Diverging Incidence and Mortality of Cutaneous Melanoma in Mainland China, 1990–2023, with Projections to 2030: A Global Burden of Disease 2023 Analysis

Abstract

Objective

To quantify changes in incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) from cutaneous melanoma in mainland China, assess demographic drivers, and project age-standardized rates to 2030 using Global Burden of Disease (GBD) 2023 estimates.

Methods

We extracted annual estimates for 1990–2023 by sex and 5-year age group. Estimated annual percentage changes summarized age-standardized rate trends. Decomposition separated changes in absolute burden into population growth, population aging, and epidemiological change, defined as residual changes in age-specific rates after demographic effects. Bayesian age-period-cohort models projected age-standardized rates to 2030.

Results

From 1990 to 2023, incident cases increased from 4,657 to 16,593, and prevalent cases increased from 15,401 to 102,526. The age-standardized incidence rate increased from 0.49 to 0.79 per 100,000, and the age-standardized prevalence rate increased from 1.39 to 5.03 per 100,000, with estimated annual percentage changes of 1.39% and 4.14%, respectively. In contrast, the age-standardized mortality rate declined from 0.33 to 0.27 per 100,000, and the age-standardized DALY rate declined from 9.74 to 7.54 per 100,000. The burden shifted toward older ages, although the largest absolute numbers of cases and DALYs clustered around ages 55–59 years. Aging contributed most to rising incident cases and DALYs, whereas epidemiological change drove prevalence expansion and partly offset DALY growth. By 2030, the combined-sex age-standardized incidence and prevalence rates were projected to reach 0.88 and 5.84 per 100,000, respectively, while mortality was projected to remain nearly stable and the DALY rate to decline slightly.

Conclusion

Cutaneous melanoma in mainland China remains uncommon but rising incidence and prevalence, alongside declining age-standardized mortality and DALY rates indicate a changing burden profile. This divergence may increase demand for longitudinal services, but it does not demonstrate improved individual survival or chronicity. Strengthened early detection, age-adapted prevention, standardized diagnosis, and long-term survivorship care are needed.

Plain Language Summary

Cutaneous melanoma is an aggressive form of skin cancer that can spread and cause death. It is much less common in China than in populations predominantly of European ancestry and is often regarded as rare there. Using the most recent Global Burden of Disease 2023 data for mainland China, we examined how the disease changed between 1990 and 2023 and projected the burden to 2030.

We found two opposite trends. The numbers of people newly diagnosed with, and living with, melanoma rose sharply, while the death rate and the rate of overall health loss declined. Most of the rise in new cases reflected China’s ageing population. The database cannot determine whether increasing prevalence reflects earlier diagnosis, registration, treatment, or longer individual survival. The burden increasingly affected older adults, although the largest numbers of patients were in their late 50s.

These findings suggest that melanoma may create greater demand for follow-up and longitudinal services in China, but they do not show that melanoma has become a chronic disease. They support earlier detection, diagnosis suited to cutaneous melanoma patterns in Chinese patients, equitable access to treatments, and planning for the long-term care of a growing number of survivors, particularly older adults.

Introduction

Cutaneous melanoma is an aggressive malignancy arising from melanocytes and contributes disproportionately to skin-cancer morbidity and mortality relative to its incidence.^1,2 Its epidemiological profile is highly heterogeneous across populations. The highest incidence rates occur in populations predominantly of European ancestry in Australia/New Zealand, Europe, and North America. Reported incidence is also been influenced by population aging and by increased diagnostic intensity, including earlier detection, diagnostic drift, and possible overdiagnosis of thin or in-situ lesions.^3,4 A recent English registry analysis similarly reported rising incidence with age-dependent mortality patterns and discussed diagnostic drift and possible overdiagnosis.⁵ In 2020, cutaneous melanoma caused an estimated 325,000 new cases and 57,000 deaths worldwide, with projected increases to approximately 510,000 new cases and 96,000 deaths by 2040 if current rates persist.³ Although mainland China remains a relatively low-incidence region, its large population base, rapid aging, and changing health-care access make even modest rate changes clinically and public-health relevant.

Previous GBD-based studies and registry analyses have shown that melanoma incidence and absolute burden in China have increased over recent decades.^6–9 A recent GBD 2021 China subnational analysis further suggested that the rising numbers of deaths and DALYs were driven mainly by population aging, with considerable geographic and age-sex heterogeneity.⁸ Clinical series indicate that acral lentiginous melanoma accounts for a larger proportion of cutaneous cases in Chinese patients; mucosal melanoma is also clinically important but represents a distinct noncutaneous entity.^10,11 Lesions on acral or less visible sites, delayed help-seeking, and diagnostic delay may contribute to advanced-stage presentation.^10–13 Because the GBD skin melanoma category does not distinguish acral melanoma and excludes mucosal melanoma, these subtype observations provide clinical context rather than findings of the present analysis. These differences limit the direct generalizability of prevention, diagnostic, and treatment strategies derived from Western cohorts and underscore the need for updated, population-specific burden assessments in China.

