
==== Front
Chin Med J (Engl)
Chin Med J (Engl)
CM9
Chinese Medical Journal
0366-6999
2542-5641
Lippincott Williams & Wilkins Hagerstown, MD

39207303
CMJ-2024-1500
10.1097/CM9.0000000000003293
00006
3
Original Article
Burden of female breast and five gynecological cancers in China and worldwide
Tan Nuopei 1
Wu You 2
Li Bin 2
Chen Wanqing 1
Yin Yanjie
1 Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
2 Department of Gynecology Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
Correspondence to: Prof. Wanqing Chen, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing 100021, China E-Mail: chenwq@cicams.ac.cn;
Prof. Bin Li, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China E-Mail: libin@cicams.ac.cn
29 8 2024
20 9 2024
137 18 21902201
13 5 2024
Copyright © 2024 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the CC-BY-NC-ND license.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

Abstract

Background:

Female breast and five gynecological cancers remain substantial burden in China and worldwide. GLOBOCAN 2022 has recently updated the estimates of cancer burden. This study aims to depict the profiles of disease burden and to compare the age-specific rates of female breast and five gynecological cancers in China with those in other countries.

Methods:

The latest estimates of incidence and mortality of female breast and five gynecological cancers from various regions and countries were extracted from the GLOBOCAN 2022 database. We compared the proportion of total cases or deaths for cancers affecting female breast and five gynecological cancers and other tumor types in China and globally. Correlation analysis was conducted to evaluate the relationship between age-standardized incidence rate (ASIR) or age-standardized mortality rate (ASMR) and the Human Development Index (HDI). Additionally, age-specific rate curves were plotted for ten exemplary countries with different income levels.

Results:

Female breast and five gynecological cancers in China accounted for 30.2% of all newly diagnosed cancer cases. Breast cancer and cervical cancer are the most commonly diagnosed, with nearly 507,000 new cases, representing 23.48% of the new cases. The incidence rates of breast, uterine corpus, ovarian, and vulvar cancers were positively associated with HDI tiers. Chinese women aged 50– 54 years are experiencing high incidence rates of breast, cervix uteri, corpus uteri, and ovarian cancers.

Conclusions:

Female breast and five gynecological cancers continue to be a significant health concern for women in China and worldwide. It is crucial to implement comprehensive prevention strategies tailored to address the increasing trend among younger individuals and reduce regional disparities.

Keywords:

Cancer incidence
Cancer mortality
China
GLOBOCAN
Worldwide
Female organ
Breast cancer
Ovarian cancer
OPEN-ACCESSTRUE
SDCT
==== Body
pmcIntroduction

Female breast and five gynecological cancers have emerged as crucial contributors to disease and financial burden worldwide, owing to their insidious onset, poor prognosis, and high risk of recurrence after treatments.[123] According to the 2022 World Health Organization (WHO) estimates, six major cancers in female organs were assessed, including female breast, vulva, vagina, cervix uteri, corpus uteri, and ovary. These cancers accounted for nearly 3.6 million new cases and 1.2 million deaths globally, with breast cancer responsible for nearly half of each number and ranking first among all cancers in women. Cervical cancer is the fourth most frequently diagnosed malignancy and the third leading cause of cancer death, whereas corpus uteri and ovary cancers within the top 10 in incidence and mortality rate.[1] Although vaginal and vulvar carcinomas are rare entities, they are increasingly being observed in younger women due to the rise in persistent high-risk human papillomavirus (HPV) infections.[4,5] Extensive geographic disparities exist in the burden of cancers in female breast and gynecological organs. Approximately 78% of new cases and over 50% of cancer deaths in these organs were in high and upper middle-income countries,[1] whereas over 80% of women diagnosed and 90% of deaths from cervical cancer were in lower-resource countries.[6]

China, as one of the most populous developing countries worldwide, contributed relatively greater numbers of diagnosed cases in female breast cancer and five gynecolgical cancers.[1,7] To address these challenges, efforts have been made in China, including the implementation of screening programs for cervical and breast cancer, as recommended by the China’s National Health Commission. The National Central Cancer Registry has been collecting continuous monitoring data of female genital organ cancers derived from 700 population-based cancer registries. However, these strategies have failed to reverse the upward trends of the six female tumors, although they have changed the age-specific incidence and mortality rates to some extent in the past two decades in China.[7,8] Differences in the peak age of disease incidence across various countries can serve as a reflection of disparities in population demographics, lifestyle, healthcare quality, and the effectiveness of prevention and control measures.[9] Comparative analysis of disease incidence rates within specific age brackets across diverse nations enables researchers to discern variations in health profiles among countries, facilitating the formulation of tailored preventive and therapeutic strategies for China.

