) infection. The global epidemic of HPV-driven OPC has been predominantly observed in men. However, studies have suggested differences in exposure, immune response, and sexual practices as potential explanations for this observation.^72–75 Disparities in healthcare access and health-seeking behaviors between genders cannot be overlooked. Older women, especially those in low-resource settings, may face barriers to timely diagnosis and treatment, which may contribute to the less favorable mortality trends observed for certain cancers, such as LOCC.^74,76

The distinct socioeconomic patterning of these cancers offers critical insights into their evolving etiology. The most substantial increases in the incidence and mortality of OPC were observed in high and high-middle SDI regions, such as those in Europe and America. This pattern is consistent with the well-documented global increase in HPV-positive oropharyngeal squamous cell carcinoma.^77,78 HPV infection has now superseded tobacco and alcohol as the leading cause of OPC in many high-income countries, especially among younger and middle-aged adults. This trend is now reflected in the older adult population studied here.⁷⁹ The reasons for this shift are multifactorial and may include changes in sexual practices over the past decades.⁸⁰ The prognosis for OPC in these high-income countries has generally been more favorable, which has contributed to the steeper declines in mortality in regions such as Europe. This improved survival can be attributed to the inherent better responsiveness of HPV-positive OPC to radiotherapy and chemotherapy, and greater access to advanced, multi-modal treatments and specialized cancer centers.⁸¹ The persistently high burden of LOCC and LC in low and low-middle SDI regions underscores the ongoing challenge of combating traditional risk factors, including tobacco (in all its forms, including smokeless tobacco and betel quid) and alcohol, in these populations.^82,83 The striking disparities in mortality rates and, by extension, survival, between countries are equally noteworthy. The significant declines in the ASMRs for LC and NPC in high-SDI countries likely reflect advancements in diagnostic imaging, precision radiotherapy, and the integration of systemic therapies.^84,85 The stagnant or even increasing mortality rates for LOCC and OPC in many low-SDI countries highlight critical gaps in healthcare access. The barriers include delayed diagnosis due to limited screening and awareness, insufficient availability of radiotherapy equipment, and a shortage of specialized healthcare professionals.⁸⁶ The high out-of-pocket expenditure for cancer care in these settings further exacerbates the survival gap. This divergence highlights a dual challenge for global HNC control: combating the legacy of tobacco and alcohol in transitioning economies and addressing the emerging epidemic of HPV-driven cancers in more developed regions.

Our results indicated increase in the age-standardized incidence and death rates for LOCC and OPC among the four cancers in the 60–89 years age group from 1992 to 2021. These increases highlight the insufficiency of current efforts in disease prevention and treatment. Superficial pharyngeal cancer has no specific symptoms in the early stages, and early detection is very challenging. Most patients who present to the clinic have missed the opportunity for early diagnosis and treatment.⁸⁷ Conventional therapies such as surgical resection and radiotherapy may improve survival to some extent but often result in a marked reduction in quality of life due to speech defects, swallowing problems, salivary disorders and cosmetic neck deformities. To mitigate this escalating burden, policy frameworks must expand beyond primary prevention to include targeted screening strategies. For LOCC, opportunistic visual screening programs integrated into routine dental and primary geriatric care can facilitate early detection in high-risk older adults. For OPC, given the rising HPV-related incidence, healthcare systems should explore the feasibility of non-invasive salivary HPV testing and emphasize thorough clinical examinations. Furthermore, prevention programs must be tailored to the elderly, focusing on late-life smoking cessation support, which remains beneficial for reducing secondary primary malignancies and improving overall survival. The age-standardized mortality rate of OPC in people aged 60–89 years has decreased in recent years. This may be attributed to the rapid development and widespread use of narrow-band optical imaging technology, which has improved the detection rate of OPC and facilitated early diagnosis and treatment.^88,89 Endoscopic minimally invasive treatment techniques have been gradually adopted for the treatment of superficial OPC, and their efficacy has been remarkable.⁹⁰