Despite these advances, important evidence gaps remain. Existing national analyses of melanoma in China have largely been based on previous GBD rounds, including GBD 2017, GBD 2019 and GBD 2021, and some have focused primarily on selected indicators such as incidence and mortality.^6–8,14 Moreover, few have examined whether case-based and fatal or disabling components of the melanoma burden are now diverging, or integrated long-term age-sex-specific trends, decomposition of demographic and epidemiological drivers, and forward projections within a single framework relevant early detection and service planning. Consequently, it remains unclear to what extent the changing absolute burden of cutaneous melanoma in mainland China reflect population growth, population aging, or residual changes in age-specific disease rates. The GBD 2023 database provides updated estimates from 1990 to 2023 using standardized modelling methods, offering an opportunity to reassess the national melanoma burden with more contemporary evidence.^15,16

Using data from GBD 2023, this study comprehensively evaluated the burden of cutaneous melanoma in mainland China from 1990 to 2023. We quantified temporal trends in incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) using age-standardized rates and estimated annual percentage changes; characterized age- and sex-specific patterns; decomposed changes in absolute burden into contributions from population growth, population aging, and epidemiological change; and applied age-period-cohort analysis and Bayesian age-period-cohort models to evaluate period and cohort effects and to project age-standardized rates through 2030.^17,18 By framing melanoma in China as a disease shifting from a predominantly fatal condition toward a long-term care burden, these findings aim to inform earlier detection, subtype-aware diagnosis, prognosis, equitable access to systemic therapy, and long-term survivorship and health-resource planning tailored to the Chinese population.

Materials and Methods

Study Design and Data Source

This population-based cross-sectional study used publicly available estimates from the Global Burden of Disease Study 2023 (GBD 2023). Annual data for cutaneous melanoma in mainland China from 1990 to 2023 were extracted from the GBD Results Tool by year, sex, and 5-year age group. GBD 2023 provides internally comparable estimates across 204 countries and territories and 660 subnational locations using standardized data processing and modelling procedures, drawing on cancer registries, vital registration systems, verbal autopsy data, health surveys, hospital records, and published literature.^15,16,19 All analyses used aggregated, de-identified public estimates; no individual-level records were accessed. The statutory basis for exemption from ethics review is provided in the Ethics approval and informed consent section. The study was reported in accordance with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) and, where applicable, the STROBE statement for observational studies.

Case Definition and Burden Measures

Cutaneous melanoma was defined according to the GBD skin melanoma cause category. Consistent with previous GBD melanoma studies and GBD 2023 cause-code mappings, this category was mapped to ICD-10 codes C43-C43.9, D03-D03.9, D22-D23.9, and D48.5, and ICD-9 codes 172–172.9.^6,8 Within the GBD framework, this cause category corresponds to malignant cutaneous melanoma; the benign and uncertain-behaviour codes (D22–D23, D48.5) reflect the cause-of-death redistribution scheme used by GBD rather than the counting of benign naevi as melanoma, and the in-situ code (D03) implies that part of the observed rise in incidence may reflect earlier detection of thin or in-situ lesions. The category does not distinguish acral from other cutaneous subtypes, and mucosal and ocular melanomas are not captured. Four burden indicators were assessed: incident cases, prevalent cases, deaths, and disability-adjusted life-years (DALYs). For each indicator, we obtained absolute numbers, age-specific rates, and age-standardized rates (ASRs), expressed per 100,000 population. ASRs were calculated by direct standardization to the GBD world standard population. DALYs were interpreted as the combined burden of fatal and non-fatal health loss, integrating years of life lost and years lived with disability within the GBD framework.^15,16 All estimates were reported with 95% uncertainty intervals (UIs).

Data Processing and Age-Sex Analyses

Data were organized by calendar year, sex, measure, metric, and 5-year age group from younger than 5 years to 95 years and older. We first summarized temporal changes in absolute burden and ASRs between 1990 and 2023 for both sexes combined and separately for males and females. Age-specific patterns were described by comparing numbers and rates across age groups in 1990 and 2023. To characterize redistribution of the burden over time, we calculated the proportional contribution of each age group to the total national burden for incidence, prevalence, deaths, and DALYs. Sex-specific age profiles were then examined to identify differences in the age at peak burden, the magnitude of male-female gaps, and age ranges in which sex dominance changed.