In this article, we aim to describe the burden of female breast and five gynecological cancers in China and worldwide in 2022 based on the GLOBOCAN estimates, with an emphasis on regional and national incidence, mortality, and the disparities in age-specific rates among countries with different income levels, in order to support the exploration of comprehensive cancer prevention strategies for Chinese women.

Methods

The data utilized in this study were sourced from the Global Cancer Observatory (GLOBOCAN) 2022 database, accessed through CANCER TODAY (https://gco.iarc.fr/today/home). The International Agency for Research on Cancer (IARC) recently released updated estimates of the global cancer burden, encompassing new cases, deaths, incidence, mortality, and prevalence across 185 countries or territories for 36 cancer types.[10,11] The detailed data sources and estimation methodologies are specific to each country and have been previously documented.[10] Briefly, GLOBOCAN estimates are compiled at the national level utilizing the most reliable sources of cancer incidence and mortality data available within each country. The methodologies employed to generate the 2022 estimates are consistent with those applied in previous years. The accuracy and coverage of recorded cancer data within each country significantly influence the quality of national estimates. No specific inclusion or exclusion criteria were applied to the GLOBOCAN data used in this study. The Human Development Index (HDI) developed by the United Nations Development Programme (UN), emphasizes societal values, capabilities, and economic growth within a country. Disparities in cancer burden become evident when comparing countries across different HDI levels, such as low (<0.640) and moderate (0.640–0.763) HDI vs. high (0.764–0.901) and very high (≥0.902) HDI categories.[12]

We offered visual representations illustrating the proportion of total cases or deaths for cancers affecting female breast cancer and five gynecolgical cancers and other tumor types in China and worldwide. Additionally, we presented tables detailing the estimated numbers of new cases, deaths, incidence, mortality, and cumulative risk (aged 0–74 years) sourced from the GLOBOCAN 2022 database for the female breast and five gynecological cancers mentioned across continents. This includes the age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) per 100,000 individuals based on the world standard population, as well as the cumulative risk of developing or succumbing to cancer before reaching the age of 75 years. The proportion of cases or deaths from specific cancer among the total cancer cases or deaths was determined. The associations between ASIR or ASMR and the HDI for each of the aforementioned cancers were assessed using Spearman’s correlation tests.

In order to provide a comprehensive analysis of the incidence and mortality burdens of female breast and five gynecological cancers across different age groups (0–84 years in 5-year intervals, and ≥85 years of an age group) and geographical regions in 2022, we carefully selected two to three exemplary countries from each income category based on the World Bank-classified income groups derived from the Gross National Income (GNI) per capita, Atlas method (current US$) of World Development Indicator 2022.[13] Each selected country met the criterion of having available data in the GLOBOCAN 2022 database. The ten exemplary countries included two low-income countries (Nepal and Uganda), two lower-middle-income countries (Vietnam and India), three upper-middle-income countries (China, Brazil, and South Africa), and three high-income countries (the United States, the United Kingdom, and the Republic of Korea). All statistical analyses and visual representations were generated using Python software (version 3.7.7, Python Software Foundation, Wilmington, Delaware, USA).

Results

Aggregate global burden of cancers in six female organs

In 2022, an estimated 39.57 million new cases and 1.35 million deaths were recorded for six female cancers, including female breast cancer, vulva cancer, vaginal cancer, cervical cancer, uterine corpus cancer, and ovarian cancer. Tables 1 and 2 illustrate the distribution of incidence, mortality, and cumulative risk for these six cancers across different world regions. Eastern Asia reported the highest number of new cases for six female cancers, with the exception of vaginal cancer, which was more prevalent in Southern Central Asia. The highest numbers of deaths from breast cancer, vaginal cancer, cervical cancer, and ovarian cancer were observed in South Central Asia, while Eastern Europe and Eastern Asia recorded the highest mortality rates for vulva cancer and uterine corpus cancer, respectively.

Table 1 New cases and age-standardized incidence rates per 100,000 population of female breast and five gynecological cancers by world region in 2022.

