Global trends and socioeconomic disparities in cancer burden among adolescents and young adults, 1990–2021
Runhua Li, MDa, Stephanie F. Smith, MB BChirb, Flavia Pennisi, MDc, Eun-Hye Park, MD, MPH, PhDd, Lingbin Du, MDa,
Background: Adolescents and young adults (AYAs, 10–24 years) constitute a distinct cancer population in whom malignancy arises during critical life transitions yet leads to substantial long-term morbidity and socioeconomic consequences. However, their global cancer burden and risk-factor profile remain incompletely characterized, especially in low- and middle-income settings. Methods: We conducted a secondary analysis of the Global Burden of Disease 2021 dataset, synthesizing estimates of cancer incidence, mortality, and disability-adjusted life years (DALYs) for 32 cancer types among AYAs across 204 countries and territories. Temporal trends (1990–2021) and associations with the socio-demographic index (SDI) were evaluated using log-linear and Spearman’s correlation analyses.
Results: Globally, from 1990 to 2021, AYA cancer incidence rose slightly (+0.12% per year), while mortality and DALY rates declined (-1.02% per year). The fastest-rising incidence involved multiple myeloma (2.39% annually), breast, testicular, thyroid, and prostate cancers, whereas stomach, liver, esophageal, nasopharynx, and lung showed the steepest declines. In 2021, incidence correlated positively with SDI, but mortality and DALY rates correlated negatively. Modifiable risks accounted for 4.32% of DALYs, dominated by unsafe sex (2.54%) in low-SDI regions versus high body mass index (0.83%) and alcohol (0.64%) in higher-SDI settings.
Conclusions: Global AYA cancer epidemiology reveals substantial geographical, temporal, and socioeconomic disparities. Rising incidence and burden of certain cancers highlight unmet prevention and diagnostic needs. Effective interventions, particularly targeting modifiable risks and promoting equitable healthcare access, are essential to reduce the global burden of AYA cancers.
Keywords: adolescents and young adults, global cancer burden, global trends, risk factors, socioeconomic disparities