LOCC includes cancers of the lip other parts of the mouth, and oropharynx. It is the thirteenth most common cancer globally. LOCC is more common in older men living in countries with low or medium SDI.⁹¹ Patients with LOCC often have a preceding clinical pre-cancer stage, and treatment of early oral cancer is associated with a favourable prognosis.^92,93 Appropriate strategies and policies should therefore be developed to facilitate investment in screening for LOCC to enable early detection and reduce morbidity and mortality. The risk of oral cancer increases sharply with age. This is due to the physiological changes that occur in older adults, which make treating them for oral cancer a major challenge.⁹⁴ Our findings suggest that the higher incidence and mortality rates of LOCC are related to aging. In light of this, screening frameworks should transition from passive tracking to active surveillance. While the World Health Organization’s Global Strategy for Oral Health (adopted in 2022) advocates for universal oral health coverage by 2030,^95–97 its primary utility in geriatric oncology lies in promoting routine, opportunistic clinical oral examinations. Integrating standardized visual oral screenings into routine geriatric primary care allows clinicians to detect asymptomatic precancerous lesions or early-stage LOCC early, significantly lowering down-staging barriers and reducing morbidity and mortality in this vulnerable aging population.

The diagnosis and treatment of several cancers, including HNC, have been affected by the COVID-19 pandemic.^98,99 A previous study reported decreases in the incidence and mortality rate of HNCs during the COVID-19 pandemic, which were attributed to their delayed monitoring due to the disruption of healthcare services.¹⁰⁰ Fewer patients have been assessed in outpatient departments, and fewer new cases of HNCs have been detected and diagnosed due to social distancing measures. Missed cancer screening may lead to increases in the number of late-stage cancer diagnoses and cancer-related deaths in the future.

Population aging has emerged as a significant global problem. The average lifespan in most developed countries has almost doubled in the last 200 years. However, the most significant transformation is currently underway in low- and middle-income countries.⁹ Two--thirds of the global population aged over 60 years will reside in low- and middle-income countries by 2050. Our study indicates that the healthification trends become less pronounced with increasing age in the 60–89 years age group. The incidence and death rates are higher in regions with low and low-middle SDI. The Western Pacific region has the highest incidence and deaths rates associated with aging. To take advantage of this demographic shift, all nations, especially those in the Western Pacific and low- and low-middle SDI regions, must support the World Health Assembly’s adoption of the Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013–2020 in 2019. This plan focuses on managing and preventing HNCs in older adults and enhancing health care systems. It will also support the United Nations Decade of Action for Healthy Ageing and promote longer and healthier lives.

