Thirty-year changes and future tendencies in Asian burden of tracheal, bronchus, and lung cancer: insights from the Global Burden of Disease Study

Introduction

Tracheal, bronchus, and lung (TBL) cancer is one of the most frequent type of cancers causing death. According to Global Cancer Statistics 2022 released by International Agency for Research on Cancer (IARC), new cases of TBL cancer reached 2.48 million, accounting for 12.4% of all new patients with cancer, and deaths amounted to 1.82 million, constituting 18.7% of all cancer-related deaths (1). TBL cancer ranked first among all cancers globally in both incidence and mortality, yet there were significant regional variations. Noticeably, Asia has emerged as the core region of this public health crisis, hosting nearly 60% of the world’s TBL cancer cases, with East Asia becoming the geographic region with the highest global incidence of 51.4 per 100,000 people (1). Compared to Western cohorts, Asian populations exhibit a distinct epidemiological and molecular landscape, characterized by a higher prevalence of epidermal growth factor receptor (EGFR) mutations among non-smokers. The increased burden of TBL cancer in Asia stems from multiple unique risk factors, such as smoking, cooking oil fumes, indoor air pollution from solid fuels, outdoor respirable particulate matter (PM) exposures associated with rapid urbanization, occupational exposures, and population ageing (2,3). TBL cancer causes a huge socio-economic burden in Asia, for instance, in China, it was estimated that the economic losses due to TBL cancer from 2020 to 2050 would reach 1.9 trillion dollars (4).

Despite the gravity of the situation, systematic research on the burden of TBL cancer in Asia is still lacking. While existing documents have focused on single countries or specific risk factors, they often fail to provide a horizontal comparative framework to evaluate relative performance across the continent. The documents have focused on single countries or specific risk factors, and comprehensive analyses integrating epidemiologic transition patterns, demographic differences, and policy-relevant indicators have been limited (5,6). This study is specifically designed to address four unresolved questions: to characterize the long-term temporal trends and inflection points of Asian TBL cancer burden; to decouple the independent impacts of population aging and epidemiological shifts on gender-specific trends; to quantify the “health efficiency gaps” across Asian countries relative to their socioeconomic development; and to evaluate the evolving contributions of traditional and emerging risk factors across diverse Asian geographical contexts.

Based on global burden of disease (GBD) 2021 database, this study aims to move beyond a descriptive assessment to conduct a systematic performance and efficiency evaluation of TBL cancer in Asia from 1990 to 2021 by comprehensively assessing incidence, prevalence, mortality and disability-adjusted life years (DALYs). We hope to provide key evidence for optimizing the continental allocation of resources for prevention and control in regionalization, formulating precise intervention strategies, and providing scientific basis for the development of TBL cancer prevention and control policies in different socio-economic contexts in Asia that account for Asia’s unique demographic and risk profiles. We present this article in accordance with the GATHER reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0740/rc).

Methods

Data sources

GBD 2021, coordinated by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in USA, compiled data from a wide range of global sources, including vital registration systems, verbal autopsies, censuses, household surveys, specific disease registries, health service contact data, and other sources, and further assessed the health risks associated with 371 diseases, injuries, and 88 risk factors in 204 countries (7,8). We depended on the GBD results tool (http://ghdx.healthdata.org/gbd-results-tool) to extract injury and risk data related to TBL cancer in Asia from GBD 2021 for the period 1990 to 2021. Socio-demographic index (SDI), which combines measures of per capital income, total fertility rate (<25 years), and average educational attainment (≥15 years), is often used to reflect the overall social and economic status of a country (7), and we obtained regional division of SDI from IHME (https://ghdx.healthdata.org/search/site/SDI) for subsequent studies. Specifically, the SDI ranges from 0 to 1, with higher values indicating higher socioeconomic status, and categorizes countries into five SDI quintiles, including low, low-middle, middle, high-middle and high. The standard population age composition proportions used in this study were obtained from the GBD world standard population calculations to age-standardize the relevant indicators and eliminate demographic differences (9). Standard population data for Asia for the period 1990-2021 were also obtained from the GBD results Tool (http://ghdx.healthdata.org/gbd-results-tool). And the Asian population projections for 2021-2050 for the projection model were also obtained from IHME (https://ghdx.healthdata.org/record/ihme-data/global-population-forecasts-2017-2100).

Study design

This study analyzed TBL cancer in Asia including all age groups from 1990 to 2021 based on GBD 2021 dataset. It focused on incidence, prevalence, death and DALYs of TBL cancer. Among these, DALYs is a composite indicator that quantifies healthy life years, consisting of years of life lost (YLLs) and years lived with disability (YLDs), and is widely used to summarize health (10). The GBD 2021 systematically adjusted epidemiological data through sophisticated statistical models (such as MR-BRT and DisMod-MR 2.1) to account for bias due to differences in data sources, definitions, and measurements, which in turn ensured internal consistency of the estimates across different regions, ages, genders, and years. For statistical modeling of GBD 2021, see the related companion documents (7,8,10). In addition, as GBD 2021 did not include data on the burden of TBL cancer in people under 15 years of age, we focused on Asian populations aged 15 years and older. As for age stratification analysis, we categorized the population into 17 groups according to a 5-year interval: 15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75–79, 85–89, 90–94, and ≥95 years. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Burden description

We presented the burden and change of TBL cancer in Asia in 1990 and 2021 through describing the distribution of absolute and age-standardized rates (ASRs) of incidence (ASIR), prevalence (ASPR), mortality (ASMR), and DALYs (ASDRs), as well as the percentage change in four major Asian regions and 49 Asian countries or regions. Firstly, we compared the burden and dynamics of TBL cancer in Asia from 1990 to 2021 under the gender dimension through biaxial bar charts. And polar bar charts visualized the differences in ASRs among countries or regions. Pyramid and line graphs were used to visualize the crude rates for different age stages and sexes, including incidence rate (IR), prevalence rate (PR), mortality rate (MR). DALYs rate (DR), to show the burden and trend of TBL cancer in different demographics in Asia. Meanwhile, the correlation between ASRs and SDIs among Asian countries or regions in 2021 was visualized and quantitatively assessed by Spearman’s test.