Introduction
Adolescents and young adults (AYAs, 10–24 years) constitute a biologically and psychosocially distinctive population that lies between pediatric and older-adult oncology[1]. Although cancers
aDepartment of Cancer Prevention, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang Province, China, bNorwich Medical School, University of East Anglia, Norwich, UK, cFaculty of Medicine, University Vita-Salute San Raffaele, Milan, Italy and dDivision of Cancer Registration and Surveillance, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
arising in AYAs account for less than 1% of global incident malignancies, their societal impact is disproportionate: disease occurs at the threshold of higher education, labor force entry, and family formation, and survivors face decades of treatment-related morbidity, fertility challenges, and economic hardship[2,3]. The tumor spectrum in AYAs (e.g., acute leukemia, Hodgkin lymphoma, bone and soft-tissue sarcomas, testicular cancer, thyroid cancer, and melanoma) differs in molecular drivers and therapeutic responses from those in younger children or older adults[4]. At the same time, adolescence is when many modifiable exposures such as tobacco initiation, hazardous alcohol use, weight gain, and ultraviolet radiation take root, shaping life-long cancer risk trajectories[5,6].
Despite these distinctive features, the global epidemiology of AYA cancer remains poorly defined. Most surveillance systems aggregate AYAs into either pediatric (0–14 years) or young adult (≥15 or ≥20 years) categories, obscuring age-specific patterns and hindering service planning, especially in low- and middleincome countries (LMICs)[7]. Available global assessments have pooled AYAs with wider “youth” definitions (15–39 years) or focused on high-income regions, leaving large evidence gaps for LMICs and for risk-factor attribution.
Previous studies on cancers among AYAs have largely been confined to single regions, limited age ranges, or specific tumor types[8–10]. Few have provided a comprehensive global assessment integrating incidence, mortality, and disability-adjusted life years (DALYs) across the full 10–24-year age spectrum using consistent methodology. Moreover, most prior analyses did not incorporate socioeconomic stratification or comparative risk-attribution modeling. In contrast, the present study leverages the Global Burden of Disease (GBD) 2021 framework to deliver a uniform, socio-demographic index (SDI)-stratified evaluation of 32 cancers across 204 countries from 1990 to 2021, offering the most detailed temporal and geographic landscape of the global AYA cancer burden to date.
The GBD 2021 study provides internally consistent estimates of incidence, mortality, and DALYs for 371 diseases, including all malignant neoplasms across 204 countries and territories from 1990 to 2021, together with harmonized risk-factor exposure datasets and SDI stratifications[11]. Leveraging these resources, we aimed to (1) quantify global, regional, national, and SDI-specific counts and rates of incidence, mortality, and DALYs for all and for 32 cancer types among AYAs in 2021; (2) identify leading causes of AYA cancer burden by geography; (3) assess temporal trends in incidence and mortality during 1990– 2021; and (4) estimate the fraction of deaths and DALYs attributable to modifiable behavioral, environmental/occupational, and metabolic risks. Findings will inform prevention, early detection, and survivorship strategies tailored to this pivotal age group. This study has been reported in line with the STROCSS guidelines[12].
Methods
Study design and data source
We conducted a secondary analysis of GBD 2021, an open, comparative risk-assessment program led by the Institute for Health Metrics and Evaluation (IHME). GBD synthesizes vital- registration, cancer-registry, survey, claims, and epidemiological- study inputs via Bayesian meta-regression and ensemble modeling to generate age–sex–location–year estimates with 95% uncertainty intervals (UIs)[11]. All incidence, mortality, and DALY estimates were obtained from the GBD 2021 global modeling framework, which synthesizes multiple input sources using spatio-temporal Gaussian process regression and ensemble modeling. Because these are model-based rather than raw registry counts, interpretation should consider potential bias in regions with limited primary data coverage[11]. All data and code are publicly available; no ethics approval was required because only de-iden- tified, aggregate data were used. This study adhered to the TITAN Guidelines 2025 for the declaration and use of artificial intelligence (AI) in research and publication[13].
Population definition and geographic hierarchy
In this study, AYAs were defined as persons aged 10–24 years. Estimates were aggregated from GBD 5-year age groups (10–14, 15–19, and 20–24 years) using population-weighted sums of 1000 posterior draws. Results are presented at four spatial scales: global; seven super-regions; 21 GBD regions; and 204 countries/territories. Locations were further grouped into five SDI quintiles (low, low-middle, middle, and high-middle, high).
Cancer selection
This study includes 32 cancer types cataloged in the GBD 2021 datasets. These include tracheal, bronchus, and lung (TBL) cancer, colon and rectum cancer, breast cancer, prostate cancer, stomach cancer, cervical cancer, non-Hodgkin lymphoma, HIGHLIGHTS
•		Global cancer incidence in adolescents and young adults (AYAs, aged 10–24 years) rose modestly (0.12% annually) from 1990 to 2021, while mortality and disability-adjusted life years (DALY) rates declined (-1.02%), driven by advances in high-resource settings but revealing widening socioeconomic disparities.
•		Multiple myeloma, breast, testicular, thyroid, and prostate cancers showed the fastest incidence increases (up to 2.39% annually), contrasting with sharp declines in stomach, liver, and esophageal cancers, highlighting evolving etiological patterns and diagnostic shifts.
•		AYA cancer mortality and DALY rates inversely correlated with socio-demographic index (SDI), with unsafe sex dominating attributable DALYs in low-SDI regions (4.87%) versus high body mass index and alcohol in high- SDI areas (1.61% and 1.04%).
•		Geographic inequities persist, with rising burdens in subSaharan Africa and South America versus declines in North America and Europe, underscoring urgent needs for equitable prevention, human papillomavirus vaccination, and survivorship care in AYAs worldwide.
esophageal cancer, bladder cancer, liver cancer, pancreatic cancer, uterine cancer, leukemia, lip and oral cavity cancer, kidney cancer, brain and central nervous system (CNS) cancers, malignant melanoma, ovarian cancer, thyroid cancer, gallbladder and biliary tract cancer, laryngeal cancer, other pharyngeal cancers, multiple myeloma, nasopharynx cancer, soft tissue and other extraosseous sarcomas, testicular cancer, malignant neoplasms of bone and articular cartilage, Hodgkin lymphoma, eye cancer, mesothelioma, neuroblastoma and other peripheral nervous system tumors, and non-melanoma skin cancer, along with other malignant neoplasms. Each cancer type was defined according to the International Classification of Diseases (ICD) coding framework, with incidence, mortality, and prevalence data extracted from cancer registries, vital statistics, hospital data, and epidemiological surveys. The detailed data sources and the specific estimation methods for each cancer type are consistent with the methodologies outlined in the GBD 2021 core publications and their supplementary appendices[11].
Key metrics
The primary metrics employed in this analysis were the rates and counts of incidence, mortality, and DALYs among AYAs aged 10–24 years. DALYs, a composite measure of disease burden, were derived from the sum of years of life lost due to premature mortality and years lived with disability, standardized to a global age distribution[14].
The study evaluates Level 2 risk factors, categorized within the GBD risk hierarchy into behavioral, metabolic, and environ- mental/occupational determinants. These Level 2 risk factors in cancers mainly include tobacco use, dietary risks, unsafe sex, alcohol use, air pollution, high body mass index (BMI), occupational risks, high fasting plasma glucose, other environmental risks, low physical activity, and drug use. Their association with 
cancer outcomes was determined through systematic meta-ana- lyses of cohort and case–control studies, integrated into the GBD comparative risk assessment framework. Each risk factor’s impact on cancer burden was quantified using population-attributable fractions, taking into account the strength of association and the prevalence of exposure. Some risk factors, such as tobacco use, overlap across multiple cancer types, highlighting the interconnected nature of cancer risk. Detailed definitions and estimation methods for each risk factor are outlined in the GBD 2021 methodology[11].
Our results are presented by SDI quintiles, a composite measure of income per capita, mean years of education, and fertility rate for those younger than 25 years. The SDI is the geometric mean of these three independently estimated and scaled components, with lower values indicating lower development[14]. For consistency, countries were grouped into quintiles based on their SDI values in 2021, termed low, low-middle, middle, high-middle, and high.
Temporal trend analysis (1990–2021)
We modeled temporal trends in incidence, mortality, and DALY rates (and, separately, crude counts with a log-population offset) among AYAs using log-linear regression: ln (Y_t) = α + β · year_t. The slope β was transformed to the average annual rate change as [exp(β) - 1] × 100%. We calculated the 95% confidence interval (CI) for β as β ± 1.96 × SE(β) and then converted those limits to the 95% CI for the average annual rate change by applying [exp(β) - 1] × 100%.
Statistical analysis
We conducted a descriptive analysis of cancer incidence, mortality, DALYs, and risk factors across 204 countries, 21 global regions, and five SDI quintiles. To evaluate temporal trends in cancer burden, we applied log-linear regression to calculate the estimated annualized rate of change in rates and absolute numbers for each cancer type and total cancers. The annualized rate of change summarized temporal trends in burden across regions and SDI quintiles.
To further explore the relationships between incidence, mortality, and DALY rates and SDI, we employed Spearman’s rank correlation analysis, calculating correlation coefficients (R) to assess the strength and direction of the associations. P-values were calculated, with a threshold of P < 0.05 considered statistically significant.
All statistical analyses and data processing were performed using Microsoft Excel 2019 (Microsoft Corporation, Redmond, WA, USA), R version 4.4.1 (R Foundation for Statistical Computing, Vienna, Austria), and JD_GBDR (V2.37, Jingding Medical Technology Co., Ltd.). Spearman’s rank correlation calculations were performed using the basic “lm” and “cor” functions from the stats package. Data cleaning and organization were conducted using the dplyr package. Visualization, including trend lines, correlation plots, and maps, was carried out using the ggplot2 package. Map data were obtained from the rnaturalearth package – World Map Data from Natural Earth.
Ethics statement
The data utilized in this study were obtained from publicly available sources, where informed consent was obtained at the time of original data collection. Consequently, ethical approval and informed consent were not applicable.
Results
Cancer group rankings and changes between 1990 and 2021