Temporal Trend Analysis

Long-term trends in ASRs were quantified using estimated annual percentage changes (EAPCs), a standard summary measure for describing linear trends in age-adjusted rates in population-based disease surveillance. For each age-standardized indicator, a log-linear regression model was fitted with the natural logarithm of the ASR as the dependent variable and calendar year as the independent variable. The EAPC and its 95% confidence interval (CI) were derived from the regression coefficient. Trends were classified as increasing when the EAPC and the lower bound of its 95% CI were both greater than zero, decreasing when the EAPC and the upper bound of its 95% CI were both below zero, and stable otherwise.^15,19,20 The EAPC was retained as a single, comparable summary of the overall linear trend, complementing the age-period-cohort and Bayesian age-period-cohort analyses described below, which separate the underlying age, period, and cohort components.

Decomposition Analysis

To assess the drivers of changes in absolute burden between 1990 and 2023, we performed decomposition analysis using a counterfactual replacement framework consistent with previous GBD applications.^8,21 Changes in incident cases, prevalent cases, and DALYs were decomposed into three additive components: population growth, reflecting changes in total population size; population aging, reflecting shifts in age structure; and epidemiological change, defined as the residual change attributable to age-specific rates after population size and age structure were held constant. This residual may reflect changes in risk, diagnosis, registration, treatment, or survival and should not be interpreted as a causal effect. Decomposition was conducted for both sexes combined and separately for males and females. Results were presented as absolute contributions and as proportions of the total decomposition effect.

Age-Period-Cohort and Projection Analyses

Age-period-cohort (APC) analysis was used to separate age, period, and birth-cohort patterns for incidence, prevalence, mortality, and DALYs. Age effects were reported as fitted age-specific rates; period and cohort effects were summarized as relative risks using the median period and reference cohort as comparators.¹⁸ To project future burden, Bayesian age-period-cohort (BAPC) models were fitted to historical age-specific counts and population denominators from 1990 to 2023. BAPC models are suitable for cancer-burden forecasting because they incorporate age structure, calendar-period patterns, and cohort replacement within a probabilistic framework.¹⁷ Projections were generated from 2024 to 2030 for both sexes combined and separately for males and females. Predicted age-specific rates were standardized to the GBD world standard population to obtain projected ASRs. These estimates were interpreted as projections under continuation of recent age-period-cohort patterns, rather than as causal forecasts of intervention effects. Projected rates are reported with 95% credible intervals derived from the posterior distribution of the BAPC model.

Statistical Analysis

Data cleaning, rate calculations, EAPC estimation, decomposition analysis, APC modelling, BAPC projection, and visualization were performed using R software (version 4.5.3). BAPC models were implemented using the BAPC and INLA packages, and figures were generated with ggplot2 and related packages. All rates are reported per 100,000 population. Because this study was based on modelled population-level estimates, analyses were descriptive; uncertainty was conveyed using 95% UIs for GBD estimates and 95% CIs for EAPCs and 95% credible intervals for the BAPC projections.

Results

Overall Trends

Between 1990 and 2023, the incidence and prevalence burden of cutaneous melanoma in mainland China increased markedly (Table 1). Incident cases rose from 4,657 to 16,593 (+256.28%), while the age-standardized incidence rate (ASIR) increased from 0.49 to 0.79 per 100,000 (+61.22%). Prevalent cases increased from 15,401 to 102,526 (+565.80%), and the age-standardized prevalence rate (ASPR) rose from 1.39 to 5.03 per 100,000 (+261.87%). Absolute case growth was greater in men: male incident and prevalent cases increased by 276.74% and 699.37%, respectively, compared with 240.13% and 482.73% in women.

Table 1.

Age-Standardized Rates, Case Numbers, and Estimated Annual Percentage Changes for Cutaneous Melanoma in Mainland China, 1990–2023