Statistical analysis

In this study, the data we used for analysis have been published in the GBD 2021 and are fully open and transparent, with all secondary data reported including estimates and 95% uncertainty intervals (UIs), and with rates (ASRs and crude rates) expressed as estimates per 100,000 population, and where not otherwise specified these UIs are shown in parentheses after estimates. All analyses were conducted using appropriate statistical models to systematically address the research questions regarding temporal trends, independent drivers, health system efficiency, and regional inequalities, including Joinpoint regression, age-period-cohort (APC₁) analysis, Bayesian age-period-cohort (BAPC) predictive analysis, decomposition analysis, frontier analysis, health inequality analysis and attributable risk factor analysis, with P<0.05 considered statistically significant, with details of each specific analysis described in subsequent sections. All data were analyzed and plotted using the R software package (version 4.4.1) and its integrated development environment Rstudio (version 2024.12.1 Build 563).

Joinpoint regression

To identify significant temporal inflection points that may reflect historical policy shifts or major epidemiological transitions, Joinpoint regression is employed. It is a regression analysis method that identifies “joinpoints” and analyzes trends in data by splitting a time series into multiple phases and then calculating the annual percentage change (APC₂) for each phase, allowing for a more accurate portrayal of local data dynamics. We used Joinpoint software (version 5.1.0.0, https://surveillance.cancer.gov/joinpoint/), developed by National Cancer Institute’s Division of Cancer Control & Population Sciences, to perform regression analyses of trends in the TBL cancer burden in Asia from 1990 to 2021.

Regression analyses were modeled using a log-linear model: ln(y)=xb. Trends in the data over the described time frame were described by calculating the APC₂ and its 95% confidence interval (CI₁), and the optimal number of joinpoints was selected using Monte Carlo permutation test. The average annual percentage change (AAPC) was also calculated based on the trend in the APC₂, with positive and negative AAPCs representing both upward and downward trends of data. Parallel pairwise comparison was also used to compare the gender differences in trend changes.

APC1 analysis and BAPC predictive analysis

To decouple the complex interplay between biological aging and historical risk exposure, APC₁ models are used to estimate the effects of three independent factors on disease outcomes: age, period and birth cohort, where age and period effects independently represent the impact of increasing age or period on outcomes, and cohort effects reflect changes in outcomes due to changes in mode of birth or differences in exposures for birth cohorts in different decades (11,12). We assessed the impact of age, period, and cohort effects on the burden of TBL cancer in Asia using an APC₁ model based on an intrinsic estimator (IE) algorithm.

Furthermore, to provide a robust projection for future resource allocation, we integrated Bayesian models often use sample data and prior information of some unknown parameters to estimate posterior distribution, and then infer those parameters based on the posterior distribution. Therefore, we add a Bayesian model to the APC₁ model to form the BAPC model. Considering the effect of continuity of temporal adjacencies, the second-order Random Walk (RW2) smoothed prior model is also used to ensure the identifiability of the BAPC model. And then the future burdens of TBL cancer in four major Asian regions from 2022 to 2050 were predicted by using the BAPC model integrated Nested Laplace Approximation (INLA) algorithm (13).

Decomposition analysis

To further clarify the potential drivers of the change in the burden of TBL cancer in Asia, we decomposed the disease burden from 1990 to 2021 into the contributions of aging, epidemiologic changes, and population growth after stratifying by gender based on the decomposition method proposed by Das Gupta and Cheng et al. (14,15). Through detailed assessment of the independent contribution of each factor to the overall change in the burden of disease, a clearer understanding of how epidemiologic changes and population growth may influence trends of TBL cancer burden over time was obtained. The choice of this method allows us to quantitatively isolate the extent to which the rising burden is driven by Asia’s rapid aging versus its population expansion.

Frontier analysis

Moving beyond descriptive epidemiology to evaluate the performance of public health interventions, Frontier analysis aims to explain the non-linear relationship between the burden of disease and the SDI of socio-demographic development through a series of complex statistical methods that focus on determining the theoretical minimum achievable burden based on the current level of development of each country or region and forming a non-linear frontier. In turn, the absolute difference between the current burden and this boundary for each country or region, defined as the effective difference (ED), represents the unrealized health gains that exist at the current level of development (16,17). We applied frontier analysis to construct a frontier model based on ASDRs using SDI to further assess the potential for improvement in the TBL cancer burden in Asia: we applied locally weighted regression (LOESS) combined with local polynomial regression for data envelopment analysis (DEA) to compute 100 bootstrap samples and the average ASDRs corresponding to each SDI value, generating smoothed boundary lines using different smoothing spans to capture the nonlinear relationship between ASDRs and nonlinear boundary by measuring the ED between ASDRs and the theoretical boundary from 1990 to 2021 for each country or region in Asia. This method is essential for identifying “health efficiency gaps”, providing a realistic benchmark for countries with similar levels of development.

Cross-country inequality analysis

To address the question of health equity across the most socioeconomically diverse continent, in accordance with the recommendations of World Health Organization (WHO), we used Slope Index of Inequality (SII) and Concentration Index (CI₂) to assess the inequality of the TBL cancer burden in Asia between countries in relation to their socioeconomic status based on total DALYs and ASDRs (18). The SII is typically used to quantify absolute inequalities in health indicators between the most advantaged and least advantaged subgroups of population, considering the overall contribution of factors such as socioeconomics. In contrast, the CI₂ quantify relative inequalities by presenting the concentration degree of health indicators among different social groups.

The mathematical meaning of SII is the slope of the regression line formed by regressing ASDRs on the relative SDI (defined as the midpoint of the cumulative population distribution of the individual countries sorted by SDI) (19). To better control for bias and improve accuracy, we modeled our analysis first using an ordinary linear regression model (lm) and then tested for heteroskedasticity using Breusch-Pagan test (ncvTest), and corrected for significant heteroskedasticity (P<0.05) if it existed using a robust regression model (rlm). In addition, we also estimated the SII trend for the period from 1990 to 2021. The CI₂ is a numerical integration of the area under the Lorenz curve fitting the cumulative DALYs and cumulative population, ordered by SDI, plotting the relationship between the cumulative DALYs and the cumulative population (20). Negative SII and CI₂ represent the fact that the high SDI corresponds to the low burden of disease, whereas the magnitude of the absolute value of the two indicates the high or low level of inequality.