Between 1990 and 2021, the global cancer burden in AYAs shifted substantially across incidence, mortality, and DALYs. Total incident cases increased from 187 470 (174 960– 197 930) to 235 250 (217 210–251 070), corresponding to an annualized gain of 0.75% and a modest incidence-rate rise of 0.12% per year. In contrast, cancer deaths declined from 105 660 (95 300–113 610) to 94 860 (85 970–102 770), giving annualized reductions of 0.39% in counts and 1.02% in mortality rate. Aggregate DALYs fell from 7 689 220 (6 935 360– 8 261 870) to 6 918 660 (6 254 350–7 480 200), an annualized contraction of 0.39% in absolute burden and 1.02% in rate (Table 1; Fig. 1; Supplemental Digital Content Figure S1, available at: http://links.lww.com/JS9/G754; Supplemental Digital Content Figure S2, available at: http://links.lww.com/JS9/ G755).
From 1990 to 2021, the five cancers with the fastest annual increases in incidence rates among AYAs were multiple myeloma (2.39%), breast cancer (2.31%), testicular cancer (1.97%), thyroid cancer (1.73%), and prostate cancer (1.65%). The steepest declines in incidence were observed for stomach cancer (-2.15%), liver cancer (-1.41%), esophageal cancer (-1.37%), nasopharynx cancer (-1.23%), and TBL cancer (-1.19%). Over the same period, mortality rates rose most rapidly for multiple myeloma (1.71%), breast cancer (1.46%), neuroblastoma and other peripheral nervous cell tumors (1.06%), other pharynx cancer (0.93%), and lip and oral cavity cancer (0.78%), while the greatest reductions in mortality were recorded for stomach cancer (-2.86%), nasopharynx cancer (-2.36%), leukemia (-1.69%), esophageal cancer (-1.67%), and colorectal cancer (-1.57%). Trends in DALY rates mirrored those for mortality: the fastest increases were seen in multiple myeloma (1.71%), breast cancer (1.49%), neuroblastoma and other peripheral nervous cell tumors (1.04%), other pharynx cancer (0.93%), and lip and oral cavity cancer (0.78%), whereas DALY rates declined most for stomach cancer (-2.86%), nasopharynx cancer (-2.34%), leukemia (-1.71%), esophageal cancer (-1.67%), and colorectal cancer (-1.56%).
Leukemia remained the leading cause of cancer incidence, mortality, and DALYs among AYAs aged 10–24 years globally, although its burden has declined across all three metrics since 1990. Incident cases of leukemia decreased from 39 130 to 34 680 (annualized rate of change -0.42%), with an annualized incidence rate reduction of -1.04%. Mortality from leukemia declined from 35 370 to 25 690 deaths, with the mortality rate decreasing by 1.69% per year. Leukemia DALYs fell from 2.59 million in 1990 to 1.88 million in 2021, an annualized DALY rate reduction of 1.71%.
Brain and CNS cancer ranked second across incidence, mortality, and DALYs in 2021. Incident cases increased from 18 560 to 25 870 (annualized rate of change 1.08%), with a modest rise in incidence rate (0.45%). Mortality remained relatively stable, rising slightly from 11 840 to 12 200 deaths, but the mortality rate decreased (-0.60%). DALYs attributable to CNS cancer
Table 1
Global incidence, deaths, and DALYs for total cancers and 32 cancer types among AYAs (10-24 years) in 2021
Cancer type	Incident cases, thousands (95% UT)	Incidence rate per 100 000 (95% UI)	Deaths (95% UI), thousands (95% UI)	Motality rate per 100 000 (95% UI)	DALYs (95% UI), thousands (95% UI)	DALY rate (95% UI)	
	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	
Total cancers	235.25 (217.21 to 25 1.07)	115.55 (104.63
to 124.71)	119.70 (108.55
to 130.86)	12.46 (11.51 to
13.30)	11.94 (10.81 to
12.89)	13.01(11.79 to
14.22)	94.86 (85.97 to 49.60 (43.24 to
102.77)	54.50)	45.26 (40.12 to
50.08)	5.02 (4.55 to 5.44)	5.13 (4.47 to 5.63)	4.92 (4.36 to 5.44)	6918.66 (6254.35 3622.56 (3161.24
to 7480.20)	to 3993.77)	3296.09 (2928.16
to 3648.59)	366.50 (331.31 to
396.24)	374.45 (326.76 to
412.82)	358.14 (318.17 to
396.44)	
Total Cancers excluding Non-melanoma skin cancer	224.09 (205.84 to 239.89)	110.30 (99.59 to 119.19)	113.79 (102.42
to 124.78)	11.87 (10.90 to
12.71)	11.4 (10.29 to
12.32)	12.36 (11.13 to
13.56)	94.70 (85.84 to
102.61)	49.51 (43.17 to
54.41)	45.19 (40.06 to
50)	5.02 (4.55 to 5.44)	5.12 (4.46 to 5.62)	4.91 (4.35 to 5.43)	6908.29 (6245.39 3617.02 (3155.96
to 7469.54)	to 3987.93)	3291.27 (2923.65
to 3643.52)	365.95 (330.83 to
395.68)	373.87 (326.22 to
412.21)	357.62 (317.68 to
395.89)	
Leukemia	34.68 (27.66 to
38.78)	19.91 (14.17 to
23.72)	14.77 (11.32 to
16.52)	1.84 (1.47 to 2.05)	2.06 (1.46 to 2.45)	1.61 (1.23 to 1.80)	25.69 (20.44 to
28.78)	14.50 (10.21 to
17.54)	11.19 (8.51 to
12.61)	1.36 (1.08 to 1.52)	1.50 (1.06 to 1.81)	1.22 (0.93 to 1.37)	1879.89 (1494.48 1061.50 (748.49
to 2110.46)	to 1283.12)	818.39 (624.24 to
922.35)	99.58 (79.17 to
111.80)	109.72 (77.37 to
132.63)	88.92 (67.83 to
100.22)	
Brain and central nervous system cancer	25.87 (21.93 to
30.76)	13.39 (10.10 to
17.58)	12.49 (10.85 to
14.03)	1.37 (1.16 to 1.63)	1.38 (1.04 to 1.82)	1.36 (1.18 to 1.52)	12.20 (10.06 to
14.59)	6.50 (4.76 to
8.57)	5.70 (4.90 to
6.44)	0.65 (0.53 to 0.77)	0.67 (0.49 to 0.89)	0.62 (0.53 to 0.70)	900.85 (742.45 to 479.89 (351.76 to
1081.65)	633.70)	420.96 (361.09 to
475.01)	47.72 (39.33 to
57.30)	49.60 (36.36 to
65.50)	45.74 (39.23 to
51.61)	
Non-Hodgkin lymphoma	21.51 (19.49 to
24.11)	12.90 (11.73 to 8.61 (7.46 to
15.13)	9.94)	1.14 (1.03 to 1.28)	1.33 (1.21 to 1.56)	0.94 (0.81 to 1.08)	8.68 (7.62 to
10.04)	5.04 (4.49 to
6.09)	3.64 (2.99 to
4.37)	0.46 (0.40 to 0.53)	0.52 (0.46 to 0.63)	0.40 (0.33 to 0.47)	638.33 (562.51 to 372.46 (332.31 to
737.54)	448.45)	265.88 (219.37 to
320.14)	33.81 (29.80 to
39.07)	38.50 (34.35 to
46.35)	28.89 (23.84 to
34.79)	
Malignant neoplasm of bone and articular cartilage	18.93 (16.01 to
22.75)	11.51 (9.04 to
14.23)	7.42 (6.17 to
9.22)	1.00 (0.85 to 1.21)	1.19 (0.93 to 1.47)	0.81 (0.67 to 1.00)	10.70 (9.11 to
13.1)	6.55 (5.04 to
8.24)	4.15 (3.40 to
5.37)	0.57 (0.48 to 0.69)	0.68 (0.52 to 0.85)	0.45 (0.37 to 0.58)	786.16 (667.00 to 480.38 (370.38 to
965.71)	605.02)	305.78 (251.24 to
395.93)	41.65 (35.33 to
51.16)	49.65 (38.28 to
62.54)	33.23 (27.30 to
43.02)	
Testicular cancer	15.56 (14.69 to
16.73)	15.56 (14.69 to
16.73)	NA	0.82 (0.78 to 0.89)	1.61 (1.52 to 1.73)	NA	1.46 (1.36 to
1.56)	1.46 (1.36 to
1.56)	NA	0.08 (0.07 to 0.08)	0.15 (0.14 to 0.16)	NA	107.98 (100.34 to 107.98 (100.34 to
115.57)	115.57)	NA	5.72 (5.32 to 6.12)	11.16 (10.37 to
11.95)	NA	
Hodgkin lymphoma	12.80 (9.72 to
15.54)	6.78 (4.84 to
8.82)	6.02 (4.15 to
7.59)	0.68 (0.52 to 0.82)	0.70 (0.50 to 0.91)	0.65 (0.45 to 0.82)	4.10 (2.68 to
5.36)	2.21 (1.31 to
3.22)	1.89 (1.07 to
2.60)	0.22 (0.14 to 0.28)	0.23 (0.14 to 0.33)	0.20 (0.12 to 0.28)	300.28 (195.82 to 162.16 (96.56 to
392.82)	235.13)	138.12 (77.64 to
190.39)	15.91 (10.37 to
20.81)	16.76 (9.98 to
24.3)	15.01 (8.44 to
20.69)	
Non-melanoma skin cancer	11.16 (7.61 to
15.78)	5.25 (3.55 to
7.64)	5.91 (4.04 to
8.25)	0.59 (0.40 to 0.84)	0.54 (0.37 to 0.79)	0.64 (0.44 to 0.90)	0.15 (0.12 to
0.17)	0.08 (0.06 to
0.09)	0.07 (0.06 to
0.08)	0.01 (0.01 to 0.01)	0.01 (0.01 to 0.01)	0.01 (0.01 to 0.01)	10.37 (8.32 to 5.55 (4.00 to 6.37) 4.82 (4.20 to 5.46)
11.50)	‘	'	0.55 (0.44 to 0.61)	0.57 (0.41 to 0.66)	0.52 (0.46 to 0.59)	
Ovarian cancer	11.09 (8.98 to
12.81)	NA	11.09 (8.98 to
12.81)	0.59 (0.48 to 0.68)	NA	1.20 (0.98 to 1.39)	1.57 (1.27 to
1.82)	NA	1.57 (1.27 to
1.82)	0.08 (0.07 to 0.10)	NA		0.17 (0.14 to 0.20)	115.07 (92.42 to
133.11)	NA	115.07 (92.42 to
133.11)	6.10 (4.90 to 7.05)	NA	12.50 (10.04 to
14.46)	
Cervical cancer	10.90 (9.56 to
12.77)	NA	10.90 (9.56 to
12.77)	0.58 (0.5 1 to 0.68)	NA	1.18 (1.04 to 1.39)	2.48 (2.14 to
2.96)	NA	2.48 (2.14 to
2.96)	0.13 (0.1	1 to 0.16)	NA		0.27 (0.23 to 0.32)	175.95 (152.10 to
209.72)	NA	175.95 (152.10 to
209.72)	9.32 (8.06 to
11.11)	NA	19.12 (16.53 to
22.79)	
Thyroid cancer	9.47 (7.74 to
12.20)	2.45 (1.97 to
2.84)	7.02 (5.48 to
9.79)	0.50 (0.41 to 0.65)	0.25 (0.20 to 0.29)	0.76 (0.60 to 1.06)	0.72 (0.57 to
0.95)	0.24 (0.19 to
0.28)	0.48 (0.36 to
0.7)	0.04 (0.03 to 0.05)	0.02 (0.02 to 0.03)	0.05 (0.04 to 0.08)	55.81 (44.16 to 18.17 (14.16 to
74.03)	21.52)	37.64 (28.23 to
54.86)	2.96 (2.34 to 3.92)	1.88 (1.46 to 2.22)	4.09 (3.07 to 5.96)	
Breast cancer	8.15 (6.92 to
9.43)	0.21 (0.11 to
0.28)	7.94 (6.76 to
9.24)	0.43 (0.37 to 0.50)	0.02 (0.01 to 0.03)	0.86 (0.73 to 1.00)	2.23 (1.82 to
2.72)	0.05 (0.03 to
0.08)	2.18 (1.78 to
2.67)	0.12 (0.10 to 0.14)	0.01 (0.00 to 0.01)	0.24 (0.19 to 0.29)	160.01 (130.82 to
_3.63 (2.14 to 5.46)
194.09)'	156.38 (127.72 to
190.08)	8.48 (6.93 to
10.28)	0.38 (0.22 to 0.56)	16.99 (13.88 to
20.65)	
Soft tissue and other extraosseous sarcomas	7.44 (6.27 to
9.63)	3.73 (2.99 to
5.37)	3.71 (3.05 to
5.00)	0.39 (0.33 to 0.51)	0.39 (0.31 to 0.56)	0.40 (0.33 to 0.54)	2.75 (2.30 to
3.65)	1.34 (1.05 to
2.01)	1.41 (1.15 to
1.93)	0.15 (0.12 to 0.19)	0.14 (0.1	1 to 0.21)	0.15 (0.13 to 0.21)	202.53 (169.46 to 98.81 (77.48 to
268.26)	148.00)	103.72 (84.49 to
142.14)	10.73 (8.98 to
14.21)	10.21 (8.01 to
15.30)	11.27 (9.18 to
15.44)	
Colon and rectum cancer	,5.69 (5.13 to
6.25)	3.23 (2.79 to
3.65)	2.45 (2.20 to
2.80)	0.30 (0.27 to 0.33)	0.33 (0.29 to 0.38)	0.27 (0.24 to 0.30)	2.59 (2.30 to
2.92)	1.46 (1.27 to
1.65)	1.13 (1.00 to
1.33)	0.14 (0.12 to 0.15)	0.15 (0.13 to 0.17)	0.12 (0.11 to 0.14)	182.61 (162.13 to 102.85 (89.31 to
205.21)	116.49)	79.76 (70.68 to
93.3)	9.67 (8.59 to
10.87)	10.63 (9.23 to
12.04)	8.67 (7.68 to
10.14)	
Malignant skin melanoma	3.94 (3.37 to
4.35)	1.47 (1.29 to
1.63)	2.47 (2.04 to
2.87)	0.21 (0.18 to 0.23)	0.15 (0.13 to 0.17)	0.27 (0.22 to 0.31)	0.51 (0.36 to
0.65)	0.22 (0.16 to
0.27)	0.29 (0.17 to
0.41)	0.03 (0.02 to 0.03)	0.02 (0.02 to 0.03)	0.03 (0.02 to 0.05)	36.91 (26.53 to 15.81 (11.67 to
46.84)	19.54)	21.10 (13.03 to
29.94)	1.96 (1.41 to 2.48)	1.63 (1.21 to 2.02)	2.29 (1.42 to 3.25)	
Lip and oral cavity cancer	3.56 (2.79 to
4.33)	1.52 (1.17 to
1.77)	2.04 (1.55 to
2.63)	0.19 (0.15 to 0.23)	0.16 (0.12 to 0.18)	0.22 (0.17 to 0.29)	1.42 (1.1 to
1.74)	0.67 (0.50 to
0.79)	0.76 (0.56 to 1)	0.08 (0.06 to 0.09)	0.07 (0.05 to 0.08)	0.08 (0.06 to 0.1 1)	100.10 (77.15 to 46.83 (34.83 to
122.77)	55.69)	53.26 (39.60 to
70.21)	5.30 (4.09 to 6.50)	4.84 (3.60 to 5.76)	5.79 (4.30 to 7.63)	
Nasopharynx cancer	3.46 (3.02 to
3.91)	2.15 (1.80 to
2.53)	1.31 (1.13 to
1.58)	0.18 (0.16 to 0.21)	0.22 (0.19 to 0.26)	0.14 (0.12 to 0.17)	1.65 (1.41 to
1.91)	0.97 (0.81 to
1.15)	0.68 (0.58 to
0.85)	0.09 (0.07 to 0.10)	0.10 (0.08 to 0.12)	0.07 (0.06 to 0.09)	120.01 (102.78 to 70.77 (58.64 to
139.43)	83.93)	49.24 (42.01 to
62.29)	6.36 (5.44 to 7.39)	7.32 (6.06 to 8.68)	5.35 (4.56 to 6.77)	
Kidney cancer	3.37 (3.14 to
3.62)	1.64 (1.51 to
1.80)	1.73 (1.56 to
1.94)	0.18 (0.17 to 0.19)	0.17 (0.16 to 0.19)	0.19 (0.17 to 0.2 1)	0.72 (0.66 to
0.79)	0.40 (0.36 to
0.44)	0.32 (0.29 to
0.36)	0.04 (0.03 to 0.04)	0.04 (0.04 to 0.05)	0.04 (0.03 to 0.04)	53.97 (49.03 to 29.64 (26.46 to
58.89)	32.98)	24.33 (21.72 to
27.39)	2.86 (2.60 to 3.12)	3.06 (2.73 to 3.41)	2.64 (2.36 to 2.98)	
Stomach cancer	2.77 (2.35 to
3.03)	1.41 (1.06 to
1.63)	1.35 (1.19 to
1.50)	0.15 (0.12 to 0.16)	0.15 (0.11 to 0.17)	0.15 (0.13 to 0.16)	1.74 (1.49 to
1.89)	0.79 (0.60 to
0.90)	0.95 (0.84 to
1.05)	0.09 (0.08 to 0.10)	0.08 (0.06 to 0.09)	0.10 (0.09 to 0.1 1)	120.76 (103.25 to 55.17 (41.49 to
131.10)	62.59)	65.59 (58.33 to
72.91)	6.40 (5.47 to 6.94)	5.70 (4.29 to 6.47)	7.13 (6.34 to 7.92)	
Liver cancer	2.41 (2.15 to
2.73)	1.36 (1.21 to
1.59)	1.05 (0.92 to
1.22)	0.13 (0.11 to 0.14)	0.14 (0.13 to 0.16)	0.11 (0.10 to 0.13)	2.30 (2.04 to
2.63)	1.27 (1.12 to
1.48)	1.03 (0.89 to
1.21)	0.12 (0.1	1 to 0.14)	0.13 (0.12 to 0.15)	0.11 (O.lO to 0.13)	163.38 (144.83 to 89.98 (79.32 to
187.19)	104.93)	73.40 (63.57 to
86.12)	8.65 (7.67 to 9.92)	9.30 (8.20 to
10.85)	7.97 (6.91 to 9.36)	
(Continues)
et al. International Journal of Surgery (2026)	International Journal of Surgery