	1990		2023		EAPC, 1990–2023 (95% CI)
	Cases×102 (95% UI)	ASR Per 100,000 (95% UI)	Cases ×102 (95% UI)	ASR Per 100,000 (95% UI)
Incidence
Both	46.57 (30.78, 65.87)	0.49 (0.33, 0.69)	165.93 (113.65, 262.88)	0.79 (0.54, 1.25)	1.39 (1.28, 1.50)
Female	25.86 (15.32, 42.67)	0.54 (0.32, 0.91)	87.93 (49.98, 161.40)	0.82 (0.47, 1.50)	1.29 (1.16, 1.42)
Male	20.71 (10.27, 31.54)	0.43 (0.22, 0.66)	78.00 (45.47, 127.02)	0.76 (0.44, 1.24)	1.51 (1.38, 1.64)
Prevalence
Both	154.01 (90.85, 237.18)	1.39 (0.82, 2.15)	1025.26 (640.68, 1736.95)	5.03 (3.17, 8.48)	4.14 (4.00, 4.28)
Female	95.17 (51.69, 170.84)	1.73 (0.94, 3.15)	555.10 (303.53, 1060.27)	5.42 (3.00, 10.27)	3.74 (3.56, 3.91)
Male	58.84 (27.77, 95.07)	1.05 (0.50, 1.70)	470.16 (275.54, 801.54)	4.60 (2.70, 7.84)	4.64 (4.52, 4.76)
Deaths
Both	28.35 (18.49, 38.60)	0.33 (0.21, 0.45)	58.23 (41.98, 84.86)	0.27 (0.19, 0.39)	−0.85 (−0.96, −0.73)
Female	14.97 (8.49, 26.20)	0.34 (0.19, 0.59)	29.61 (17.31, 47.87)	0.26 (0.15, 0.41)	−1.03 (−1.15, −0.90)
Male	13.38 (6.67, 21.24)	0.31 (0.16, 0.49)	28.61 (17.02, 46.23)	0.27 (0.16, 0.44)	−0.66 (−0.81, −0.51)
DALYs
Both	983.86 (635.85, 1327.34)	9.74 (6.36, 13.17)	1575.95 (1134.47, 2328.99)	7.54 (5.40, 11.12)	−1.06 (−1.18, −0.95)
Female	498.77 (283.17, 851.48)	9.99 (5.71, 17.25)	723.51 (417.74, 1196.78)	6.73 (3.88, 11.16)	−1.42 (−1.52, −1.32)
Male	485.08 (236.65, 759.49)	9.41 (4.67, 14.79)	852.44 (512.03, 1367.42)	8.27 (4.87, 13.30)	−0.73 (−0.88, −0.58)

Notes: Case and DALY counts are presented in hundreds (×10²); multiply tabulated values by 100 to obtain estimated absolute numbers.

Abbreviations: ASR, age-standardized rate; CI, confidence interval; DALYs, disability-adjusted life-years; EAPC, estimated annual percentage change; UI, uncertainty interval.

By contrast, age-standardized mortality and DALY rates declined over the same period despite increases in absolute counts (Table 1). Deaths increased from 2,835 to 5,823 (+105.40%), whereas the age-standardized mortality rate (ASMR) decreased from 0.33 to 0.27 per 100,000 (−18.18%). DALYs increased from 98,386 to 157,595 person-years (+60.18%), while the age-standardized DALY rate (ASDR) declined from 9.74 to 7.54 per 100,000 (−22.59%). The reductions were larger in women than in men: female ASMR and ASDR decreased by 23.53% and 32.63%, respectively, compared with 12.90% and 12.11% in men. Together, absolute incidence/prevalence burden expanded while age-standardized fatal and disabling burden declined.

Age-Stratified Trends

Incident cases were concentrated in older adults (Figure 1A). In 2023, incident cases peaked at 2,350 (95% UI: 1,582–3,804) in the 55–59-year age group. At ages ≥ 50 years, incident counts rose from 435 to 1,839 in the 50–54-year group and from 398 to 1,632 in the 65–69-year group. Age-specific incidence rose with age, with the highest rate in the 85–89-year group rising from 2.95 per 100,000 in 1990 to 6.72 per 100,000 in 2023 (+127.64%; Figure 1A).

Figure 1.

Age-specific distribution of cutaneous melanoma burden in mainland China, 1990–2023. Age-specific numbers and rates of cutaneous melanoma burden are shown by 5-year age group for incidence (A), prevalence (B), deaths (C), and disability-adjusted life-years (DALYs) (D). Blue and red bars and lines represent 1990 and 2023, respectively. Bars indicate absolute numbers, and solid lines indicate age-specific rates per 100,000 population. Vertical error bars indicate 95% uncertainty intervals (UIs) for numbers, and shaded bands indicate 95% UIs for rates.