Estimated distribution of attributable risk factors

To quantify the evolving contribution of different health determinants and explain the geographical heterogeneity of TBL cancer drivers across Asia, the attributable burden due to risk factors in the GBD 2021 study is based on the Comparative Risk Assessment framework (CRA), and for calculation of attributable burden, only those pairs of risk-outcomes considered appropriate according to the World Cancer Research Fund (WCRF) criteria are considered (8). GBD 2021 categorizes the attributable risk of disease into three primary categories: environmental or occupational, metabolic, and behavioral risks, which contain 88 subcategories. We decided to assess the changes in the following seven key risk factors for TBL cancer in Asia from 1990 to 2021, taking into account previous epidemiologic studies of TBL cancer and consultations among our team researchers: “Smoking”, “Secondhand smoke”, “Residential radon”, “Particulate matter pollution”, “Occupational carcinogens”, “High fasting plasma glucose”, and “Diet low in fruits”. We extracted component ratios of age standardized mortality percent (ASMP) and age standardized DALYs percent (ASDP) to plot grouped bar chats to assess differences in TBL cancer burden.

Results

Burden and trends of TBL cancer in Asia from 1990 to 2021

From 1990 to 2021, the incident cases of TBL cancer in Asia increased from 452,554 (408,181 to 498,556) to 1,385,198 (1,175,886 to 1,598,254), approximately two-fold; the prevalent cases rose from 532,020 (483,035 to 582,939) to 1,922,639 (1,637,213 to 2,207,698); the death cases became 2.7-fold the previous, growing from 448,085 (403,330 to 494,731) to 1,228,186 (1,042,150 to 1,410,930); and the contributing DALYs went from 12,302,447 (11,044,408 to 13,639,676) to 28,773,291 (24,283,688 to 33,146,721). After standardizing the demographics, we found that the percentage change in ASIR reached 22% (1% to 47%), with a significant increase from 22.66 (20.47 to 24.86) in 1990 to 27.72 (23.66 to 31.91) per 100,000; and the ASPR increased even more from 25.1 (22.84 to 27.4) to 37.51 (31.96 to 43) per 100,000, a change of 49% (24% to 79%); whereas the ASMR increased by only 8% (−11% to 3%) to 24.89 (21.24 to 28.53) per 100,000 in 2021 compared to 1990; furthermore, the ASDR declines by 2% (−0.2% to 0.19%) from 568.16 (510.68 to 628.07) to 557.34 (470.98 to 640.31) per 100,000 (Table 1). The number of cases for all four assessment indicators increased steadily from 1990 to 2021 both genders, with males having significantly higher rates than females for all assessment indicators. The ASIR and ASMR fluctuated within a relatively small range for both males and females, with the ASPR showing an upward trend and the ASDRs trend showing a slight decrease (Figure 1).

Figure 1 Trends in numbers and ASRs of incidence, prevalence, deaths, and DALYs, for TBL cancer in Asia from 1990 to 2021, by sex. (A) The number of incident cases and ASIR per 100,000 people of TBL cancer by year and sex. (B) The number of prevalent cases and ASPR per 100,000 people of TBL cancer by year and sex. (C) The number of deaths cases and ASMR per 100,000 people by year and sex. (D) The number of DALYs and ASDRs per 100,000 people by year and sex. ASDRs, age-standardized DALY rates; ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; ASPR, age-standardized prevalence rate; ASRs, age-standardized rates; DALYs, disability-adjusted life years; TBL, tracheal, bronchus, and lung.

In the four major Asian subregions, East Asia had the highest cases of incidence, prevalence, deaths, DALYs, and ASRs in both 1990 and 2021.Its 2021 incidence was a whopping 954,914 (770,479 to 1,154,843), accounting for nearly 70% of the total incidence cases in Asia, with an ASIR of 43.41 ( 35.14 to 52.35) per 100,000, 1.6 times the ASIR in Asia, and 834,106 (673,133 to 1,005,111) deaths, which contributed to about 68% of the total, with an ASDR of 38.53 (31.22 to 46.22) per 100,000, 1.5 times the average ASDR. Excluding DALYs in South Asia, East Asia contributed the highest positive percentage change in the cases of incidence, prevalence, deaths and ASRs for TBL cancer in Asia over the 30-year period. And it is to be noted that both the cases and ASRs in Central Asia showed negative percentage changes from 1990 to 2021 (Table 1).

Among all 49 countries or regions in Asia, China, Japan and India ranked in the top three by a wide margin in terms of the cases of TBL cancer incidence, prevalence, deaths and DALYs in 2019 and 2021. In 2021 only, the cases of incidence reached 934,704 (750,040 to 1,136,938), 121,731 (105,282 to 131,198), and 73,180 (60,076 to 84,552), respectively; and the death cases reached 814,364 (652,636 to 987,795), 92,119 (78,912 to 98,959) and 74,649 (61,314 to 86,157). It is notable that Georgia, Kazakhstan, Kyrgyzstan and Uzbekistan had negative percentage change in each of assessed indicators from 1990 to 2021 purely in cases (Table S1). For ASIR, China, Republic of Korea, and Turkey were the highest in 2021, reaching 44.01 (35.45 to 53.35), 32.5 (27.16 to 38.38), and 32.48 (25.52 to 40.02) per 100,000, respectively; while for ASMR in 2021, China, Turkey, and Armenia ranked high, peaking at 38.98 (31.4 to 47.06), 34.37 (26.99 to 42.51), and 27.35 (24.36 to 30.82) per 100,000 (Table S2). Except for Republic of Korea having the highest positive percentage change in ASPR [128% (83 to 187)] from 1990 to 2021, the highest ASIR [37% (−1% to 79%)], ASMR [38% (−1% to 79%)], and ASDR [29% (−7% to 69%)] belonged to Indonesia. Moreover, from 1990 to 2021, 67.3%, 53.1%, 69.4%, and 77.6% of the countries or regions showed negative growth in ASIR, ASPR, ASMR, and ASDR, respectively (Figure 2A-2D). The correlations between ASRs and SDIs in 2021 for Asian countries or regions were detailed in Figures S1-S4, and we found that there were correlations between ASIR, ASPR and SDIs, which did not exist in ASMR and ASDRs.