CH
(Continued).	
Cancer type	Incident cases, the usands (95% UI)	Incidence rate per 100 000 ι 95% UI)	Deaths (95% UI), thousands (95% UI)	Motality rate per 100 000 (95% UI)	DALYs (95% UI), thousands (95% UI)	DALY rate (95% UI)	
	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	
Tracheal, bronchus, and lung cancer	2.21 (2.04 to
2.38)	1.30 (1.14 to
1.46)	0.91 (0.81 to
1.02)	0.12 (0.11 to 0.13)	0.13 (0.12 to 0.15)	0.10 (0.09 to 0.11)	2.06 (1.9 to
2.23)	1.24 (1.09 to
1.4)	0.82 (0.73 to 0.93)	0.11 (0.10 to 0.12)	0.13 (0.11 to 0.14)	0.09 (0.08 to 0.10)	143.70 (132.39 to 86.54 (75.61 to
155.25)	97.26)	57.16 (50.73 to
64.51)	7.61 (7.01 to 8.22)	8.95 (7.82 to
10.05)	6.21 (5.51 to 7.01)	
Eye cancer	2.12 (1.24 to
3.28)	0.93 (0.49 to 1.68)	1.20 (0.65 to
2.00)	0.11 (0.07 to 0.17)	0.10 (0.05 to 0.17)	0.13 (0.07 to 0.22)	0.17 (0.11 to
0.22)	0.07 (0.04 to
0.1 I)	0.10 (0.06 to 0.16)	0.01 (0.01 to 0.01)	0.01 (0.00 to 0.01)	0.01 (0.01 to 0.02)	13.05 (8.70 to
17.50)	5.25 (2.87 to 8.48)	7.80 (4.82 to
11.92)	0.69 (0.46 to 0.93)	0.54 (0.30 to 0.88)	0.85 (0.52 to 1.30)	
Bladder cancer	0.84 (0.75 to
0.96)	0.53 (0.46 to
0.63)	0.31 (0.26 to 0.36)	0.04 (0.04 to 0.05)	0.06 (0.05 to 0.07)	0.03 (0.03 to 0.04)	0.19 (0.17 to
0.22)	0.10 (0.09 to 0.12)	0.09 (0.08 to
0.1 I)	0.01 (0.01 to 0.01)	0.01 (0.01 to 0.01)	0.01 (0.01 to 0.01)	13.91 (12.11 to
16.21)	7.40 (6.25 to 8.82) 6.51 (5.43 to 7.90)	0.74 (0.64 to 0.86)	0.76 (0.65 to O.91)	0.71 (0.59 to 0.86)	
Neuroblastoma and other peripheral nervous cell tumors	0.81 (0.62 to
1.02)	0.41 (0.33 to 0.52)	0.40 (0.29 to
0.54)	0.04 (0.03 to 0.05)	0.04 (0.03 to 0.05)	0.04 (0.03 to 0.06)	0.41 (0.34 to
0.47)	0.21 (0.18 to
0.24)	0.21 (0.15 to
0.26)	0.02 (0.02 to 0.02)	0.02 (0.02 to 0.02)	0.02 (0.02 to 0.03)	30.74 (25.51 to
35.11)	15.39 (13.20 to
17.66)	15.35 (11.49 to
19.54)	1.63 (1.35 to 1.86)	1.59 (1.36 to 1.82)	1.67 (1.25 to 2.12)	
Uterine cancer	0.69 (0.52 to 0.81)	NA	0.69 (0.52 to 0.81)	0.04 (0.03 to 0.04)	NA	0.07 (0.06 to 0.09)	0.12 (0.09 to 0.15)	NA	0.12 (0.09 to 0.15)	0.01 (0.00 to 0.01)	NA	0.01 (0.01 to 0.02)	8.62 (6.54 to
10.41)	NA	8.62 (6.54 to
10.41)	0.46 (0.35 to 0.55)	NA	0.94 (0.71 to 1.13)	
Esophageal cancer	0.45 (0.40 to 0.53)	0.26 (0.23 to 0.29)	0.20 (0.15 to 0.26)	0.02 (0.02 to 0.03)	0.03 (0.02 to 0.03)	0.02 (0.02 to 0.03)	0.41 (0.36 to 0.49)	0.23 (0.21 to 0.26)	0.18 (0.14 to 0.25)	0.02 (0.02 to 0.03)	0.02 (0.02 to 0.03)	0.02 (0.02 to 0.03)	27.95 (24.76 to
33.17)	15.75 (14.20 to
17.74)	12.20 (9.48 to
16.8)	1.48 (1.31 to 1.76)	1.63 (1.47 to 1.83)	1.33 (1.03 to 1.83)	
Pancreatic cancer	0.43 (0.38 to 0.49)	0.23 (0.20 to 0.25)	0.20 (0.18 to 0.24)	0.02 (0.02 to 0.03)	0.02 (0.02 to 0.03)	0.02 (0.02 to 0.03)	0.40 (0.36 to 0.46)	0.21 (0.19 to
0.24)	0.19 (0.17 to
0.22)	0.02 (0.02 to 0.02)	0.02 (0.02 to 0.03)	0.02 (0.02 to 0.02)	28.09 (25.07 to
31.99)	14.83 (13.18 to
16.76)	13.25 (11.59 to
15.50)	1.49 (1.33 to 1.69)	1.53 (1.36 to 1.73)	1.44 (1.26 to 1.68)	
Prostate cancer	0.31 (0.24 to
0.35)	0.31 (0.24 to
0.35)	NA	0.02 (0.01 to 0.02)	0.03 (0.03 to 0.04)	NA	0.06 (0.04 to 0.07)	0.06 (0.04 to 0.07)	NA	NA	0.01 (0.00 to 0.01)	NA		4.35 (3.23 to
5.15)	4.35 (3.23 to 5.15) 0.00 (0.00 to 0.00)	0.23 (0.17 to 0.27)	0.45 (0.33 to 0.53)	0.00 (0.00 to 0.00)	
Other pharynx cancer	0.30 (0.23 to 0.37)	0.12 (O.lO to 0.15)	0.18 (0.12 to 0.24)	0.02 (0.01 to 0.02)	0.01 (0.01 to 0.02)	0.02 (0.01 to 0.03)	0.20 (0.15 to 0.24)	0.08 (0.07 to 0.10)	0.12 (0.08 to 0.16)	0.01 (0.01 to 0.01)	0.01 (0.01 to 0.01)	0.01	(0.01 to 0.02)	13.41 (10.15 to
16.58)	5.30 (4.47 to 6.66)	8.11 (5.39 to
10.78)	0.71 (0.54 to 0.88)	0.55 (0.46 to 0.69)	0.88 (0.59 to 1.17)	
Larynx cancer	0.22 (0.19 to 0.26)	0.11 (O.lO to 0.13)	0.11 (0.08 to 0.15)	0.01 (0.01 to 0.01)	0.01 (0.01 to 0.01)	0.01 (0.01 to 0.02)	0.14 (0.12 to 0.17)	0.07 (0.06 to 0.08)	0.07 (0.05 to 0.10)	0.01 (0.01 to 0.01)	0.01 (0.01 to 0.01)	0.01	(0.01 to 0.01)	9.66 (8.01 to
11.81)	4.59 (4.15 to 5.24) 5.07 (3.64 to 6.88)	0.51 (0.42 to 0.63)	0.47 (0.43 to 0.54)	0.55 (0.4 to 0.75)	
Multiple myeloma	0.20 (0.13 to 0.25)	0.12 (0.07 to
0.15)	0.08 (0.05 to
0.11)	0.01 (0.01 to 0.01)	0.01 (0.01 to 0.02)	0.01 (0.01 to 0.01)	0.14 (O.lOto 0.17)	0.08 (0.05 to
0.1 I)	0.06 (0.03 to 0.08)	0.01 (0.01 to 0.01)	0.01 (0.01 to 0.01)	0.01	(0.00 to 0.01)	9.68 (6.48 to
11.88)	5.64 (3.32 to 7.17) 4.04 (2.32 to 5.28)	0.51 (0.34 to 0.63)	0.58 (0.34 to 0.74)	0.44 (0.25 to 0.57)	
Gallbladder and biliary tract cancer	0.17 (0.13 to
0.20)	0.07 (0.04 to
0.08)	0.10 (0.07 to 0.13)	0.01 (0.01 to 0.01)	0.01 (0.00 to 0.01)	0.01 (0.01 to 0.01)	0.13 (O.lOto 0.16)	0.05 (0.03 to 0.06)	0.09 (0.06 to
0.1 I)	0.01 (0.01 to 0.01)	0.00 (0.00 to 0.01)	0.01	(0.01 to 0.01)	8.95 (6.64 to
10.98)	3.12 (2.00 to 3.77) 5.83 (3.89 to 7.74)	0.47 (0.35 to 0.58)	0.32 (0.21 to 0.39)	0.63 (0.42 to 0.84)	
Mesothelioma	0.11 (O.lO to 0.13)	0.06 (0.05 to
0.07)	0.06 (0.05 to 0.07)	0.01 (0.01 to 0.01)	0.01 (0.00 to 0.01)	0.01 (0.01 to 0.01)	0.11 (0.09 to 0.12)	0.05 (0.04 to 0.06)	0.05 (0.04 to 0.06)	0.01 (0.00 to 0.01)	0.01 (0.00 to 0.01)	0.01	(0.00 to 0.01)	7.15 (6.10 to
8.15)	3.67 (2.99 to 4.41) 3.48 (2.90 to 4.29)	0.38 (0.32 to 0.43)	0.38 (0.31 to O.46)	0.38 (0.32 to 0.47)	
Other malignant neoplasms	13.63 (11.43 to
15.27)	6.62 (5.22 to
7.79)	7.01 (5.83 to
8.04)	0.72 (0.61 to 0.81)	0.68 (0.54 to 0.81)	0.76 (0.63 to 0.87)	6.65 (5.51 to
7.53)	3.39 (2.61 to
4.01)	3.26 (2.69 to
3.84)	0.35 (0.29 to 0.40)	0.35 (0.27 to 0.4 1)	0.35 (0.29 to 0.42)	488.42 (404.08 to 249.14 (191.99 to
553.47)	294.35)	239.29 (197.48 to
281.36)	25.87 (21.41to
29.32)	25.75 (19.85 to
30.43)	26.00 (2 1.46 to
30.57)	
AYAs, adolescent and young adults; DALYs, disability-adjusted life years.
et al. International Journal of Surgery (2026)