Population	Breast cancer	Vulva cancer	Vagina cancer	Cervix uteri cancer	Corpus uteri cancer	Ovary cancer	
Number of cases	ASR	Cumulative risk: Birth to age 74 years, %	Number of cases	ASR	Cumulative risk: Birth to age 74 years, %	Number of cases	ASR	Cumulative risk: Birth to age 74 years, %	Number of cases	ASR	Cumulative risk: Birth to age 74 years, %	Number of cases	ASR	Cumulative risk: Birth to age 74 years, %	Number of cases	ASR	Cumulative risk: Birth to age 74 years, %	
Africa																			
Eastern Africa	47,300	31.9	3.4	2135	1.30	0.13	787	0.55	0.07	58,145	40.4	4.40	3809	3.0	0.38	7690	5.3	0.60	
Western Africa	53,605	41.6	4.5	1390	1.20	0.14	451	0.35	0.04	31,249	26.7	3.00	3672	3.4	0.44	6790	5.1	0.54	
Middle Africa	16,856	30.0	3.2	551	1.00	0.12	277	0.50	0.05	16,268	31.1	3.40	1164	2.4	0.30	2458	4.3	0.45	
Southern Africa	15,815	46.2	5.0	776	2.10	0.20	255	0.73	0.08	12,351	34.9	3.60	1957	5.9	0.73	1677	4.9	0.55	
Northern Africa	64,977	53.2	5.5	777	0.65	0.07	284	0.24	0.03	7686	6.5	0.75	4302	3.7	0.47	7145	6.0	0.66	
America																			
Caribbean	14,862	49.6	5.3	192	0.55	0.06	190	0.62	0.07	4012	14.0	1.40	3855	12.0	1.50	1450	4.9	0.53	
Central America	39,835	38.3	4.1	605	0.53	0.06	328	0.31	0.03	15,119	14.3	1.50	6725	6.7	0.83	6175	6.0	0.64	
South America	165,427	57.2	6.2	2858	0.85	0.09	1100	0.35	0.04	44,040	15.6	1.60	24,151	8.2	0.99	16,447	5.6	0.62	
Northern America	306,307	95.1	10.3	7187	1.90	0.21	1664	0.43	0.05	15,654	6.4	0.61	73,977	22.3	2.70	24,484	7.5	0.83	
Asia																			
Eastern Asia	480,019	37.5	4.0	5724	0.35	0.04	3198	0.22	0.03	167,528	13.4	1.40	100,275	7.5	0.84	75,773	6.0	0.64	
Western Asia	63,360	45.4	4.8	668	0.46	0.05	240	0.18	0.02	5724	4.1	0.45	13,382	10.1	1.20	8406	6.1	0.66	
South-Eastern Asia	168,536	41.7	4.5	2239	0.54	0.06	968	0.22	0.02	69,886	17.4	1.80	26,601	6.6	0.76	32,113	8.1	0.85	
South Central Asia	273,902	26.7	2.9	4086	0.40	0.05	5765	0.58	0.07	153,944	15.1	1.70	27,172	2.7	0.33	61,931	6.1	0.67	
Europe																			
Eastern Europe	163,474	58.3	6.5	4973	1.30	0.15	1111	0.34	0.04	35,052	15.7	1.50	57,095	19.2	2.40	29,416	11.0	1.20	
Western Europe	180,113	89.8	9.5	6841	2.40	0.26	1019	0.38	0.04	9716	6.6	0.65	27,257	11.2	1.40	17,004	7.1	0.81	
Southern Europe	124,621	81.8	8.6	3436	1.30	0.16	646	0.28	0.03	7792	6.4	0.64	23,786	14.0	1.70	13,265	8.4	0.93	
Northern Europe	89,324	90.8	9.8	2401	1.90	0.21	388	0.34	0.04	5659	8.2	0.74	16,736	14.8	1.80	9787	9.1	1.00	
Oceania																			
Australia–New Zealand	25,786	100.3	10.8	480	1.50	0.16	126	0.43	0.05	1047	5.2	0.48	3884	14.2	1.80	2177	8.0	0.89	
Melanesia	2294	49.2	5.2	17	0.35	0.04	22	0.51	0.05	1340	27.6	2.60	466	10.7	1.30	359	7.5	0.77	
Micronesia	133	43.9	4.6	0	0	0	0	0	0	54	18.6	1.90	44	14.4	1.80	22	7.3	0.91	
Polynesia	294	76.9	8.0	0	0	0	0	0	0	35	9.6	0.99	58	15.5	1.90	34	9.0	1.10	
Total	2,296,840	46.8	5.1	47,336	0.83	0.09	18,819	0.36	0.04	662,301	14.1	1.50	420,368	8.4	1.00	324,603	6.7	0.73	
ASR: Age-standardized rate per 100,000 population.

Table 2 Deaths and age-standardized mortality rates per 100,000 population of female breast and five gynecological cancers by world region in 2022.