Figure 2 ASIR, ASPR, ASMR, and ASDRs, as well as age-specific incidence, prevalence, mortality, and DALYs for TBL cancer in Asian countries or regions in 1990 and 2021. (A) The ASIR for TBL cancer in Asian countries or regions. (B) The ASPR for TBL cancer in Asian countries or regions. (C) The ASMR for TBL cancer in Asian countries or regions. (D) The ASDRs for TBL cancer in Asian countries or regions. (E) The number of age-specific incident cases for TBL cancer in Asia. (F) The age-specific incident rate per 100,000 people for TBL cancer in Asia. (G) The number of age-specific prevalent cases for TBL cancer in Asia. (H) The age-specific prevalent rate per 100,000 people for TBL cancer in Asia. (I) The number of age-specific deaths cases for TBL cancer in Asia. (J) The age-specific deaths rate per 100,000 people for TBL cancer in Asia. (K) The number of age-specific DALYs for TBL cancer in Asia. (L) The age-specific DALYs rate per 100,000 people for TBL cancer in Asia. ASDRs, age-standardized DALY rates; ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; ASPR, age-standardized prevalence rate; DALYs, disability-adjusted life years; TBL, tracheal, bronchus, and lung.

The age group with the highest number of TBL cancer incidence and deaths in Asia changed from 65–69 years in 1990 to 70–74 years in 2021, while the age group with the highest number of prevalence and DALYs changed from 60–64 years in 1990 to 65–69 years in 2021, with an overall delay of 5 years (Figure 2E-2H). This trend was also reflected in the analysis stratified by gender (Figures S5-S8). IR was not significantly different between 1990 and 2021 before age 64, but was significantly higher in 2021 after age 64, while age group with the highest incidence remained 85-89 years (Figure 1I). PR in 2021 was significantly higher after age 44 than in 1990, and the highest prevalence age group changed from 70–79 years to 85–89 years (Figure 1J). As for the MR and DR, there were three stages in the distribution of their changes in 1990 and 2021 among the age groups: before age 34, 34–69 years, and over age 69. There was no significant difference before age 34, significantly lower than 1990 in 2021 for 34–69 years, and significantly higher than 1990 in 2021 after age 69. Additionally, the peak age of deaths remained at 90–94 years, while the DR was delayed from 70–74 years to 75–79 years (Figure 1K,1L). See Figures S5-S8 for details of age-based analyses of rates based on gender.

Joinpoint regression analysis of TBL cancer burden in Asia from 1990 to 2021

Joinpoint regression analysis of ASRs for TBL cancer in Asia from 1990 to 2021 revealed major trends and gender differences in the four assessed metrics. ASIR showed an overall increasing trend (AAPC =0.67), excluding 2011–2016 (APC₂ =−0.43), with positive APC₂ values for the rest of the years
(Figure 3A). ASIR was significantly higher in males than females, with all females showing an upward trend in ASIR, while males had downward trends in 2004–2007 (APC₂ =−0.01) and 2011–2021 (APC₂ =−0.49) (Figure S9). ASPR exhibited a significant upward trend over time (AAPC =1.31) (Figure 3B), with the fastest rate in 1998–2001 (APC₂ =3.54). For gender differences remained (AAPC difference =0.48), but all accelerated over time, yet males grew significantly slower (APC₂ =0.14) than females (APC₂ =2.24) in the last period (Figure S10). As for the ASMR, even though it generally showed a slight upward trend (AAPC =0.26), there were large fluctuations in the middle, with the fastest growing period from 1997–2004 (APC₂ =1.23), and downward trends from 2004–2007 (APC₂ =−1.16) and 2011–2021 (Figure 3C). The fluctuating trend of ASMR for males was similar to the overall ASMR change, and a similar two-period decline in ASMR for females was present, but the second period showed an upward trend starting in 2014 (APC₂ =1.29) (Figure S11). The ASDR was the most volatile indicator, with a nearly symmetrical distribution on the axis of 2004, with a significant increase from 1990–2004, and a downward trend after 2004, except for a brief increase from 2007–2011 (APC₂ =0.12) (Figure 3D). The difference in ASDR between genders was significant (AAPC difference =0.35), and the overall changes were all similar to the total ASDR, but females showed a significant increase after 2014 (APC₂ =1.04) (Figure S12). For 95% CI₁s and specific P values for APC₂ and AAPC, please refer to the corresponding picture information.

Figure 3 Joinpoint regression analysis of trends in ASIR, ASPR, ASMR, and ASDRs in Asian TBL cancer from 1990 to 2021, with Asterisks indicating statistically significant changes (P<0.05). (A) Trends in ASIR per 100,000 people of TBL cancer in Asia; (B) Trends in ASPR per 100,000 people of TBL cancer in Asia; (C) Trends in ASMR per 100,000 people of TBL cancer in Asia; (D) Trends in ASDRs per 100,000 people of TBL cancer in Asia. AAPC, average annual percent change; ASDRs, age-standardized DALY rates; ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; ASPR, age-standardized prevalence rate; CI, confidence interval;DALYs, disability-adjusted life years; TBL, tracheal, bronchus, and lung.

Impact of age, period, and cohort on TBL cancer burden in Asia

APC₁ analysis of TBL cancer burden in Asia from 1990 to 2021 revealed important trends in different population groups. Among them, IR increased over time and age, peaking at 85–89 years (Figure 4A). Figure 4B showed the same trend. As shown in Figure 4C,4D, the IR at 45–65 years remained essentially stable, whereas there was a decreasing trend with the period of birth for those under 45 years and a significant increasing trend for those over 65 years, with a peak at around 85–89 years. The overall PR also showed an age-dependent increasing trend, with a peak around 85–89 years and a more significant difference in PR within the 60 plus age group (Figure 4E,4F). There was an increasing trend in PR over the age of 45 years, and this was more pronounced over the age of 65 years, again peaking at 85–89 years (Figure 4G,4H). MR showed a time-dependent increasing trend until 90–94 years, and then gradually decreased, as shown in Figure 4I,4J. The MR did not change significantly over time for ages 45–65 years, whereas it showed a decreasing and increasing trend before 45 years and after 65 years, respectively (Figure 4K), with the highest rate at ages 90–94 years (Figure 4L). As for DR, the peak age group was already at 70–74 years, with an age-dependent decreasing trend after 74 years old (Figure 4M), and the gap between different years was obvious, showing that the earlier the year, the lower the value (Figure 4N). Taking 65 years as the cut-off, DR was decreasing over time in the age group below 65 years, while above 65 years showed a significant increase (Figure 4O), especially in the age group of 90–94 years, while the peak was in the age group of 70–74 years (Figure 4P).