RANK	Cancer 1990	Cases in 1990, thousands (95% UI)	
1	Leukemia	39.13 (32.84 to 43.73)	
			
2	Brain and central nervous system cancer	18.56 (15.29 to 21.28)	
			
3	Non-Hodgkin lymphoma	15.49 (14.23 to 16.93)	
			
4	Malignant neoplasm of bone and articular cartilage	12.95 (11.20 to 15.24)	
5	Hodgkin lymphoma	11.98 (9.93 to 13.26)	
			
6	Cervical cancer	8.69 (7.77 to 9.74)	
			
7	Non-melanoma skin cancer	8.45 (5.57 to 12.14)	
			
8	Testicular cancer	7.63 (7.22 to 8.07)	
			
9	Ovarian cancer	6.88 (5.25 to 8.54)	
			
10	Soft tissue and other extraosseous sarcomas	6.51 (5.39 to 7.83)	
			
11	Colon and rectum cancer	5.37 (4.64 to 5.94)	
			
12	Thyroid cancer	4.74 (4.12 to 5.47)	
			
13	Stomach cancer	4.71 (4.05 to 5.17)	
			
14	Nasopharynx cancer	3.92 (3.52 to 4.35)	
			
15	Breast cancer	3.43 (3.17 to 3.77)	
			
16	Malignant skin melanoma	2.82 (2.62 to 2.97)	
			
17	Liver cancer	2.74 (2.42 to 3.17)	
			
18	Tracheal, bronchus, and lung cancer	2.73 (2.48 to 3.00)	
			
19	Kidney cancer	2.27 (2.15 to 2.40)	
			
20	Lip and oral cavity cancer	1.96 (1.83 to 2.10)	
			
21	Eye cancer	1.46 (0.91 to 2.21)	
			
22	Bladder cancer	0.79 (0.63 to 0.86)	
			
23	Esophageal cancer	0.58 (0.5 to 0.65)	
			
24	Uterine cancer	0.55 (0.36 to 0.67)	
			
25	Pancreatic cancer	0.43 (0.39 to 0.48)	
			
26	Neuroblastoma and other peripheral nervous cell	0.43 (0.32 to 0.56)	
			
27	Larynx cancer	0.21 (0.16 to 0.23)	
			
28	Other pharynx cancer	0.17 (0.14 to 0.19)	
			
29	Prostate cancer	0.16 (0.13 to 0.19)	
			
30	Gallbladder and biliary tract cancer	0.15 (0.11 to 0.17)	
			
31	Multiple myeloma	0.09 (0.07 to 0.12)	
			
32	Mesothelioma	0.09 (0.07 to 0.10)	
			
	Total cancers	187.47 (174.96 to 197.93)	
RANK		Cancer 2021		Cases in 2021, thousands (95% UI)		nnualized rate of change in incident cases,
% (95% CI)		Annualized rate of change in incidence rate, % (95% CI)	
1		Leukemia		34.68 (27.66 to 38.78)		-0.42 (-0.52 to -0.32)		-1.04 (-1.08 to -1.01)	
									
2		Brain and central nervous system cancer		25.87 (21.93 to 30.76)		1.08 (0.99 to 1.16)		0.45 (0.41 to 0.48)	
									
3		Non-Hodgkin lymphoma		21.51 (19.49 to 24.11)		0.93 (0.81 to 1.06)		0.30 (0.21 to 0.39)	
									
4		Malignant neoplasm of bone and articular cartilage		18.93 (16.01 to 22.75)		1.24 (1.11 to 1.37)		0.61 (0.55 to 0.67)	
									
5		Testicular cancer		15.56 (14.69 to 16.73)		2.62 (2.50 to 2.73)		1.97 (1.89 to 2.06)	
									
6		Hodgkin lymphoma		12.80 (9.72 to 15.54)		0.19 (0.01 to 0.36)		-0.44 (-0.55 to -0.33)	
									
7		Non-melanoma skin cancer		11.16 (7.61 to 15.78)		1.09 (0.79 to 1.38)		0.45 (0.14 to 0.77)	
									
8		Ovarian cancer		11.09 (8.98 to 12.81)		1.56 (1.49 to 1.63)		0.93 (0.89 to 0.96)	
									
9		Cervical cancer		10.90 (9.56 to 12.77)		0.75 (0.59 to 0.91)		0.12 (0.03 to 0.21)	
									
10		Thyroid cancer		9.47 (7.74 to 12.20)		2.37 (2.18 to 2.56)		1.73 (1.60 to 1.87)	
									
11		Breast cancer		8.15 (6.92 to 9.43)		2.96 (2.88 to 3.03)		2.31 (2.23 to 2.39)	
									
12		Soft tissue and other extraosseous sarcomas		7.44 (6.27 to 9.63)		0.27 (0.17 to 0.37)		-0.36 (-0.44 to -0.28)	
									
13		Colon and rectum cancer		5.69 (5.13 to 6.25)		0.32 (0.22 to 0.41)		-0.31 (-0.43 to -0.19)	
									
14		Malignant skin melanoma		3.94 (3.37 to 4.35)		1.15 (0.74 to 1.57)		0.52 (0.19 to 0.86)	
									
15		Lip and oral cavity cancer		3.56 (2.79 to 4.33)		2.00 (1.92 to 2.07)		1.36 (1.32 to 1.40)	
									
16		Nasopharynx cancer		3.46 (3.02 to 3.91)		-0.60 (-0.72 to -0.49)		-1.23 (-1.40 to -1.05)	
									
17		Kidney cancer		3.37 (3.14 to 3.62)		1.53 (1.38 to 1.68)		0.89 (0.78 to 1.01)	
									
18		Stomach cancer		2.77 (2.35 to 3.03)		-1.54 (-1.71 to -1.36)		-2.15 (-2.30 to -2.01)	
									
19		Liver cancer		2.41 (2.15 to 2.73)		-0.79 (-0.94 to -0.63)		-1.41 (-1.53 to -1.29)	
									
20		Tracheal, bronchus, and lung cancer		2.21 (2.04 to 2.38)		-0.56 (-0.67 to -0.46)		-1.19 (-1.29 to -1.08)	
									
21		Eye cancer		2.12 (1.24 to 3.28)		1.21 (1.18 to 1.24)		0.58 (0.48 to 0.68)	
									
22		Bladder cancer		0.84 (0.75 to 0.96)		0.20 (0.13 to 0.27)		-0.43 (-0.50 to -0.36)	
									
23		Neuroblastoma and other peripheral nervous cell		0.81 (0.62 to 1.02)		1.95 (1.72 to 2.18)		1.31 (1.14 to 1.48)	
		tumors							
24		Uterine cancer		0.69 (0.52 to 0.81)		0.95 (0.72 to 1.19)		0.32 (0.13 to 0.51)	
									