Prevalence showed a similar age pattern (Figure 1B). The largest prevalent count occurred in the 55–59-year group, increasing from 1,538 in 1990 to 16,146 (95% UI: 9,916–26,527) in 2023, while the 65–69-year group increased from 696 to 10,048. The peak prevalence rate rose from 2.60 to 18.34 per 100,000 (Figure 1B). Mortality declined among younger groups: deaths decreased from 52 to 16 in the 15–19-year group (−68.23%) and from 72 to 16 in the 20–24-year group (−78.15%; Figure 1C). DALYs in the 20–24-year group fell from 4,924 to 1,129 person-years (−77.06%; Figure 1D). At ages ≥50 years, deaths and DALYs increased. In the55–59-year group, deaths increased from 390 to 746 (Figure 1C), and DALYs increased by 96.00% (Figure 1D); in the 65–69-year group, deaths and DALYs increased by 105.00% and 110.00%, respectively (Figure 1C and D). The steep mortality rise beyond age 75 in 1990 was replaced by a flatter older-age profile in 2023 (Figure 1C).

Shifts in Age Composition

From 1990 to 2023, the age composition of all four measures shifted toward older populations (Figure 2); the corresponding absolute totals are reported in Table 1. Younger-adult contributions declined across metrics. For incidence, the share attributed to the 20–39-year group decreased from 23.23% to 10.23%, whereas the 60–79-yearr share rose from 31.30% to 37.03%, becoming the largest contributor (Figure 2A). For prevalence, the 20–39-year share fell from 39.61% to 13.89%, while the 60–79-year share increased from 15.65% to 34.42% (Figure 2B).

Figure 2.

Changes in the age composition of cutaneous melanoma burden in mainland China, 1990–2023. Temporal changes in the age composition of absolute cutaneous melanoma burden are shown for incident cases (A), prevalent cases (B), deaths (C), and DALYs (D). Stacked areas represent the percentage contributed by age groups ≤19, 20–39, 40–59, 60–79, and ≥80 years, with colors defined in the in-figure legend; proportions sum to 100% in each year.

Expansion was strongest among those aged ≥ 80 years. Incident cases in this group increased from 228 to 2,351, and their share rose from 4.89% to 14.17% (Figure 2A). Prevalent cases increased from 158 to 6,097, with the share rising from 1.03% to 5.95% (Figure 2B). Deaths increased from 227 to 1,395, and their share rose from 8.00% to 23.96% (Figure 2C); DALYs increased from 2,676 to 15,600 person-years, with the share increasing from 2.72% to 9.90% (Figure 2D). Within the 40–59-year band, the 55–59-year subgroup remained a major burden node: incident cases rose from 605 to 2,350 (Figure 2A), prevalent cases from 1,538 to 16,146 (Figure 2B), and DALYs from 13,253 to 25,978 person-years (Figure 2D).

Sex- and Age-Stratified Analysis

In 2023, age- and sex-specific curves differed by metric. For incidence, females had higher rates in adolescence and early adulthood; in the 15–19-year group, the female rate was 0.28 per 100,000, 1.88 times the male rate of 0.15 per 100,000 (Figure 3A). Rates were nearly equal in the 30–34-year group (0.52 vs 0.51 per 100,000; Figure 3A). Males first exceeded females in the 35–39-year group (0.75 per 100,000; 1.27 times the female rate), females regained a small advantage in the 45–49-year group (1.11 vs 1.09 per 100,000), and males again predominated at 50–59 years (Figure 3A). The male incidence peak occurred in the 55–59-year group, with 1,366 cases and a rate of 2.32 per 100,000, 1.40 times the female rate. From the 60–64-year group onward, females had consistently higher incidence rates, reaching 4.82 per 100,000 in the 75–79-year group, 1.58 times the male rate (Figure 3A).

Figure 3.

Sex- and age-specific patterns of cutaneous melanoma burden in mainland China in 2023. Age-specific numbers and rates of cutaneous melanoma burden are shown by sex and 5-year age group for incidence (A), prevalence (B), deaths (C), and DALYs (D). Pink denotes females and blue denotes males. Bars indicate sex-specific absolute numbers, and lines indicate sex-specific age-specific rates per 100,000 population. Vertical error bars indicate 95% UIs for numbers, and shaded bands indicate 95% UIs for rates.

Prevalence showed delayed female dominance in older ages. The male prevalent case peak occurred at 55–59 years (8,893 cases), whereas the female peak occurred 15 years later at 70–74 years (5,771 cases; Figure 3B). In the 80–84-year group, the female prevalence rate was 23.30 per 100,000, 2.46 times the male rate of 9.48 per 100,000 (Figure 3B). Mortality showed male predominance in middle age and female excess in older age. Male deaths in the 35–39-year group reached 110, 2.04 times the 54 female deaths; in the 40–44-year group, the male mortality rate was 0.33 per 100,000, 2.15 times the female rate (Figure 3C). DALY rate differences were largest in the 40–44-year group, where the male-to-female ratio reached 2.11 (16.31 vs 7.72 per 100,000; Figure 3D). DALY counts peaked at 55–59 years in both sexes, with 16,297 person-years in men and 9,681 person-years in women. After age 70, female DALY rates were consistently higher than male rates, including a female-to-male ratio of 1.44 in the 80–84-year group (Figure 3D).