Figure 4 Age, period, and cohort effects on the incidence, prevalence, deaths and DALYs of TBL cancer in Asia. (A) The ASIR of TBL cancer according to time periods. Each line connects the ASIRs for a 5-year period. (B) The ASIR of TBL cancer according to birth cohorts. Each line connects the age-specific ASIRs for a 5-year birth cohort. (C) The period-specific IR of TBL cancer according to age groups. Each line connects the period-specific IRs for a 5-year age group. (D) The birth cohort-specific IRs of TBL cancer according to age groups. Each line connects the birth cohort-specific IRs for a 5-year age group. (E) The ASPR of TBL cancer according to time periods. Each line connects the ASPRs for a 5-year period. (F) The ASPR of TBL cancer according to birth cohorts. Each line connects the age-specific ASPRs for a 5-year birth cohort. (G) The period-specific PR of TBL cancer according to age groups. Each line connects the period-specific PRs for a 5-year age group. (H) The birth cohort-specific PR of TBL cancer according to age groups. Each line connects the birth cohort-specific PRs for a 5-year age group. (I) The ASMR of TBL cancer according to time periods. Each line connects the ASMRs for a 5-year period. (J) The ASMR of TBL cancer according to birth cohorts. Each line connects the age-specific ASMRs for a 5-year birth cohort. (K) The period-specific MR of TBL cancer according to age groups. Each line connects the period-specific MRs for a 5-year age group. (L) The birth cohort-specific MR of TBL cancer according to age groups. Each line connects the birth cohort-specific MRs for a 5-year age group. (M) The ASDRs of TBL cancer according to time periods. Each line connects the ASDRs for a 5-year period. (N) The ASDRs of TBL cancer according to birth cohorts. Each line connects the age-specific ASDRs for a 5-year birth cohort. (O) The period-specific DR of TBL cancer according to age groups. Each line connects the period-specific DRs for a 5-year age group. (P) The birth cohort-specific DR of TBL cancer according to age groups. Each line connects the birth cohort-specific DRs for a 5-year age group. ASDRs, age-standardized DALY rates; ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; ASPR, age-standardized prevalence rate; DALYs, disability-adjusted life years; DR, DALY rate; IR, incidence rate; MR, mortality rate; PR, prevalence rate; TBL, tracheal, bronchus, and lung.

Decomposition analysis of factors influencing TBL cancer burden in Asia

The decomposition analysis of factors influencing TBL cancer burden in Asia from 1990 to 2021 assessed the different contributions of factors such as aging, population growth, and epidemiologic changes (Figure 5A-5D and Table S3). Overall, the population growth contributed the most cases to TBL cancer in Asia, both in males and females, amounting to 45.26%, 39.39%, 50.39%, and 59.98% in incidence, prevalence, deaths, and DALYs, respectively, especially for males who were higher than females in terms of mortality and DALYs (6.32%, 8.05%) (Figure 5C,5D). Aging was the second most important contributor to disease burden, with a greater impact observed in males compared to females, with differences in the percentage of incidence, prevalence, deaths and DALYs reaching 5.66%, 4.4%, 6.22%, and 7.36%. Epidemiologic changes, while taking an advancing role based on incidence and prevalence, nevertheless contributed to mitigating deaths (−0.35%) and DALYs (−10.33%) in males (Figure 5C,D), but this was not reflected in females.

Figure 5 Decomposition analysis of the contributions of aging, epidemiological changes, and population factors to the incidence, prevalence, deaths and DALYs of TBL cancer in Asia, stratified by gender. Positive values on the x-axis indicate an increase in burden indicators, while negative values indicate a decrease. The black dots represent the total impact of these three factors. (A) Contributions of aging, epidemiological changes, and population factors to the incidence of TBL cancer for females, males, and both sexes. (B) Contributions of aging, epidemiological changes, and population factors to the prevalence of TBL cancer for females, males, and both sexes. (C) Contributions of aging, epidemiological changes, and population factors to the deaths of TBL cancer for females, males, and both sexes. (D) Contributions of aging, epidemiological changes, and population factors to the DALYs of TBL cancer for females, males, and both sexes. DALYs, disability-adjusted life years; TBL, tracheal, bronchus, and lung.

Frontier analysis on TBL Cancer in Asia based on ASDRs

Frontier analyses around ASDR and SDI were conducted to explore the relationship between country or region levels of development and the burden of TBL cancer based on data from 1990 to 2021 (Figure 6A,6B and Table S4). The 10 countries or regions with the largest actual differences in potential improvements (ED range, 457.57–759.46) included China, Turkey, Armenia, Georgia, Democratic People’s, Republic of Korea, Taiwan (Province of China), Cambodia, Thailand, Brunei Darussalam, and Mongolia. While border countries or regions with low SDI included Nepal, Bhutan, Bangladesh, India, and Tajikistan, those with high SDI and high potential for improvement included Brunei Darussalam, Taiwan (Province of China), Republic of Korea, Cyprus, and Israel, Notably Saudi Arabia, Kuwait, and United Arab Emirates, which even though high SDI countries (SDI: 0.82–0.85), still have more favorable ASDRs values (49.58–169.75).

Figure 6 Frontier analysis based on SDI and ASDRs of TBL cancer in Asia. The frontier is delineated in solid black color; countries and regions are represented as dots. (A) The unrealized health gains about ASDRs of TBL cancer in Asian countries or regions at different levels of development from 1990 to 2019; (B) The DALYs burden and the effective difference in Asian countries or regions with different SDI levels between 1990 and 2021. The top 10 countries or regions with the largest effective difference are labeled in black; examples of frontier countries with low SDI and low effective difference are labeled in blue, and examples of countries or regions with high SDI and relatively high effective difference for their level of development are labeled in red. The red dots indicate an increase in ASDRs from 1990 to 2019; and the blue dots indicate a decrease in ASDRs between 1990 and 2019. The country corresponding to the overlapping marker is Brunei Darussalam. ASDRs, age-standardized DALY rates; DALYs, disability-adjusted life years; SDI, socio-demographic index; TBL, tracheal, bronchus, and lung.