25		Esophageal cancer		0.45 (0.40 to 0.53)		-0.74 (-0.90 to -0.59)		-1.37 (-1.51 to -1.22)	
									
26		Pancreatic cancer		0.43 (0.38 to 0.49)		0.09 (-0.02 to 0.19)		-0.54 (-0.64 to -0.43)	
									
27		Prostate cancer		0.31 (0.24 to 0.35)		2.29 (2.11 to 2.47)		1.65 (1.49 to 1.81)	
									
28		Other pharynx cancer		0.30 (0.23 to 0.37)		2.13 (2.03 to 2.23)		1.49 (1.38 to 1.60)	
									
29		Larynx cancer		0.22 (0.19 to 0.26)		0.31 (0.21 to 0.42)		-0.31 (-0.43 to -0.20)	
									
30		Multiple myeloma		0.20 (0.13 to 0.25)		3.04 (2.74 to 3.34)		2.39 (2.12 to 2.66)	
									
31		Gallbladder and biliary tract cancer		0.17 (0.13 to 0.20)		0.59 (0.42 to 0.75)		-0.04 (-0.19 to 0.10)	
									
32		Mesothelioma		0.11 (0.10 to 0.13)		1.04 (0.88 to 1.19)		0.41 (0.28 to 0.53)	
									
		Total cancers		235.25 (217.21 to 251.07)		0.75 (0.67 to 0.82)		0.12 (0.08 to 0.15)	
Rankings are by incident cases. Cancers are ordered by rank in 2021, with lines connecting to their rank in 1990. Colors refer to the directional change in cancer rank from 1990 to 2021: red signifies an increase in rank, blue signifies no change in rank, and green signifies a decrease in rank. UI, indicates uncertainty interval; CI, confidence interval.
Figure 1. Cancer group rankings by incident cases and changes among AYAs (10–24 years), from 1990 to 2021, Global Burden of Disease 2021 study. Panels display global rankings for total cancers and 32 specific cancer types by incident cases and by annualized rate of change in incidence rates over time. Estimates are derived from the GBD 2021 modeling framework; 95% UIs are shown where applicable. Annualized percentage changes were obtained from log-linear regression models fitted to incidence rates from 1990 to 2021, with the regression coefficient transformed as [exp(β) – 1] × 100%. AYAs, adolescents and young adults; CI, confidence interval; GBD, Global Burden of Disease; UI, uncertainty interval.

increased marginally from 873 000 to 901 000, with an annualized DALY rate decrease of -0.60%.
Non-Hodgkin lymphoma ranked third in incidence in 2021, with incident cases rising from 15 490 to 21 510 (0.93% per year), although it ranked fourth in both mortality and DALYs. Malignant neoplasm of bone and articular cartilage showed a marked rise in burden, advancing to third in both mortality and DALYs rankings in 2021. Incident cases grew from 12 950 to 18 930 (1.24% annually), with a concurrent increase in deaths (8 350 to 10 700) and DALYs (615 000 to 786 000), reflecting an annualized DALY rate increase of 0.16%.
Testicular cancer rose from eighth to fifth in incidence, with a substantial annualized rise in incident cases (2.62%) and incidence rates (1.97%), and corresponding increases in deaths and DALYs (from 87 100 to 107 980). Hodgkin lymphoma ranked sixth in incidence and fifth in both mortality and DALYs in 2021. While mortality and DALYs continued to decline, the incidence rate showed a modest decrease (-0.44%) despite a slight rise (0.19%) in absolute case counts since 1990.
Cervical cancer contributed 10 900 incident cases, ranking ninth for incidence and eighth for both deaths and DALYs; although absolute case counts increased relative to 1990, the incidence rate plateaued, and both mortality and DALY rates continued to decline. Ovarian cancer rose to 8th in incidence with 11 090 new cases and stood 14th for deaths and DALYs, with all three indicators climbing steadily-reflected in a 0.48% annual increase in the DALY rate. By contrast, uterine cancer remained a rare malignancy, occupying 24th place for incidence and 13th for deaths and DALYs; despite slight growth in case numbers, its mortality and DALY rates fell by more than 1% per year, driving a marked drop in its ranking.
Notably, thyroid, breast, and lip and oral cavity cancers showed the most prominent increases in incident cases, with breast cancer moving from 15th to 11th in incidence, and from 14th to 10th in DALYs. Breast cancer DALYs rose from 84 500 to 160 000 (2.13% annually), with an annualized DALY rate increase of 1.49%. Thyroid cancer advanced from 12th to 10th in incidence (cases up from 4 740 to 9 470; 2.37% per year) and from 18th to 17th in DALYs, with absolute DALYs increasing from 42 200 to 55 800 (0.93% annually). Lip and oral cavity cancer climbed from 20th to 15th in incidence (cases up from 1 960 to 3 560; 2.00% per year) while maintaining 16th place in DALYs, where the burden almost doubled from 65 400 to 100 100 (1.41% annually).
Cancers with decreasing burden included stomach, nasopharynx, and tracheal/bronchus/lung cancer. Stomach cancer showed the sharpest declines across all metrics, falling from 6th to 12th in DALYs, with an annualized DALY rate decrease of -2.86%. Nasopharynx cancer DALYs fell from 191 000 to 120 000 (-2.34% per year for DALY rate), while lung cancer DALYs decreased from 188 000 to 144 000 (-1.39% per year).
Rare cancers such as neuroblastoma, multiple myeloma, and mesothelioma showed upward trends despite lower absolute numbers. Multiple myeloma exhibited the fastest growth in DALY burden (2.35% per year), followed by neuroblastoma (1.67%) and other pharynx cancers (1.57%). By contrast, cancers of the bladder, esophagus, and gallbladder remained low in absolute burden and showed only minor ranking shifts, whereas uterine cancer, despite its small burden, fell six places in DALY ranking between 1990 and 2021.

Cancer burden by SDI quintiles
In 2021, cancer was the fifth leading death cause of disease burden in this age group, highlighting its significant impact (Fig. 2A). However, substantial heterogeneity existed across SDI levels and regions.
In the high SDI quintile, leukemia, brain & CNS cancer, and bone & cartilage cancer were the leading causes of cancer deaths and DALYs. Conversely, in the low SDI quintile, the burden of leukemia, bone & cartilage cancer, and non-Hodgkin lymphoma was more pronounced (Fig. 2B,D). Incidence patterns also varied. The high SDI quintile experienced higher cases of brain & CNS cancer, non-melanoma skin cancer, and testicular cancer. In contrast, leukemia, bone & cartilage cancer, and nonHodgkin lymphoma predominated in the low SDI quintile (Fig. 2C).
In 2021, total cancer burden varied across SDI quintiles. The middle SDI with the largest population had the highest incident cases (72 605), while the low-middle SDI had the highest deaths (29 645). Conversely, the low SDI recorded the lowest incident cases (32 515), and the high SDI had the lowest deaths (6280) (Fig. 2E). Incidence rates peaked in the high SDI (>20 per 100 000) and were lowest in the low SDI (<10 per 100 000), whereas mortality rates were highest in the low-middle SDI (5.36 per 100 000) and lowest in the high SDI (3.27 per 100 000) (Fig. 2F), highlighting disparities linked to socio-demographic factors.
Risk factors for global cancer burden
Figure 3 presents SDI-stratified risk-factor contributions to AYA cancer DALYs as grouped bar charts, enabling direct comparison across SDI quintiles under a unified x-axis (0–5%). In 2021, global AYA cancer DALYs were attributable to six assessed risk factors. Unsafe sex accounted for the largest share (2.54%), followed by high BMI (0.83%), alcohol use (0.64%), occupational exposures (0.18%), other environmental risks (0.08%), and drug use (0.05%). Risk-factor profiles varied by SDI quintile. In high SDI settings, high BMI (1.61%) and alcohol use (1.04%) predominated, whereas unsafe sex contributed only 0.67%. In high-middle SDI countries, high BMI (1.24%), unsafe sex (0.90%), and alcohol use (0.81%) were the principal drivers. In middle SDI countries, unsafe sex, high BMI, and alcohol use accounted for 1.52%, 1.05%, and 0.76% of AYA cancer DALYs, respectively. In low-middle SDI regions, unsafe sex rose to 3.00%, exceeding all other factors combined. The low SDI quintile exhibited the greatest concentration, with unsafe sex responsible for 4.87% of DALYs, while the next largest factors were alcohol use (0.49%) and high BMI (0.39%) (Fig. 3).
Global cancer burden by countries and regions
Total cancer incidence (per 100 000 population) in AYAs varied widely by country and region. The incidence ranged from approximately 4.1 to 62.6 per 100 000. The highest incidence rates (≥20.0 per 100 000) were observed in North America (USA and Canada), Western Europe (e.g., France, Italy, Spain, and UK), and Oceania (Australia and New Zealand); some countries in South America (Uruguay and Chile) also fell into this highest category. By contrast, the lowest incidence rates (4.1–6.3 per 100 000) were seen in many sub-Saharan African countries (e.g., Niger, Congo, Chad, and Benin), whereas incidence in most
A rank of total cancers in deaths
B rank of 32 cancer types in deaths

Number
66379.2-280560.7
37624.9-66379.2
22868.3-37624.9
14181.6-22868.3
9548.4-14181.6
5185.2-9548.4
1966.6-5185.2
790.7-1966.6
221.9-790.7
0-221.9