Decomposition Analysis

Decomposition analysis identified distinct contributors to changes from 1990 to 2023. The net increase in incident cases was 11,935, including 5,729 in men and 6,207 in women (Figure 4A). Aging contributed 5,664 cases (47.46%), epidemiologic change contributed 4,403 (36.89%), and growth contributed 1,868 (15.65%) to the incidence increase (Figure 4A). By sex, the share attributable to epidemiologic change was higher in men than in women (41.03% vs 33.78%; Figure 4A). For prevalence, the net increase was 87,125 cases, comprising 41,132 in men and 45,993 in women (Figure 4B). Epidemiologic change was the dominant contributor, accounting for 55,228 cases (63.39%), followed by population aging (22,207; 25.49%) and population growth (9,690; 11.12%; Figure 4B). The epidemiologic-change contribution to prevalence was also higher in men than in women (66.27% vs 61.12%; Figure 4B).

Figure 4.

Decomposition analysis of changes in cutaneous melanoma burden in mainland China, 1990–2023. Changes in absolute numbers of incident cases (A), prevalent cases (B), and DALYs (C) were decomposed into contributions from population growth, population aging, and epidemiological change. Stacked colored bars show the component contributions for both sexes combined and separately for females and males. Black dots indicate the observed net change. The vertical dotted line marks zero; positive values increase burden and negative values offset it.

For DALYs, the net increase was 59,209 person-years, including 36,736 in men and 22,474 in women (Figure 4C). Aging contributed 68,676 person-years (115.99%) and growth contributed 24,699 person-years (41.72%), whereas epidemiologic change contributed −34,166 person-years (−57.70%), partly offsetting the increases associated with demographic change (Figure 4C). This offset differed by sex: epidemiologic change contributed −9,256 person-years (−25.20%) in men and −24,364 person-years (−108.41%) in women (Figure 4C). Overall, decomposition patterns differed by metric: aging contributed most strongly to incident cases and DALYs, whereas epidemiologic change drove prevalence expansion while reducing DALY growth.

Age–Period–Cohort Analysis

Age effects increased steeply with age: fitted incidence reached 7.51 per 100,000 at 77.5 years, and prevalence peaked at 30.93 per 100,000 at 72.5 years; mortality and DALY age effects also rose with age (Supplementary Figure S1A–D). Period and cohort effects diverged by metric. From 1992.5 to 2022.5, period RRs increased from 0.84 to 1.28 for incidence and from 0.53 to 1.89 for prevalence, but declined by 24.75% for mortality and 21.91% for DALYs. Cohort effects showed the same pattern, increasing for incidence and prevalence in later birth cohorts while declining for mortality and DALYs after peaking around the 1935 cohort (Supplementary Figure S1A–D).

Projection Analysis

BAPC projections indicated that, by 2030, the combined-sex ASIR and ASPR would reach 0.88 and 5.84 per 100,000, respectively, whereas ASMR would remain nearly stable and ASDR would decline slightly (Supplementary Figure S2A–D). Sex-specific projections preserved the observed divergence: women were projected to have higher ASIR and ASPR than men in 2030 (1.03 vs 0.78 and 6.56 vs 5.13 per 100,000, respectively), while female ASMR and ASDR remained below male rates (Supplementary Figure S2A–D).

Discussion

Cutaneous melanoma remains uncommon in mainland China, but GBD 2023 shows a widening divergence between rising case-based burden and declining age-standardized fatal and disabling burden. By integrating age-sex analyses, decomposition, APC modelling, and projections, this study extends earlier Chinese analyses through 2023.^6–8,14 The pattern implies increasing demand for follow-up and longitudinal services, although GBD prevalence cannot establish improved survival, treatment effects, recurrence, or chronicity.

The rising ASIR and ASPR are consistent with earlier Chinese and global evidence, but our estimates demonstrate that the upward trend has continued through 2023. Wu et al reported a marked increase in China’s ASIR from 1990 to 2017, Bai et al showed continued incidence growth through 2019, and Yu et al documented increasing melanoma burden through 2021 with substantial age, sex, and provincial heterogeneity.^6–8 A recent registry study from England likewise reported rising melanoma incidence alongside falling or stabilizing mortality in younger age groups and concentration of burden growth among older adults; it also emphasized diagnostic drift and overdiagnosis as possible contributors to incidence trends.⁵ Our findings extend this trajectory through 2023. Although the ASIR in China remains far below that in Australia, New Zealand, North America, and Northern Europe, the combination of a very large population, rapid aging, and increased diagnostic intensity means that even modest rate increases in age-standardized rates can generate a substantial clinical workload.