Cross-country inequalities on TBL cancer DALYs burden in Asia

Based on the cases and ASRs of DALYs, we assessed the inequality of the TBL burden across countries or regions using data from 1990 to 2021 and observed a significant transformation of the burden from TBL across countries or regions with different SDIs (Figure 7A,7B and Table S5). As can be seen from SII, the gap in ASDRs between countries or regions with the highest and lowest SDIs decreases from 377.0 (95% CI₁: 193.96 to 561.44) in 1990 to 83.10 (95% CI₁: −69.90 to 236.10) in 2021. In addition, the overall SII showed a decreasing trend between 1990 and 2021 (Figure S13), and these results suggested a decrease in absolute imbalance. In contrast, the CI₂ shifted from 0.12 (95% CI₁: −0.11 to 0.33) in 1990 to −0.14 (95% CI₁: −0.36 to 0.08) in 2021, suggesting a further increase in relative inequality.

Figure 7 Cross-country health inequality analysis for the DALYs of TBL cancer in Asian between 1990 and 2021. (A) Absolute income-­related healthy inequality in TBL cancer burden according to the ASDRs in Asian countries or regions between 1990 and 2021, presented using regression lines. (B) Relative income-­related healthy inequality in TBL cancer burden according to the ASDRs in Asian countries or regions between 1990 and 2021, presented using concentration curves. ASDRs, age-standardized DALY rates; DALYs, disability-adjusted life years; SDI, socio-demographic index; TBL, tracheal, bronchus, and lung.

Trends in TBL cancer burden in four major Asian subregions projected to 2050

We performed forecasting analysis of BAPC using Asian lung cancer burden from 1990 to 2021 and population projection data to 2100 (Figure 8 and Table S6). From 2022 to 2050, ASIR, ASPR, ASMR, and ASDRs in Central Asia showed a significant downward trend, with ASDRs likely to decrease to 231.43 (95% CI: 140.27, 322.59) per 100,000 population in 2035 (Figure 8A-8D). In East Asia, ASIR and ASPR showed an increasing trend, with ASIR reaching 48.34 (95% CI: 28.55, 68.13) per 100,000 and ASPR reaching 70.74 (95% CI: 39.73, 101.75) per 100,000 by 2035, while ASMR and ASDRs showed insignificant changes (Figure 8E-8H). In South Asia, ASIR, ASPR and ASDRs are likely to have an increase in the future, while ASMR stabilizes to reach 7.07 (95% CI: 4.73, 9.41) per 100,000 people in 2035 (Figure 8I-8L). ASIRs, ASPRs, ASMRs and ASDRs in Southeast Asia showed a slight upward trend over the next 30 years (Figure 8M-8P).

Figure 8 BAPC analysis predicting the ASIR, ASPR, ASMR and ASDRs of TBL cancer in Asian main subregions by 2050. (A) Predicted ASIR for Central Asia, illustrating the estimated rates up to the year 2050. (B) Predicted ASPR for Central Asia, illustrating the estimated rates up to the year 2050. (C) Predicted ASMR for Central Asia, illustrating the estimated rates up to the year 2050. (D) Predicted ASDRs for Central Asia, illustrating the estimated rates up to the year 2050. (E) Predicted ASIR for East Asia, illustrating the estimated rates up to the year 2050. (F) Predicted ASPR for East Asia, illustrating the estimated rates up to the year 2050. (G) Predicted ASMR for East Asia, illustrating the estimated rates up to the year 2050. (H) Predicted ASDRs for East Asia, illustrating the estimated rates up to the year 2050. (I) Predicted ASIR for South Asia, illustrating the estimated rates up to the year 2050. (J) Predicted ASPR for South Asia, illustrating the estimated rates up to the year 2050. (K) Predicted ASMR for South Asia, illustrating the estimated rates up to the year 2050. (L) Predicted ASDRs for South Asia, illustrating the estimated rates up to the year 2050. (M) Predicted ASIR for Southeast Asia, illustrating the estimated rates up to the year 2050. (N) Predicted ASPR for Southeast Asia, illustrating the estimated rates up to the year 2050. (O) Predicted ASMR for Southeast Asia, illustrating the estimated rates up to the year 2050. (P) Predicted ASDRs for Southeast Asia, illustrating the estimated rates up to the year 2050. ASDRs, age-standardized DALY rates; ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; ASPR, age-standardized prevalence rate; BAPC, Bayesian age-period-cohort; DALYs, disability-adjusted life years; TBL, tracheal, bronchus, and lung.

Attributable risk factor analysis of TBL cancer burden in Asia

We evaluated the impact of seven risk factors currently receiving widespread attention on the burden of ASMR and ASDRs in Asian countries or regions (Figure 9, Figures S14,S15). Analysis found that smoking remained the primary factor, with a reduction of 5.5% and 5% in 2021 compared to 1990 regarding the overall percentage of smoking for ASMR and ASDRs, most notably in South Asia, with reductions of 15.4% and 15.2%, respectively (Figure 9). Whereas, Lebanon, Afghanistan, Georgia, Uzbekistan, and Mongolia had increases in the percentage of smoking in both ASMR and ASDRs. Particulate matter pollution was the second most important factor, similar to smoking, and both decreased in 2021. While Jordan, Lebanon, Palestine, Saudi Arabia showed an increasing trend in the share of it. Occupational carcinogens, while only accounting for about 10% of the influencing factors, has increased its percentage in recent years. It was noteworthy that South Asia had a large proportion of ASMR and ASDRs attributed to diet low in fruit, both reaching more than 15%. This was especially observed in Bangladesh, India, Mongolia, and Timor-Leste. The rest of the factors showed little fluctuation in change and accounted for a relatively small weight, such as residential radon, secondhand smoke, and high fasting plasma glucose.

Figure 9 Risk factor analysis of ASMP and ASDP attributable to TBL cancer between 1990 and 2021 in major Asian regions: smoking, secondhand smoke, residential radon, particulate matter pollution, occupational carcinogens, high fasting plasma glucose, and diet low in fruits. (A) Risk factors derived from ASMP attributable to TBL cancer between 1990 and 2021 in Asia, Central Asia, East Asia, South Asia, and Southeast Asia. (B) Risk factors derived from ASDP attributable to TBL cancer between 1990 and 2021 in Asia, Central Asia, East Asia, South Asia, and Southeast Asia. ASDP, age standardized DALYs percent; ASMP, age standardized mortality percent; TBL, tracheal, bronchus, and lung.

Discussion

TBL cancer is a major challenge for global public health, especially for Asian regions, resulting in a huge socioeconomic burden. Based on GBD 2021 data for 4 subregions and 49 countries or regions in Asia, we conducted comprehensive and deep analyses of TBL cancer burden in Asia from 1990 to 2021 using various advanced analysis models to reveal the spatial and temporal evolution, the attributing factors, and the future development trend from multiple perspectives. This study not only provided comprehensive insights into TBL cancer burden in Asia, but also provided valuable references for prevention and treatment of TBL cancer.