Population	Breast cancer	Vulva cancer	Vagina cancer	Cervix uteri cancer	Corpus uteri cancer	Ovary cancer	
Number of cases	ASR	Cumulative risk: Birth to age 74 years, %	Number of cases	ASR	Cumulative risk: Birth to age 74 years, %	Number of cases	ASR	Cumulative risk: Birth to age 74 years, %	Number of cases	ASR	Cumulative risk: Birth to age 74 years, %	Number of cases	ASR	Cumulative risk: Birth to age 74 years, %	Number of cases	ASR	Cumulative risk: Birth to age 74 years, %	
Africa																			
Eastern Africa	25,330	17.6	1.9	1207	0.83	0.09	467	0.35	0.04	39,476	28.9	3.20	1272	1.1	0.13	5518	4.2	0.50	
Western Africa	27,901	22.3	2.4	755	0.63	0.06	277	0.22	0.03	18,306	16.3	1.80	1219	1.2	0.16	4601	3.8	0.43	
Middle Africa	9142	16.8	1.8	341	0.65	0.07	166	0.31	0.03	11,293	22.9	2.60	381	0.9	0.11	1794	3.5	0.39	
Southern Africa	5693	16.6	1.6	325	0.89	0.08	84	0.25	0.03	7114	20.4	2.10	828	2.5	0.30	1424	4.2	0.47	
Northern Africa	23,186	19.0	2.0	366	0.30	0.03	125	0.10	0.01	4425	3.8	0.46	962	0.8	0.10	4687	4.0	0.48	
America																			
Caribbean	5953	18.2	1.9	59	0.13	0.01	79	0.25	0.03	2397	7.7	0.83	1210	3.4	0.41	1012	3.2	0.36	
Central America	10,670	10.1	1.1	242	0.20	0.02	107	0.09	0.01	7646	7.2	0.79	1689	1.6	0.20	4033	3.9	0.44	
South America	43,253	13.8	1.5	1058	0.28	0.03	387	0.11	0.01	23,471	7.8	0.83	6389	2.0	0.24	10,866	3.5	0.41	
Northern America	49,744	12.3	1.3	1876	0.37	0.04	471	0.10	0.01	6692	2.2	0.23	13,543	3.2	0.38	15,554	3.8	0.44	
Asia																			
Eastern Asia	97,389	6.5	0.7	2371	0.13	0.01	1287	0.08	0.01	62,094	4.3	0.48	17,818	1.1	0.13	40,264	2.7	0.32	
Western Asia	21,344	15.1	1.6	304	0.20	0.02	121	0.09	0.01	3036	2.2	0.25	3079	2.2	0.27	5930	4.3	0.51	
South-Eastern Asia	61,228	14.9	1.6	813	0.19	0.02	441	0.10	0.01	38,703	9.5	1.10	7936	1.9	0.22	20,514	5.1	0.58	
South Central Asia	135,348	13.4	1.5	1997	0.20	0.02	2827	0.28	0.03	95,962	9.5	1.10	10,143	1.0	0.12	42,839	4.3	0.51	
Europe																			
Eastern Europe	49,973	14.4	1.7	2443	0.55	0.06	510	0.13	0.02	16,669	6.3	0.68	13,388	3.5	0.45	19,165	6.1	0.73	
Western Europe	44,387	15.4	1.6	1945	0.50	0.05	365	0.10	0.01	4396	2.1	0.23	6842	2.0	0.23	12,083	4.1	0.48	
Southern Europe	31,450	13.8	1.5	1446	0.43	0.04	278	0.10	0.01	3740	2.2	0.24	5824	2.3	0.27	8398	4.1	0.48	
Northern Europe	18,629	13.7	1.4	900	0.47	0.04	188	0.12	0.01	2145	2.2	0.22	4218	2.6	0.30	6586	4.8	0.56	
Oceania																			
Australia–New Zealand	4152	12.8	1.4	126	0.28	0.03	41	0.11	0.01	386	1.4	0.15	833	2.3	0.27	1384	4.0	0.46	
Melanesia	1179	26.8	2.9	5	0.12	0.02	19	0.44	0.05	873	19.3	2.00	121	2.9	0.40	262	5.8	0.64	
Micronesia	53	16.7	1.7	0	0	0	0	0	0	33	10.9	1.40	8	2.5	0.27	19	6.4	0.83	
Polynesia	99	25.3	2.6	0	0	0	0	0	0	17	4.6	0.45	20	5.4	0.74	23	6.0	0.76	
Total	666,103	12.7	1.4	18,579	0.30	0.03	8240	0.15	0.02	348,874	7.1	0.79	97,723	1.7	0.20	206,956	4.0	0.46	
ASR: Age-standardized rate per 100,000 population.