Number
2311.8 - 25688.5
864.4 - 2311.8
544.1 - 864.4
290.8 - 544.1
149.2 - 290.8
105.1 - 149.2
59.22 - 105.1
37.02 - 59.22
15.39 - 37.02
0 - 15.39

Leukemia Brain and central nervous system cancer Malignant neoplasm of bone and articular cartilage Non-Hodgkin lymphoma Hodgkin lymphoma Soft tissue and other extraosseous sarcomas Colon and rectum cancer Cervicalcancer Liver cancer Breast cancer Tracheal, bronchus, and lung cancer Stomach cancer Nasopharynx cancer Ovarian cancer Testicular cancer Lip and oral cavitycancer Kidneycancer Thyroid cancer Malignant skin melanoma Neuroblastoma and other peripheral nervous cell tumors Esophagealcancer Pancreatic cancer Other pharynx cancer Bladder cancer Eyecancer Non-melanoma skin cancer Multiple myeloma Larynx cancer Gallbladder and biliarytract cancer Uterine cancer Mesothelioma
Prostate cancer
C rank of32 cancer types in incident cases
D rank of 32 cancer types in dalys

Leukemia Brainandcentral nervous system cancer
Non-Hodgkin lymphoma Malignant neoplasm of bone and articularcartilage Testicular cancer Hodgkin lymphoma Non-melanoma skin cancer Ovarian cancer Cervical cancer Thyroidcancer
Breast cancer Softtissue and other extraosseous sarcomas
Colonandrectum cancer Malignant skin melanoma Lipandoralcavity cancer Nasopharynx cancer Kidney cancer Stomachcancer Liver cancer
Tracheal, bronchus,andlungcancer Eye cancer Bladder cancer
Neuroblastoma and other peripheral nervous cell tumors Uterine cancer
Esophageal cancer Pancreatic cancer
Prostate cancer Otherpharynx cancer Larynx cancer Multiple myeloma
Gallbladder and biliary tract cancer Mesothelioma
Number
5416.9-34684.7
3440.1-5416.9
2111.5-3440.1
1067.4-2111.5
745.5-1067.4
421.8-745.5
201.7-421.8
111.9-201.7
42.69-111.9
0-42.69
Leukemia Brain and central nervous system cancer Malignant neoplasm of bone and articular cartilage Non-Hodgkin lymphoma Hodgkin lymphoma Soft tissue and other extraosseous sarcomas Colon and rectum cancer Cervical cancer Liver cancer Breast cancer Tracheal, bronchus, and lung cancer Stomach cancer Nasopharynx cancer Ovarian cancer Testicular cancer Lip and oral cavity cancer Thyroid cancer Kidney cancer Malignant skin melanoma Neuroblastoma and other peripheral nervous cell tumors Pancreatic cancer Esophageal cancer Bladder cancer Other pharynx cancer Eye cancer Non-melanoma skin cancer Multiple myeloma Larynx cancer Gallbladder and biliary tract cancer Uterine cancer Mesothelioma
Prostate cancer
Number
168675.1 - 1879886.2
63429.9 - 168675.1
39157.9 - 63429.9
21117.5 - 39157.9
10633.7 - 21117.5
7491.6 - 10633.7
4237.2 - 7491.6
2586.2 -4237.2
1055.0 - 2586.2
0 - 1055.0

E absolute number of incident cases and deaths in 2021
F total cancer incidence and mortality rate in 2021

70000
60000
50000
40000
30000
20000
18
15
10000
DeathNumber
IncidenceNumber
Death Rate
Incidence Rate

Figure 2. Rankings of deaths, incident cases, DALYs for total cancers and 32 cancer types among AYAs (10–24 years) in 2021, Global Burden of Disease 2021 study. (A) Rank of total cancers by number of deaths among 21 major disease groups; (B) rank of cancer types by number of deaths; (C) rank of cancer types by the number of incident cases; (D) rank of cancer types by DALYs; (E) absolute numbers of incident cases and deaths by SDI quintile; and (F) total cancer incidence and mortality rates by SDI quintile, per 100 000 population. AYAs, adolescents and young adults; DALYs, disability-adjusted life years; SDI, sociodemographic index; GBD, Global Burden of Disease.

Asian countries was intermediate; for example, China, India, and Japan had rates around 8–16 per 100 000. Overall, incidence was markedly higher in high-income regions than in low- income regions (Fig. 4A).
AYA cancer mortality rate likewise showed substantial geographic disparity. Mortality rates ranged from approximately 2.0 to 10.3 per 100 000. The highest mortality (>7.0 per 100 000) was concentrated in sub-Saharan Africa (for example,

Figure 3. SDI-stratified risk-factor contributions to cancer DALYs among AYAs (10–24 years) in 2021. For each risk factor, five adjacent bars display PAFs (%) for SDI quintiles (low, low-middle, middle, high-middle, and high). Risk factors are ordered by global PAF (descending). A unified x-axis facilitates cross-SDI comparisons. AYAs, adolescents and young adults; DALYs, disability-adjusted life years; SDI, socio-demographic index; PAF, population-attributable fractions.

Uganda, Zimbabwe, Zambia, Ethiopia) and in parts of South and Central Asia (Afghanistan, Pakistan, Turkmenistan), as well as in selected Latin American countries (Venezuela, Mexico). Conversely, the lowest mortality rates (2.0–3.3 per 100 000) were found in high-income countries including Australia, New Zealand, Western Europe, North America (United States, Canada), as well as some countries of Asia (e.g., Japan and South Korea) (Fig. 4B).
The distribution of cancer-related DALY rates mirrored the mortality pattern. DALY rates varied from approximately 144 to 768 per 100 000. The highest DALY burdens (≥510 per 100 000) were observed in sub-Saharan Africa (e.g., Uganda, Zimbabwe, and Zambia) and in South Asia (Afghanistan and Pakistan), with elevated values also in some Latin American and Caribbean countries (e.g., Guatemala, Haiti, Venezuela, and Mexico). The lowest DALY rates (144–216 per 100 000) occurred in high-income regions such as Australia, Western Europe, and North America; East Asian countries (South Korea) also fell in this lowest category (Fig. 4C). In 2021, the incidence rate of cancers among AYAs increased significantly with rising SDI (R = 0.72, 95% CI: 0.65–0.79), whereas mortality (R = - 0.35, 95% CI: - 0.48 to -0.22) and DALY rates (R = - 0.34, 95% CI: - 0.46 to -0.20) declined (Fig. 4D–F).
Between 1990 and 2021, global geographical disparities were observed in the annualized rate of change in cancer incidence, mortality, and DALY rates among AYAs. Incidence rates predominantly increased in South America, sub-Saharan Africa, and certain Middle Eastern regions, whereas notable decreases were observed in North America, parts of Europe, and East Asia. Mortality and DALY rates generally declined in high-SDI regions such as North America, Western Europe, and East Asia, but increased markedly in low- and middle-SDI settings, especially within sub-Saharan Africa and parts of Latin America (Fig. 5A–C). Spearman’s correlation analysis revealed a weak and non-significant association between SDI and changes in incidence rates (R = - 0.03, P = 0.62). Conversely, significant negative correlations were found between SDI and changes in mortality (R = - 0.52, P < 0.001) and DALY rates (R = - 0.51, P < 0.001) (Fig. 5D–F).
Discussion
Our study provides the most comprehensive global assessment of cancer burden among AYAs to date, identifying significant epidemiological shifts from 1990 to 2021. While overall cancer incidence modestly increased, mortality and DALY rates significantly declined, reflecting advancements in cancer detection, management, and survivorship care primarily in high-resource settings. However, persistent geographic and socioeconomic disparities underscore ongoing global inequities, particularly impacting LMICs.
This study adds important value beyond previous AYA cancer investigations. First, it employs the most recent GBD 2021 data to generate a unified, age-restricted (10–24 years) and site-comprehensive global analysis, enabling valid comparisons across regions and SDI strata. Second, by combining trend estimation with risk-attribution profiling, it reveals distinct etiologic transitions such as the growing contribution of metabolic and behavioral risks in high-SDI areas and infection-related cancers in low-SDI regions that earlier reports could not quantify. Third, the integration of SDI gradients offers a framework for prioritizing prevention resources and benchmarking progress toward global equity. Clinically, our findings underscore the necessity of AYA-specific cancer pathways, fertility preservation, and psychosocial survivorship care, while from a public health perspective, they provide actionable evidence for designing SDI- tailored cancer control strategies in line with the WHO’s elimination and SDG 3.4 targets[15,16].
Notably, we observed pronounced increases in the incidence rates of multiple myeloma, breast, testicular, thyroid, and prostate cancers. The rising incidence of breast cancer, particularly in higher SDI regions, likely reflects shifts in reproductive behaviors, obesity prevalence, and enhanced screening and diagnostic

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Figure 5. Geographic patterns and SDI-related associations in the annualized rate of change (1990–2021) of cancer burden among adolescent and young adult (AYAs, 10–24 years). (A) Annualized rate of change in incidence rates by country. (B) Annualized rate of change in mortality rates by country. (C) Annualized rate of change in DALY rates by country. (D) Country-level scatter plot of annualized changes in incidence versus baseline rates and SDI. (E) Country-level scatter plot of annualized changes in mortality versus baseline rates and SDI. (F) Country-level scatter plot of annualized changes in DALY rates versus baseline rates and SDI. In Panels D–F, each point represents one country; fitted lines are shown, and Spearman’s correlation coefficients (R) and P-values are reported within each panel. Annualized percentage changes in incidence, mortality, and DALY rates were derived from log-linear regression models fitted to rates for 1990–2021. AYAs, adolescents and young adults; DALYs, disability-adjusted life years; SDI, socio-demographic index.