Over the three decades from 1990 to 2021, the number of TBL cancer incident cases in Asia increased substantially, and the number of deaths reached 2.7-fold increase. Joinpoint analysis revealed significant temporal inflection points, indicating that the TBL cancer burden in Asia has been increasing over the past three decades, which was closely related to the aging of the population (21). Of course, it also relied on the increasing health awareness of the population and the improvement and popularization of early diagnostic tools for TBL cancer, such as, thin-layer computed tomography (CT) and low-dose spiral CT (22).

Regarding the change in the age distribution of the TBL cancer burden, the overall number of cases showed a trend of delaying the age group by 5 years. The highest age groups for incidence and deaths have changed to 70–74 years, and for prevalence and DALYs to 65–69 years. The peak ages for ASIR and ASPR have been pushed back to 85–89 years; ASMR has remained at 90–94 years, and the peak age for ASDRs has been delayed by five years to 75–79 years. The overall delay in the age group of high disease burden may be due to the facts that older people were exposed to longer enrichment of various risk factors than younger people, such as smoking, environmental pollution, and chronic diseases (23); and it was also attributed to the progress made in TBL cancer interventions in some Asian countries and regions, such as enhancement of early diagnosis technologies and treatments (24). The APC₁ analysis similarly revealed the combined age, period and cohort effects on TBL cancer burden. TBL cancer burden rates showed a time-age-dependent upward trend up to the high prevalence age, as described earlier, and it is true that aging increases the body’s susceptibility to cancer-causing factors, and decreases in immune function, resulting in a gradual increase in TBL cancer burden. Whereas a decline in TBL cancer burden occurs beyond that high occurrence age, Nature published studies suggesting that this may be related to iron homeostasis reprogramming by aging restricting cell stemness, and some scholars have proposed the innate gene theory or suggested that it is due to statistical bias (25,26). Noteworthy was 45–65 years age group, where there were no significant fluctuations in the TBL cancer burden rates. However, in the birth cohort below 45 years old, namely those born after 1945, the TBL cancer burden rates showed a time-dependent decreasing trend. On the contrary, those above 65 years showed an increasing trend in TBL cancer burden. This may stem from the fact that improvements in early diagnostic techniques have facilitated the detection of more TBL cancer cases in the older age groups, whereas environmental improvements and better medical care have reduced the burden of TBL cancer originating in the younger age groups. Differences in the risk of TBL cancer among different birth cohorts have inspired us to take into account the characteristics of different birth cohorts and changes in the burden of disease over time and age when formulating strategies for lung cancer prevention and control, and to adopt targeted interventions.

Furthermore, all indicators of TBL cancer burden in males was significantly higher than that in females, including cases and ASDs. The reasons behind this gender difference were complex: on the one hand, the smoking rates of males were generally higher than females, and the long-term and large amount of smoking made males much more exposed to carcinogenic substances in tobacco than females, which increased the risk of TBL cancer (27); on the other hand, in occupational environments, males were likely to be more engaged in jobs that exposed to carcinogenic substances, such as mine mining and chemical production, which further increased the risk of TBL cancer incidence in males (28). However, it is important to note that the trend of the indicators in the most recent period showed a significant increase in females, while in males they showed a decrease, for example, ASIR (APC₂: females vs. males =1.63: −0.49), ASMR (APC₂: females vs. males =1.29: −0.75), ASDR (APC₂: females vs. males =1.04: −1.05). This gender difference may be caused by the increased prevalence of TBL cancer in female smokers and the higher sensitivity to tobacco carcinogens in women due to mutations in genes such as p53 and K-RAS (29). However, studies have shown that about 60–80% of women with TBL cancer in Asia have never smoked, so the source of this difference may be attributed to the complex causal relationship between estrogen and TBL cancer (30,31).

As a high incident area of TBL cancer in the world, East Asia accounted for about 70% of the total number of TBL cancer incident and death cases in the whole Asia in 2021, with ASIR and ASDR reaching 1.6 and 1.5 times of the Asian average, respectively. Although the total population of East Asia accounted for 40% of the total population of Asia, there was a significant imbalance between TBL cancer burden and population ratio. We could observe that even though East Asia consists of only a few countries, among them China and Japan contributed a huge proportion as the top three countries in Asia in terms of disease burden. Excluding the large population base in East Asia itself, the type-specific distribution of TBL cancer types was also an important reason for the disproportionate burden of TBL cancer. Statistics have found that adenocarcinoma dominates lung cancer in East Asia, especially in female patients, where the proportion of non-smoking patients reached close to 80%, while squamous and small-cell carcinomas dominate in North America and Eastern Europe (32). It has been shown that adenocarcinomas are more likely to be induced by fewer genetic damages, such as 19-del and 21-L858R in the driver genes EGFR, and that susceptibility to different TBL cancer subtypes varies among different populations, with 50% of East Asian TBL cancers having EGFR mutations compared to 10% of white TBL cancers (33-35). A million-person genome-wide association study (GWAS) has further identified susceptibility genes among different populations, laying the foundation for the diagnosis and treatment of TBL cancer (36). In contrast to East Asia, TBL cancer burden has changed negatively in Central Asia, such as Georgia, Kazakhstan, Kyrgyzstan, and Uzbekistan. This change may be attributed to the gradual improvement of local healthcare system, especially in the context of the “Silk Road of Health” between China and Central Asia, which has led to promotion of early screening and upgrading of medical technology for TBL cancer. According to projections, the high TBL cancer burden in East Asia and the negative trend in Central Asia are likely to continue in the coming decades.

Our decomposition analysis showed that population growth contributed the most to the burden of TBL cancer in Asia for both males and females, followed by population aging. Population growth and aging are social problems faced globally, and further exacerbation of this problem will inevitably lead to a rise in the absolute number of TBL cancer patients (37). The role of epidemiologic changes in the TBL cancer burden was more complex, and although still driving to incidence and prevalence, contributed to a reduction in mortality and DALYs in men, yet this phenomenon was not reflected in women. This may be related to the differences between males and females in the pattern of exposure to TBL cancer risk factors, the body’s response to carcinogenic factors, and the effectiveness of medical interventions. For example, males may be more deeply exposed to cancer-causing factors due to poor lifestyle habits such as smoking, and thus the mortality and DALYs rate in males have been reduced to a certain extent under epidemiologic changes (such as tobacco control, environmental improvements); whereas, female TBL cancer patients with low percentage of smoking and difficulty in reducing exposure to cooking fumes of life did not show a similar change (38-40).