Female breast cancer emerged as the most prevalent cancer among the six female cancers globally, with 2,296,840 cases and an age-standardized rate (ASR) of 46.8 per 100,000 population, followed by cervical cancer (662,301 cases, ASR = 14.1 per 100,000 population) and uterine corpus cancer (420,368 cases, ASR = 8.4 per 100,000 population). The distribution of these prevalent cancer types varied across continents. Northern America exhibited relatively high incidence rates for breast, vulva, vagina, uterine corpus, and ovarian cancers. Western and Northern Europe displayed a similar pattern to Northern America, with the exception of a relatively lower incidence of vaginal cancer. Africa reported the highest incidence of cervical cancer globally. Corresponding to the incidence ranking, breast cancer also had the highest mortality rates (666,103 deaths, ASR = 12.7 per 100,000 population), followed by cervical cancer (348,874 deaths, ASR = 7.1 per 100,000 population), whereas ovarian cancer ranked third in terms of ASMR at 4.0 per 100,000 population. It is worth noting that mortality rates were comparatively lower in Northern America for the six female cancers, contrasting with their incidence rates. Eastern Africa exhibited particularly high mortality rates for vulva, vaginal, and cervical cancers. Notably, the cumulative risk of cancer diagnosis among women closely mirrored the observed incidence rates. Melanesia demonstrated relatively high rates of cumulative risk of death for female breast and five gynecological cancers, excluding vulva and cervical cancer.

Figure 1 illustrates the estimated new cases and deaths of the six female cancer types in China and globally, combined and separately. In China, these cancers constitute over 30% of newly diagnosed cancer cases and 20% of cancer-related deaths. Female breast cancer stands out as the most prevalent cancer type, representing 16.51% of total cases, closely followed by cervical cancer (6.97%), uterine corpus cancer (3.59%), and ovarian cancer (2.82%). The distribution of mortality rates mirrors that of new cases, with the exception of uterine corpus cancer ranking third and ovarian cancer ranking fourth. These cancer types exhibit similar trends on a global scale, collectively representing over 20% of new cases and over 30% of cancer-related deaths.

Figure 1 Proportion of incidence and mortality of cancers in female breast and five gynecological cancers in China and worldwide in 2022. (A) Proportion of new cases of female breast and five gynecological cancers in China. (B) Proportion of new cases of female breast and five gynecological cancers worldwide. (C) Proportion of deaths of female breast and five gynecological cancers in China. (D) proportion of deaths of female breast and five gynecological cancers worldwide. Data are from the GLOBOCAN database, collated by the IARC and hosted by the Global Cancer Observatory (Available from:https://gco.iarc.who.int/today. [Last accessed on 2024 March 7]). IARC: International Agency for Research on Cancer.

Impact of national development on cancer burden

Figure 2 illustrates the ASRs of cancer incidence and mortality in higher HDI countries compared to lower HDI countries. Breast cancer incidence ranks highest at 57.20 per 100,000 in developed nations, which is approximately twice as high as in developing countries. In higher HDI countries, cervix uteri ranks second in incidence at 11.70 per 100,000, whereas in lower HDI countries, the ranking is reversed with 31.90 per 100,000 for breast cancer and 20.90 per 100,000 for cervix uteri. Following these, incidence of uterine corpus cancer was 11.25 per 100,000 in higher HDI countries, and ovarian cancer was 5.65 per 100,000 in lower HDI countries. The patterns in mortality are the same as incidence. The relationship between HDI and ASIR and ASMR for each cancer type is depicted in Supplementary Figures S1 and S2, and summarized in Supplementary Table S1, http://links.lww.com/CM9/C142. Incidence rates of breast, uterine corpus, ovary, and vulva cancers exhibit a positive correlation with HDI levels, whereas cervix uteri and vaginal cancers show a negative association with HDI categories. More intricate associations are observed between HDI and ASMR. A positive correlation is noted between higher HDI tiers and mortality rates in uterine corpus and ovarian cancers (both P <0.001). Conversely, a negative correlation exists between HDI tier and ASMR in cervix uteri and vaginal cancers (both P <0.001). These disparities primarily reflect the influence of national development levels on the efficacy of treatment outcomes for specific female cancers. The absence of associations in breast and vulva cancers suggests that these malignancies may have distinct etiologies compared to other cancers.