This GBD-based study is the first to report the global incidence and mortality rates of these cancers in individuals aged 60–89 years, investigate the most pertinent risk factors, and forecast the future burden of these cancers in this demographic. It has important implications for the prevention and control of HNC and health promotion in older patients. However, it has some limitations. First, population-based cancer registries are unavailable in some countries (or regions), and important data sources for estimating the cancer burden are therefore lacking. Second, we focused on the 60–89 years age group to ensure robust and interpretable age-specific trend analysis. Consequently, our findings do not capture the disease burden experienced by the oldest population (individuals aged ≥90 years). Third, many countries in Africa and other low-SDI regions have limited coverage by high-quality, population-based cancer registries. This can lead to underreporting of cases. The GBD study employs sophisticated models to estimate the burden in data-sparse areas by borrowing strength from regions with high-quality data and using covariates. These provide the best available estimates, but the uncertainty is greater for these regions. Fourth, it is crucial to recognize the inherent data quality limitations of the GBD estimates. The GBD relies heavily on model-based estimations rather than primary, real-world clinical registry data for all regions. Consequently, our findings are subject to potential ecological bias; the observed population-level trends and associations—such as those with the sociodemographic index or regional risk factors—cannot be directly used for individual-level causal inference. Furthermore, while GBD estimates provide a comprehensive global overview, they heavily rely on modeling assumptions and predictive covariates in regions lacking robust vital registration systems. This methodological reliance introduces inherent uncertainty. Additionally, in low-income and low-middle SDI regions, limited access to advanced diagnostic infrastructure (such as endoscopy or biopsy facilities) likely results in significant underdiagnosis and underreporting. Consequently, the true disease burden in these resource-limited settings may be substantially higher than the current estimates suggest. Furthermore the GBD 2021 only provides some behavioral risks (smoking and alcohol consumption) that can be used for further research. Infection with HPV, the use of betel quid or areca nut, and certain occupational exposures are significant contributors to the burden of this disease but have not yet been quantified in GBD estimates. Our results present a conservative picture of the total burden attributable to known risk factors, and the absence of these factors should be considered when interpreting them. Finally, our study relies on the aggregate GBD 2021 framework, which analyzes 30-year macroeconomic trends and cannot granularly isolate short-term, single-year epidemiological shifts. Consequently, potential immediate fluctuations in HNC sub-sites during the 2020–2021 COVID-19 pandemic could not be empirically tested. Although some clinical literature hypothesizes that COVID-19 infection might trigger the reactivation of latent Epstein-Barr virus (EBV)—a known etiological driver of NPC—this biological intersection remains a theoretical conjecture within the scope of our study. Future investigation utilizing longitudinal, individual-level post-pandemic registries and serial serological EBV tracking is warranted to evaluate these short-term cohort deviations.

Conclusion

The age-standardized incidence and mortality rates of HNCs among older adults (aged 60–89 years) vary widely across the 204 countries and areas. We report several temporal patterns of head and neck malignancies in older adults globally, which highlight possible deficiencies in prevention, management, and therapy. To address this, healthcare systems must implement actionable, targeted prevention policies, such as late-life tobacco and alcohol cessation programs specifically tailored for older demographics, alongside the strategic promotion of HPV vaccination programs to mitigate the future long-term burden of OPC. Furthermore, proactive screening strategies—including the integration of opportunistic visual oral examinations into routine geriatric and dental care—should be urgently prioritized to facilitate early detection, particularly for LOCC. Crucially, clinical treatment strategies should prioritize the preservation of swallowing and speech functions to safeguard the quality of life in this aging population. Ultimately, this research may enhance the understanding of the epidemiology of these disease, optimize the allocation of healthcare resources, and inform the formulation of relevant health policies.

Funding Statement

This work was supported by the Natural Science Foundation of China (82171127, and 82371133) and Discipline Construction Project of the First Affiliated Hospital of Anhui Medical University (NO. 4245).

Abbreviations

HNC, head and neck cancer; GBD, Global Burden of Disease; DALYs, disability adjusted life-years; NPC, nasopharyngeal cancer; LOCC, lip and oral cavity cancer; OPC, other pharyngeal cancer; LC, laryngeal cancer; SDI, sociodemographic index; ASIR, age-standardized incidence rate; ASMRs, age-standardized mortality rates; APC, annual percentage change; AAPC, Average Annual Percent Change; GHDx, Global Health Data Exchange; CI, confidence interval; UI, uncertainty interval; BAPC, Bayesian age-period-cohort analysis; INLA, integrated nested Laplace approximation; MAPE, mean absolute percentage error; TORS, transoral robotic surgery; HPV, human papillomavirus; EBV, Epstein-Barr virus.

Data Sharing Statement

The data utilized in this study can be found in the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 (https://ghdx.healthdata.org/gbd-2021).

Ethics Approval and Consent to Participate

GBD data is open and transparent, therefore it has obtained ethical exemption from the Ethics Committee of the First Affiliated Hospital of Anhui Medical University (PJ2025-05-580). All methods were carried out in accordance with relevant guidelines and regulations of the Declaration of Helsinki (https://www.wma.net/policies-post/wma-declaration-of-helsinki/). The GHDx data infrastructure ensures compliance with international data protection standards through rigorous de-identification processes prior to public release.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare no conflicts of interest in this work.