modalities[17–20]. Similarly, increasing thyroid cancer incidence may partially represent overdiagnosis linked to widespread ultrasound use, particularly in affluent settings[21–23]. In our AYA analyses, the steep rise in thyroid cancer incidence is not matched by comparable increases in DALYs or mortality, a decoupling that is consistent with intensified detection of small, low-risk papillary tumors rather than a true surge in life-threatening disease[24]. Accordingly, we interpret AYA thyroid cancer trends cautiously and emphasize that the apparent increase likely reflects a combination of modest changes in underlying risk and heightened diagnostic intensity. The marked rise in testicular and prostate cancers may be partly related to early-life exposure to endocrine-disrupting chemicals, underscoring the need for further etiological research[25–27]. Conversely, significant decreases in stomach, liver, and esophageal cancers likely stem from improved infection control (e.g., Helicobacter pylori and hepatitis viruses) and dietary practices globally[28–30].
Our analysis demonstrates substantial progress in reducing mortality and DALYs associated with leukemia, stomach, nasopharynx, esophageal, and colorectal cancers in AYAs. These declines likely reflect advances in chemotherapy protocols, targeted therapies, improved nutrition, vaccination programs (e.g., Epstein–Barr virus and hepatitis B virus), and enhanced access to effective treatments in AYA cancer, especially in high-resource settings[31,32]. Nevertheless, the minimal reductions or increases in mortality from multiple myeloma, breast cancer, and neuroblastoma suggest that these malignancies remain challenging to manage effectively in AYAs, highlighting critical gaps in treatment and survivorship care[33–35].
Furthermore, substantial variations were evident in cancer burden distribution across SDI quintiles. High-SDI regions experienced a pronounced burden of malignancies related to lifestyle and metabolic risks, including high BMI and alcohol use. Conversely, in low-SDI regions, unsafe sex emerged as a dominant contributor to cancer DALYs, primarily driving cervical and other human papillomavirus (HPV)-related cancers, underscoring inadequate access to preventive measures like HPV vaccination and effective screening programs in these settings[36–38]. Geographical disparities further highlight stark contrasts between high- and low-resource regions. Rising cancer burden in sub-Saharan Africa, South America, and parts of the Middle East, compared with declines in North America, Europe, and East Asia, underscores marked inequities in cancer prevention, diagnosis, and treatment capacity[39–42]. These disparities are likely exacerbated by differences in healthcare infrastructure, human resources, economic investments, and policy implementation in AYAs.
Several upward trends observed in high-SDI settings, most notably for breast, thyroid, testicular, and prostate cancers, are compatible with a convergence of metabolic and lifestyle exposures during late adolescence and early adulthood, alongside diagnostic intensity[43–45]. First, sustained positive energy balance and adolescent weight gain amplify insulin–IGF signaling and low-grade inflammation, promoting proliferation and impairing apoptosis[46,47]; adiposity also perturbs sex-hormone biosynthesis (e.g., aromatase-mediated estrogen), biologically linking excess weight to breast and potentially thyroid/prostate carcinogenesis[48,49]. Second, alcohol contributes via acetaldehyde-mediated DNA damage and hormonal effects[50], consistent with the higher attributable fractions we observe in affluent regions. Third, sedentary behavior, shifts in reproductive timing (e.g., delayed first childbirth), and endocrine-disrupting chemical exposures may further modulate risk during a hormonally dynamic life-stage[51–53]. Fourth, increased diagnostic intensity, particularly thyroid ultrasonography and biopsy cascades, can elevate detected incidence through identification of indolent lesions[45]; this underscores the need for diagnostic stewardship to prevent overdiagnosis and overtreatment. By contrast, marked declines in stomach and liver cancers correspond to infection prevention and control including H. pylori management and hepatitis B vaccination plus environmental and dietary improvements, with the steepest gains in higher-resource settings[54,55]. In many low-SDI countries, however, infection- related malignancies remain predominant, and limited registry and diagnostic capacity can obscure true incidence[56].
Addressing the disproportionate cancer burden among AYAs globally requires integrated, equitable strategies targeting key modifiable risk factors, robust early detection methods, improved therapeutic options, and tailored survivorship support services. Strengthening health systems, particularly in LMICs, expanding access to vaccinations (notably HPV), and improving awareness and control of obesity and alcohol consumption are critical. International collaborations, equitable resource allocation, and targeted policy interventions will be essential to mitigate the global AYA cancer burden and reduce existing health disparities.
Translating mechanisms to action requires SDI-stratified strategies. In low/low-middle SDI settings, priorities include HPV vaccination and screening scale-up, timelier referral pathways, and registry strengthening to reduce underdiagnosis. In middle/ high-middle SDI contexts, integrated programs should couple vaccination with organized screening, adolescent risk-behavior reduction (tobacco, alcohol, and ultraviolet radiation), and institutionalization of AYA-friendly care. In high SDI settings, comprehensive obesity prevention (nutrition policy and active transport), alcohol-harm reduction, and diagnostic stewardship (e.g., avoiding routine thyroid ultrasonography in asymptomatic individuals; risk-stratified testing discussions) are crucial to curb both metabolic-linked and overdiagnosis-related incidence. These measures should be paired with survivorship services addressing late effects and equity gaps.
However, several limitations merit consideration. First, data completeness and quality remain uneven across regions, particularly in low-SDI countries with limited cancer registration or vital statistics coverage, potentially leading to underestimation or misclassification of cancer types[57,58]. Second, the risk factor attribution is constrained by available evidence and assumes causal links derived from global epidemiologic studies, which may not fully capture local exposure patterns or biological heterogeneity in AYA populations[59]. Third, the estimates in this study were largely generated through modeling approaches, and the selection of models and parameters may have impacted the results[60]. A key limitation of this analysis is its reliance on GBD modeled estimates, which depend on the completeness and quality of cancer registration and vital statistics. In low-SDI countries where cancer surveillance remains incomplete, incidence may be underestimated due to diagnostic scarcity, while mortality could be overestimated if certification accuracy is low or cause-of-death attribution is uncertain. Although the GBD framework mitigates these gaps through covariate smoothing, internal cross-validation, and uncertainty quantification, the absence of independent external validation introduces residual uncertainty, especially for rare or underdiagnosed cancers[11]. Therefore, cross-country comparisons should be interpreted cautiously, and our SDI-specific findings are intended to highlight broad patterns rather than precise national rankings. Strengthening population-based cancer registries and standardizing cause-of-death reporting, particularly in low- and middleincome settings, remain essential for improving the accuracy and interpretability of future global assessments.
Nonetheless, this study possesses major strengths. It provides the most comprehensive and systematic global assessment to date of cancer burden among AYAs across 204 countries and territories, spanning over three decades and 32 cancer types. By leveraging the standardized and internally consistent estimation platform of the GBD 2021 study, we enable direct comparisons across countries, cancer types, and time periods. The disaggregation by SDI quintile highlights profound disparities and provides critical evidence to inform equitable policy responses. Importantly, the inclusion of comparative risk attribution for six key exposures such as unsafe sex, high BMI, and alcohol use sheds light on upstream prevention targets, offering actionable insights to mitigate future cancer burden in this neglected population.
Conclusions
Over the past three decades, global cancer mortality and DALY rates among AYAs have fallen, yet incidence continues to rise with multiple myeloma, breast, thyroid, testicular, and prostate cancers increasing most rapidly and profound socio-demographic disparities persist. High-income settings now face an AYA cancer burden driven largely by metabolic and behavioral risks, whereas infection-related malignancies remain predominant in low-SDI regions. Strengthening cancer registries, scaling proven preventive measures (particularly HPV vaccination), and ensuring timely, equitable access to diagnosis, treatment, and survivorship care are imperative to sustain recent gains and close existing gaps. Tailored, risk-based interventions focused on unsafe sex, obesity, and alcohol use, coupled with intensified research into the etiology of emerging malignancies, will be essential to reduce the future burden of cancer in this pivotal age group worldwide.
Ethical approval
Not required as this study used secondary data aggregated at both the country and global levels.
Consent
Not applicable.
Sources of funding
This study was supported by the Zhejiang Provincial Medical and Health Science and Technology Plan Project (Grant No. 2024KY826) and the 2022 Digestive Tract Early Cancer Physician Growth Plan Research Project (Grant No. GTCZ- 2022-ZJ-33-0001). These funding sources had no role in the design, conduct, or reporting of the study.
Author contributions
R.L. and L.D. contributed to the concept and design of the study. R.L. and L.D. were involved in the acquisition, analysis, or interpretation of data. R.L. and L.D. drafted the manuscript. R.L., S.F.S., F.P., E.-H.P., and L.D. provided critical revisions of the manuscript for important intellectual content. R.L. and L.D. conducted the statistical analysis. R.L., S.F.S., F.P., E.-H.P., and L.D. provided administrative, technical, or material support. R.L. and L.D. supervised the study. All authors read and approved the final manuscript.
Conflicts of interest disclosure
The authors have declared no conflicts of interest.
Research registration unique identifying number
(UIN)
Not applicable.
Guarantor
Runhua Li and Lingbin Du.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Data availability statement
Data are available in a public, open access repository. All the analyses were carried out using publicly available datasets that can be obtained directly from the GBD website (https://vizhub. healthdata.org/gbd-results/).
Presentation
None.
Assistance with the study
None.
AI usage statement
This study complies with the TITAN Guidelines 2025 for declaring the use of AI tools (https://doi.org/10.70389/PJS.100082). No AI tools were employed in the conception, execution, analysis, or manuscript preparation of this work.
Acknowledgements
Not applicable.
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