Figure 2 Incidence and mortality ASRs of female breast and five gynecological cancers in high/very high HDI countries vs. low/medium HDI countries in 2022. Source: GLOBOCAN 2022. Data are from the GLOBOCAN database, collated by the IARC and hosted by the Global Cancer Observatory (Available from:https://gco.iarc.who.int/today. [Last accessed on 2024 March 7]). ASR: Age-standardized rate; HDI: Human Development Index; IARC: International Agency for Research on Cancer.

Age-standardized incidence and mortality patterns by different age bands

Figures 3–8 described the ASIRs and ASMRs in different ages of female breast and five gynecological cancers in ten exemplary countries stratified by income levels. After the age of 25 years, four patterns were observed in the age-specific incidence rate of breast cancer. The first pattern, occurring in low-income countries, was a rapid increase until menopause, followed by a slow increase. The second pattern, observed in lower-middle-income countries, was a rapid increase until menopause followed by a plateau. The third pattern showed a steady increase by age independent of menopause, mainly in the USA and the UK. China and the Republic of Korea had the fourth pattern, which showed a similar trend before menopause but illustrated a declined ASIR afterward. Notably, the ASIR of China had a bimodal distribution, peaking at 50–55 years and 60–64 years age groups, which were 10–15 years earlier than the USA. Mortality rates for cancer generally rose with age, except for Uganda, which peaked at the 70–74 years age band.

Figure 3 Incidence and mortality ASRs of female breast cancer in countries by age bands. Source: GLOBOCAN 2022. Data are from the GLOBOCAN database, collated by the IARC and hosted by the Global Cancer Observatory (Available from:https://gco.iarc.who.int/today. [Last accessed on 2024 March 7]). ASR: Age-standardized rate; IARC: International Agency for Research on Cancer.

Figure 4 Incidence and mortality ASRs of cervix uteri cancer in countries by age bands. Source: GLOBOCAN 2022. Data are from the GLOBOCAN database, collated by the IARC and hosted by the Global Cancer Observatory (Available from:https://gco.iarc.who.int/today. [Last accessed on 2024 March 7]). ASR: Age-standardized rate; IARC: International Agency for Research on Cancer.

Figure 5 Incidence and mortality ASRs of corpus uteri cancer in countries by age bands. Source: GLOBOCAN 2022. Data are from the GLOBOCAN database, collated by the IARC and hosted by the Global Cancer Observatory (Available from:https://gco.iarc.who.int/today. [Last accessed on 2024 March 7]). ASR: Age-standardized rate; IARC: International Agency for Research on Cancer.

Figure 6 Incidence and mortality ASRs of ovary cancer in countries by age bands. Source: GLOBOCAN 2022. Data are from the GLOBOCAN database, collated by the IARC and hosted by the Global Cancer Observatory (Available from:https://gco.iarc.who.int/today. [Last accessed on 2024 March 7]). ASR: Age-standardized rate; IARC: International Agency for Research on Cancer.

Figure 7 Incidence and mortality ASRs of vagina cancer in countries by age bands. Source: GLOBOCAN 2022. Data are from the GLOBOCAN database, collated by the IARC and hosted by the Global Cancer Observatory (Available from:https://gco.iarc.who.int/today. [Last accessed on 2024 March 7]). ASR: Age-standardized rate; IARC: International Agency for Research on Cancer.

Figure 8 Incidence and mortality ASRs of vulva cancer in countries by age bands. Source: GLOBOCAN 2022. Data are from the GLOBOCAN database, collated by the IARC and hosted by the Global Cancer Observatory (Available from:https://gco.iarc.who.int/today. [Last accessed on 2024 March 7]). ASR: Age-standardized rate; IARC: International Agency for Research on Cancer.

The peak ages of the highest ASIRs in high-income countries were basically 35–44 years age bands in cervix uteri cancer, earlier than those in middle- and low-income countries (approximately 50–69 years). The profiles of ASIR showed a consistent increase in Brazil, whereas dramatically increasing until the age group of 50–54 years and subsequently decreasing in China. Generally, ASIRs and ASMRs were relatively lower in high- and middle-income countries but higher in African countries. Different from profiles in cervical cancer, the ages of the highest incidence of corpus uteri cancer mainly peaked after menopause. After a significant or slight increase, ASIRs decreased later or reached a plateau and remained the same later. A constant increase in the incidence rate with ages was shown in South Africa. The profiles of age-specific incidence and mortality changes in China and the Republic of Korea were similar. It is noted that ASMRs in several high- (USA and UK) and middle- (Brazil and South Africa) countries demonstrated a sharp increase from the mid-50s.