The decomposition and APC analyses indicate that the changing burden is not solely demographic, and also involve residual changes in age-specific rates.⁸ Population aging was a major contributor to incident-case and DALY growth, whereas epidemiological change drove prevalence expansion and offset part of DALYs growth. The APC results further support a temporal separation: period and cohort effects increased for incidence and prevalence but declined for mortality and DALYs. This pattern may reflect a combination of improved case ascertainment, greater clinical attention to pigmented lesions, wider access to dermatology and pathology services, and changes in survival, but these mechanisms cannot be distinguished using GBD estimates.^9,22–25 Importantly, the “epidemiological change” component in GBD decomposition is descriptive and cannot distinguish true changes in risk exposure from improved diagnosis or cancer registration; future linkage with cancer-registry stage data and clinical cohorts will be needed to clarify the underlying mechanisms.^12,21,22,26

The Chinese clinicopathological context is relevant, but subtype observations derive from external clinical series rather than the GBD estimates analyzed here. In populations predominantly of European ancestry, ultraviolet radiation is the principal preventable cause of cutaneous melanoma, whereas clinical series from China report a larger proportion of acral lentiginous melanoma and an important burden of mucosal melanomas.^10,11,27,28 Mucosal melanoma is a distinct noncutaneous entity. Acral lesions on soles or nail units and mucosal lesions at less visible anatomical sites may escape routine observation and be diagnosed later; delayed help-seeking and diagnosis have also been documented.^10–13 The GBD skin melanoma category neither identifies acral cases nor includes mucosal melanoma, so our data cannot estimate subtype-specific trends or infer biological aggressiveness. Rising incidence should therefore not be attributed to a particular subtype or to sun-related behavior alone. Urbanization, occupational and recreational exposure patterns, improved access to specialist care, greater awareness of skin lesions, and changes in cancer registration may all have contributed.^9,26,28,29 Future surveillance should incorporate anatomical site, histology, Breslow thickness, stage, time to diagnosis, and treatment delay to distinguish changes in disease occurrence from diagnostic and registration effects.^{9,12,22,30–33}

The decline in ASMR and ASDR despite increasing deaths and DALYs is another central feature of the results. Similar decoupling between incidence and mortality has been reported in several high-income settings and is commonly attributed to earlier diagnosis, changes in diagnostic intensity, and advances in systemic therapy.^23,34,35 In China, this interpretation should remain cautious because population-level access to modern therapy is uneven, but it is clinically plausible. Anti-PD-1 agents have shown activity in Chinese patients with advanced melanoma, including pembrolizumab in KEYNOTE-151 and toripalimab in POLARIS-01.^24,25 These developments provide plausible clinical context, but the present GBD analysis cannot attribute the decline in age-standardized fatal burden to treatment, earlier diagnosis, or any specific intervention. The continued increase in absolute deaths and DALYs indicates that progress in care has not fully offset the demographic pressure from population aging. Reducing melanoma mortality in China will therefore require not only access to effective systemic therapy, but also earlier recognition, timely referral, standardized pathological diagnosis, equitable access to appropriate systemic therapy, and improved affordability of innovative anticancer medicines.^12,36–38

The age-specific findings identify two complementary targets for prevention and service planning. The highest age-specific mortality and DALY rates occurred in the oldest age groups, and the contribution of adults aged 80 years or older increased sharply across all measures. Cumulative exposure, immune senescence, multimorbidity, and diagnostic delay may contribute; in some older or frail patients, comorbidity and functional vulnerability may also limit eligibility for or tolerance of systemic treatment.^39,40 Geriatric assessment should therefore guide individualized treatment and supportive care rather than presume equal access to or suitability for anticancer therapy.⁴¹ At the same time, absolute incident cases, prevalent cases, and DALYs clustered around ages 55–59 years and adjacent groups. Rates identify the oldest adults as having the greatest individual risk, whereas counts identify late-middle-aged and early-older adults as the main source of clinical workload and health loss.⁴²

The sex-specific patterns also have implications for targeted control. Females had slightly higher ASIR and ASPR in 2023 and were projected to maintain higher incidence and prevalence rates through 2030, whereas males had a higher ASDR and more pronounced middle-age fatal and disabling burden. This differs from the overall male excess commonly reported in many populations predominantly of European ancestry, but it is compatible with the marked age-sex heterogeneity observed in recent Chinese GBD analyses and with broader evidence that melanoma outcomes and treatment patterns differ by sex.^{7,8,35,43–45} Higher female prevalence may reflect age-specific incidence patterns and unmeasured differences in diagnosis, survival, or care, whereas the higher male DALY burden may reflect later presentation, different occupational exposures, comorbidity, health-seeking behaviour, tumour thickness or subtype, and differential treatment uptake.^{10–12,43–45} Because GBD data do not include individual-level clinical variables, these explanations remain inferential. Future registry-linked studies should examine whether the observed sex differences persist after stratification by stage, anatomical site, histological subtype, mutation status, treatment exposure, and socioeconomic factors.