Frontier analysis showed that countries or regions with greater potential, such as China, Turkey, Armenia, and Georgia, may need to further optimize public health policies, increase the investment of medical resources, and strengthen health education in controlling the TBL cancer burden. In countries or regions with lower SDI, such as Nepal, Bhutan, and India, the TBL cancer burden was high, which may be related to the low level of socio-economic development, the lack of medical resources, and the low health awareness of the residents. Some countries or regions with high SDI and high potential for improvement, such as Brunei Darussalam, Republic of Korea, and Cyprus, had deficiencies in controlling the TBL cancer burden despite their high level of socio-economic development, suggesting that these regions may need to make efforts in the refinement of the healthcare service system, and the precise prevention and control of risk factors. Moreover, Saudi Arabia, Kuwait, and United Arab Emirates, although belonging to the high SDI countries, had favorable ASDR values, which may be attributed to their effective initiatives in the construction of healthcare systems, and environmental management, which could provide valuable lessons for other countries or regions. Estimates of inequality between countries or regions found that SII showed an overall decreasing trend during 1990–2021, while CI changed from 0.12 in 1990 to −0.14 in 2021, implying that the absolute imbalance of the TBL cancer burden in Asian regions has improved, but the relative inequality has increased. This seemingly contradictory result may stem from the further emphasis on TBL cancer prevention and control and the further improvement in the level of control in high SDI countries. Even though low SDI countries have made efforts, they still bear more of the TBL cancer burden. This imbalance in the burden of TBL cancer is likely to widen in the future as socio-economic and medical standards develop at different rates.

Our analysis of risk factors for ASMR and ASDRs revealed that smoking remains the leading factor. However, its overall burden has declined significantly over the past three decades, especially in South Asia, which stems from fruitful global tobacco control in recent years, such as the implementation of the Framework Convention on Tobacco Control (FCTC) in 2005, which has attracted participation from various countries or regions worldwide (38,41). However, countries such as Lebanon, Afghanistan, and Georgia have not had sufficient tobacco control efforts, and the percentage of smoking was on the rise. Furthermore, the differences in smoking between males and females are of concern, especially the increase in the proportion of females who smoke, which may be an important reason for the increase in the number of female patients with TBL cancer. Ambient particulate matter pollution, especially PM2.5, was an important source of TBL cancer burden. Some studies have shown that some countries or regions in Asia contribute more than half of the world’s population exposed to air pollution, such as China, India and other countries with low to medium SDI, which was closely related to their pollution due to industrial development and use of solid fuels (42). However, the proportion attributable to ambient particulate matter pollution has generally declined, which may stem from the emphasis placed on environmental improvement in recent years, such as China’s promulgation of the Action Plan for Air Pollution Prevention and Control, which guides the prevention and control of air pollution (43). Recently, the United Nations Environment Programme (UNEP) also released a report on 25 measures to combat air pollution, which are expected to reduce premature deaths due to air pollution by one third (44). Although occupational carcinogens only contributed to about 10% of the factors influencing the burden of TBL cancer, they have shown an increasing trend in recent years. This reflected the increase in some high-risk occupational exposures, such as asbestos, silica, radioactive radon, and heavy metals, with economic development and industrial restructuring in some parts of Asia (45,46). In South Asia, Bangladesh, India and Mongolia, the proportion of TBL cancer attributable to fruit intake was larger, suggesting that the problem of diet low in fruits in the dietary structure of the residents in this region is more prominent. Some studies have shown that more intake of vegetables and fruits could reduce the risk of TBL cancer, therefore, a moderate increase in fruit intake has a role in reducing the burden of TBL cancer (47). Even though factors such as residential radon, secondhand smoke, and high fasting plasma glucose have not changed with much fluctuation and account for a relatively small portion of the TBL cancer burden, they are still potential risk factors that should not be ignored and require continuous attention.

Admittedly, this study has several limitations. First, unavoidable missing data affected the completeness and representativeness of the data, especially the under-registration of data in some remote areas of Asia, and the misdiagnosis or omission of cases due to low health resources. Secondly, the quality of GBD data varies across years, with the earlier the period, the lower the quality of the data, which was closely related to the imperfections of the early statistical modeling and incomplete data collection. Moreover, GBD results are heavily dependent on statistical modeling, and despite multiple corrections, the estimates may not accurately reflect real-world conditions, thus affecting the accuracy of our results. Finally, TBL cancers have various subtypes in the real world, such as adenocarcinoma, squamous carcinoma, and so on, yet based on the limitations of the GBD database, we were unable to perform a fine-grained analysis, and thus our conclusions were guided by more generalized meanings. Thus, these limitations should be considered along with the interpretation of our results.

Conclusions

TBL cancer is a major public health challenge in Asia. From 1990 to 2021, ASIR, ASPR, and ASMR for TBL cancer in Asia have increased significantly, while ASDRs have declined. Regarding gender, the TBL cancer burden showed a decreasing trend in males, while it was increasing in females. In contrast, the age group with high burden shifted back by 5 years, as evidenced by a decreasing burden before the age of 45 years and an increasing burden with age above 65 years. Decomposition analyses indicated that population aging contributed the most to the TBL cancer burden, while the impact of epidemiologic changes showed significant contrasts between males and females. We found that the absolute differences in TBL cancer burden among Asian countries or regions have narrowed, yet the relative differences remain significant. Meanwhile, most countries or regions have much space for improvement in controlling the disease burden. Among them, Saudi Arabia, Kuwait, and United Arab Emirates are the countries to learn from. Smoking and particulate matter pollution remained the main causes of TBL cancer burden, although the proportion has been gradually decreasing. Additionally, the effects of low fruit intake and high fasting glucose on TBL cancer burden also need to be paid attention to. The results of this study could provide a basis for policy formulation and rational allocation of resources for TBL cancer prevention and control in Asia.

Acknowledgments

We acknowledge the Institute for Health Metrics and Evaluation (University of Washington), the GBD 2021 Collaborators, and all contributing staff for providing the data essential to this study.

Footnote

Reporting Checklist: The authors have completed the GATHER reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0740/rc

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Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0740/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

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