The age-specific curves of ovarian cancer incidence between country groups differed. The curves generally increased with minimal variation among countries within age groups 0–55 years, but significant differences emerged for ages over 55 years, with plateaus in Nepal and the Republic of Korea and decreasing trends in Vietnam and China, and a constant increase in reminders. The patterns in ASMR were roughly the same as in ASIR.

Within country groups, the patterns of age-specific curves of vagina and vulva cancers had similarities with increased incidence and mortality with ages shown in most countries. However, compared to all other country groups, China had a peak age band of 70–74 years of vagina cancer incidence. Comparatively, in low-income countries, vaginal cancer demonstrated peak incidence and mortality during the menopausal period, followed by a gradual decline, but experienced a sharp increase after the age of 65 years. Furthermore, vulvar cancer in these nations displayed a bimodal distribution, with peaks observed in the age groups of 45–49 years and 60–64 years.

Discussion

Several major findings have been derived from our study. There is a wide variation in the global burden of cancers in female organs, with relatively higher incidence rates in Northern America. However, high ASIR and ASMRs in Africa was observed. Cancers in female breast and gynecological organs in China remain a substantial burden compared with those worldwide. This is because the prevalence of these tumors in China constitutes a larger proportion of the overall tumor burden in the country. We identified a significant and positive correlation between socioeconomic development and the incidence of cancers of the breast, corpus uteri, ovary, and vulva, whereas a negative association between four HDI tiers and mortality was found in cervix uteri and vagina cancers. Age is one of the predictors of incidence and maintenance for cancers in female organs. Insights gained from successful cancer prevention efforts in several developed countries could offer valuable guidance for shaping cancer control strategies in China.

In a given country, the increasing incidence of breast cancer and decreased ASIR and ASMR of infectious-related cancers (including cervical and vagina cancers) are important signs of social and economic transition.[14] The national incidence burden of these two diseases by levels differed mostly as the implementation of effective population-based screening and changed reproductive patterns in females in high HDI countries or, a declined HPV prevalence compared with those in low HDI countries. In lower-resource settings, especially in some countries in Eastern Europe and Central Asia such as Uganda and Zimbabwe, the lack of efficient preventive strategies and insufficient treatment schedules led to an increasing premature cervical cancer mortality.[6] The rise in premature cervical cancer mortality is evident from specific cohort trends in certain Eastern European and Central Asian countries, including former Soviet republics.[15] Additionally, a positive correlation between HDI and the incidence and mortality of ovarian and corpus uteri cancer was confirmed, as per previous data.[16,17] In countries where women are well-educated, there is a higher report of ovarian cancer and vulva cancer incidence because of a higher participation rate in cancer screening or diagnosis.[16,18]

The age-specific curve changes and the peak ages in the incidence and mortality of cancers in female breast and gynecological organs in different countries are generally consistent with previous studies.[67192021] Separately, the higher incidence of premenopausal breast cancer in low-income African countries is directly related to their younger population structure.[22] Separately, higher proportions of women developing breast cancer at premenopausal ages in low-income countries in Africa are directly related to the much younger age structure.[20] A potential explanation lies in the difference in genetic susceptibility between Eastern and Western women. In East Asian populations, BRCA2 mutations are more prevalent than BRCA1 mutations, whereas in Caucasians, the situation is reversed.[20] Individuals with BRCA1 mutations have a high risk of progressing to breast cancer by the age of 50 years. In women aged 80 years and over, although the cumulative risk of breast cancer is similar for both genetic mutations, the risk of developing ovarian cancer is higher with the BRCA1 mutation.[23] It is noted that the age-specific incidence rate of these two cancers roughly decreases after menopause in China and South Korea, which is in contrast to the USA and UK, where they continue to increase. The primary factors that contribute to this variation include younger age, potentially more negative estrogen receptor (ERN) tumors, and distinct histopathology among breast cancer patients in these countries and other similar regions compared to Western countries.[19,24] Moreover, the differences in profiles in breast and ovarian cancer may be affected by the age cohort effect. Previous studies found that compared with those born in the 1920s, Chinese females born in the 1960s tend to be exposed to more risk factors such as benign and malignant breast disease, earlier age at menarche, later first childbirth, lower parity, shorter duration of breastfeeding, and the use of menopausal hormone therapy, which increase the risk of progressing to breast and ovarian cancers.[7,25,26] Of note, the use of oral contraceptive pills and hormone treatments led to a high risk of developing cancer in the corpus uteri in women aged over 45 years.[7] Notably, there is still an increasing trend of breast, ovarian, and corpus uteri cancers’ incidence because of a “Westernized” style and increasing obesity rate in China.[272829] This transformation has led to increasing burdens in elders in China and may result in more similar specific-age-related incidence patterns between the East and the West.[20] A 23-year follow-up study in the UK Age trial presented delightful results that bringing the screening age forward to 40 years might decrease the mortality rate without increased overdiagnosed rates, which was consistent with the recommendations issued by United States Preventive Services Task Force (USPSTF).[30] Considering the increased diagnosed cases in women aged under 40 years and over 74 years,[31,32] there is an urgent need to investigate the optimal screening ages in China.