The BAPC projections indicate that the sex-differentiated pattern may persist in the near term: ASIR and ASPR are projected to increase through 2030, while ASMR is expected to remain nearly stable and ASDR to decline slightly overall. These projections are consistent with international modelling studies showing that population aging and growth can expand patient numbers even when age-standardized fatal burden is stable or decreasing.^3,46 The projected increase in prevalence may signal greater demand for longitudinal services. Survivorship literature indicates that some patients require long-term recurrence surveillance, management of immune-related adverse events or targeted-therapy toxicities, rehabilitation, and psychosocial support.^47–49 These are contextual care implications rather than outcomes measured in GBD; prevalence is not a direct measure of recurrence, treatment toxicity, chronicity, or individual survival. BAPC outputs should therefore be treated as planning baselines rather than deterministic forecasts, because they cannot fully capture abrupt changes in screening intensity, diagnostic technology, insurance coverage, treatment prices, clinical guidelines, or environmental exposure.^36,50

Several limitations should also be acknowledged. First, as with all GBD-based analyses, estimates depend on the completeness and quality of surveillance, mortality, and cancer-registry data; in settings with sparse direct data, modelled estimates and uncertainty intervals may be influenced by data borrowing and modelling assumptions.^15,16 Second, GBD does not provide information on melanoma subtype, anatomical site, Breslow thickness, stage at diagnosis, mutation status, treatment exposure, recurrence, socioeconomic status, or individual survival. Consequently, prevalence cannot be interpreted as direct evidence of stage migration, treatment effects, recurrence patterns, improved survival, or chronicity.^10,11 Third, this analysis was national. The absence of provincial stratification means that national averages may mask geographic differences in incidence, diagnostic access, treatment, and data quality; a robust subnational extension would require separate extraction, harmonization, and validation. Fourth, mucosal melanoma is important in the broader Chinese clinical profile, but isa distinct noncutaneous entity and cannot be directly evaluated using the GBD skin melanoma category. Fifth, the decomposition, APC, and BAPC analyses are descriptive rather than causal. Epidemiological change cannot separate true risk change from improved diagnosis or registration, and projections assume continuation of historical age-period-cohort patterns. Future research should link GBD estimates with population-based cancer registries, hospital cohorts, pathology databases, genomic data, and reimbursement records and should include validated subnational analyses.

Conclusion

Cutaneous melanoma remains uncommon in mainland China, but its burden profile is changing: incidence and prevalence increased, the burden shifted toward older ages, and population aging drove DALY growth, while age-standardized mortality and DALY rates declined. Control strategies should prioritize earlier recognition, standardized subtype-aware diagnosis, equitable treatment access, and age-adapted long-term care.

Funding Statement

There is no funding to report.

Abbreviations

ASDR, age-standardized DALY rate; ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; ASPR, age-standardized prevalence rate; ASR, age-standardized rate; BAPC, Bayesian age-period-cohort; CI, confidence interval; DALY, disability-adjusted life-year; EAPC, estimated annual percentage change; GBD, Global Burden of Disease; GHDx, Global Health Data Exchange; ICD, International Classification of Diseases; INLA, integrated nested Laplace approximation; UI, uncertainty interval; YLD, year lived with disability; YLL, year of life lost.

Data Sharing Statement

All source data used in this study are publicly available from the Global Health Data Exchange Global Burden of Disease Results Tool (https://vizhub.healthdata.org/gbd-results/). Processed datasets generated for this analysis are available from the corresponding authors, Xixi Yu and Qinglin Hu, upon reasonable request. These aggregated, de-identified estimates were used in accordance with the Institute for Health Metrics and Evaluation (IHME) Free-of-Charge Non-Commercial User Agreement, and no additional permissions were required.

Ethics Approval and Informed Consent

According to Article 32 of the Ethical Review Measures for Life Science and Medical Research Involving Human Beings of the People’s Republic of China, the data used in this study will not cause any form of harm to human beings, nor will it touch sensitive personal privacy or trade secrets, so the ethical review can be exempted. In addition, the database used in this study was publicly available and legally available.

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 have no conflicts of interest to declare for this work.