HPV remains the main factor in cervical cancer, the majority of vaginal cancer, and certain vulvar cancers.[6,33] Differences in incidence rates and age of diagnosis among various countries and regions underscore this evolving epidemiological age-specific trend. Regional differences in HPV prevalence and other risk factors, including ethnic demographics, smoking habits, vulvar conditions such as atrophy or inflammation, and human immunodeficiency virus (HIV) infection, further shape these patterns.[33] In low-income and middle-income countries, the relatively high incidence and mortality rates of cervical, vaginal, and vulvar cancers in menopausal and postmenopausal women result from a lack of sanitation, inadequate organized screening and HPV vaccination programs, and insufficient appropriately trained healthcare resources.[6,9] In high-income countries such as the USA and UK, the increased incidence of vulvar cancer in elders may be attributed to age factors and benefit from screening programs for cervical cancer.[9,15] Interestingly, the peak age of the incidence rate of cervical cancer is younger in high-income countries. This may be caused by various factors such as increasing HPV exposure, higher screening participation rates, earlier sexual debut, and a history of a high number of sexual partners.[9] Due to changes in sexual concepts, the incidence of cervical cancer in China has tended to be younger across all regions. As a result, cervical cancer poses a significant threat to the health of rural middle-aged women as they generate proportionally a greater loss of life-years.[34] Simultaneously, the “overlapping challenge,” whereby breast cancer incidence and mortality are increasing while the burden of cervical cancer is not yet declining, poses a threat to Chinese women. Although efforts have been made in China to prevent and control cervical cancer, the incidence and mortality of cervical cancer in China were still at slightly high levels worldwide, and the mortality was two times higher than that in the United States of America and the United Kingdom.[35] These results can be explained by the low screening coverage rate in China (33%) compared with that in high-income countries (84%),[36] highlighting the crucial need for implementing tailored, comprehensive, and sustainable control strategies that address the diverse socioeconomic development levels across China’s regions.

This study has several limitations. First, the epidemiological data derived from GLOBOCAN 2022 were possibly based by differing screening standards and data quality. For several countries, data originated exclusively from major cities and may not accurately reflect the overall burden in some countries. Substantial random variation might occur because data analysis in low- and middle-income countries was based on a small number of patients, and the analysis may lack sufficient statistical power. Second, substantial random variation might occur because recent and high-quality data in low- and middle-income countries were missing. Third, HDI can only assess a nation’s level of development but fails to consider certain critical dimensions of human development, notably social equity and environmental sustainability. Finally, the lack of detailed information including staging and various subtypes in the GLOBOCAN database clearly represents a further limitation.

In conclusion, female breast and five gynecological cancers have the majority of the disease burden occurring in China and worldwide. Although variations in the epidemiological patterns based on geographic location exist in its burden, six female cancers still represent an important cause of mortality, particularly in women living in transitioning countries. Chinese women aged 50–54 years are under a high incidence rate of breast, cervix uteri, corpus uteri, and ovary cancers. Future efforts can focus on identifying the most relevant factors modifying cancer risks and making more optimal and age-specific screening strategies to help guide preventive actions.

Acknowledgements

We would like to express our gratitude to the staff of the International Agency for Research, as well as their collaborators for compiling and making these valuable data publicly available. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.

Funding

This study was supported by the special research fund for central universities, Peking Union Medical College (No. 3332023025).

Conflicts of interest

None.

Data availability statement

Publicly available datasets were used in this study. These can be found on the International Agency for Research on Cancer (IARC) websites at https://gco.iarc.fr/today/en.

Supplementary Material

Nuopei Tan and You Wu contributed equally to this work.

How to cite this article: Tan NP, Wu Y, Li B, Chen WQ. Burden of female breast and five gynecological cancers in China and worldwide. Chin Med J 2024;137:2190–2201. doi: 10.1097/CM9.0000000000003293
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