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CA: A Cancer Journal for Clinicians
Volume 71, Issue 3 p. 209-249
Article
Free Access
GLOBAL CANCER STATISTICS 2020: GLOBOCAN ESTIMATES OF INCIDENCE AND MORTALITY
WORLDWIDE FOR 36 CANCERS IN 185 COUNTRIES
Hyuna Sung PhD,
Hyuna Sung PhD
* orcid.org/0000-0002-8021-5997
Surveillance and Health Equity Science, American Cancer Society, Atlanta,
Georgia
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Jacques Ferlay MSc, ME,
Jacques Ferlay MSc, ME
Section of Cancer Surveillance, International Agency for Research on Cancer,
Lyon, France
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Rebecca L. Siegel MPH,
Rebecca L. Siegel MPH
* orcid.org/0000-0001-5247-8522
Surveillance and Health Equity Science, American Cancer Society, Atlanta,
Georgia
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Mathieu Laversanne MSc,
Mathieu Laversanne MSc
Section of Cancer Surveillance, International Agency for Research on Cancer,
Lyon, France
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Isabelle Soerjomataram MD, MSc, PhD,
Isabelle Soerjomataram MD, MSc, PhD
Section of Cancer Surveillance, International Agency for Research on Cancer,
Lyon, France
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Ahmedin Jemal DMV, PhD,
Ahmedin Jemal DMV, PhD
Surveillance and Health Equity Science, American Cancer Society, Atlanta,
Georgia
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Freddie Bray BSc, MSc, PhD,
Corresponding Author
Freddie Bray BSc, MSc, PhD
* brayf@iarc.fr
Section of Cancer Surveillance, International Agency for Research on Cancer,
Lyon, France
Corresponding Author: Freddie Bray, BSc, MSc, PhD, Section of Cancer
Surveillance, International Agency for Research on Cancer, 150, cours Albert
Thomas, F-69372 Lyon Cedex 08, France (brayf@iarc.fr).
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Hyuna Sung PhD,
Hyuna Sung PhD
* orcid.org/0000-0002-8021-5997
Surveillance and Health Equity Science, American Cancer Society, Atlanta,
Georgia
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Jacques Ferlay MSc, ME,
Jacques Ferlay MSc, ME
Section of Cancer Surveillance, International Agency for Research on Cancer,
Lyon, France
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Rebecca L. Siegel MPH,
Rebecca L. Siegel MPH
* orcid.org/0000-0001-5247-8522
Surveillance and Health Equity Science, American Cancer Society, Atlanta,
Georgia
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Mathieu Laversanne MSc,
Mathieu Laversanne MSc
Section of Cancer Surveillance, International Agency for Research on Cancer,
Lyon, France
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Isabelle Soerjomataram MD, MSc, PhD,
Isabelle Soerjomataram MD, MSc, PhD
Section of Cancer Surveillance, International Agency for Research on Cancer,
Lyon, France
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Ahmedin Jemal DMV, PhD,
Ahmedin Jemal DMV, PhD
Surveillance and Health Equity Science, American Cancer Society, Atlanta,
Georgia
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Freddie Bray BSc, MSc, PhD,
Corresponding Author
Freddie Bray BSc, MSc, PhD
* brayf@iarc.fr
Section of Cancer Surveillance, International Agency for Research on Cancer,
Lyon, France
Corresponding Author: Freddie Bray, BSc, MSc, PhD, Section of Cancer
Surveillance, International Agency for Research on Cancer, 150, cours Albert
Thomas, F-69372 Lyon Cedex 08, France (brayf@iarc.fr).
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First published: 04 February 2021
https://doi.org/10.3322/caac.21660
Citations: 1,979
DISCLOSURES: Hyuna Sung, Rebecca L. Siegel, and Ahmedin Jemal are employed by
the American Cancer Society, which receives grants from private and corporate
foundations, including foundations associated with companies in the health
sector for research outside of the submitted work. They are not funded by or key
personnel for any of these grants, and their salary is solely funded through
American Cancer Society funds. The remaining authors report no conflicts of
interest.
Where authors are identified as personnel of the International Agency for
Research on Cancer/World Health Organization, the authors alone are responsible
for the views expressed in this article, and they do not necessarily represent
the decisions, policy, or views of the International Agency for Research on
Cancer/World Health Organization.
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* Data Sources and Methods
* Results
* Summary and Conclusions
* Acknowledgements
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ABSTRACT
This article provides an update on the global cancer burden using the GLOBOCAN
2020 estimates of cancer incidence and mortality produced by the International
Agency for Research on Cancer. Worldwide, an estimated 19.3 million new cancer
cases (18.1 million excluding nonmelanoma skin cancer) and almost 10.0 million
cancer deaths (9.9 million excluding nonmelanoma skin cancer) occurred in 2020.
Female breast cancer has surpassed lung cancer as the most commonly diagnosed
cancer, with an estimated 2.3 million new cases (11.7%), followed by lung
(11.4%), colorectal (10.0 %), prostate (7.3%), and stomach (5.6%) cancers. Lung
cancer remained the leading cause of cancer death, with an estimated 1.8 million
deaths (18%), followed by colorectal (9.4%), liver (8.3%), stomach (7.7%), and
female breast (6.9%) cancers. Overall incidence was from 2-fold to 3-fold higher
in transitioned versus transitioning countries for both sexes, whereas mortality
varied <2-fold for men and little for women. Death rates for female breast and
cervical cancers, however, were considerably higher in transitioning versus
transitioned countries (15.0 vs 12.8 per 100,000 and 12.4 vs 5.2 per 100,000,
respectively). The global cancer burden is expected to be 28.4 million cases in
2040, a 47% rise from 2020, with a larger increase in transitioning (64% to 95%)
versus transitioned (32% to 56%) countries due to demographic changes, although
this may be further exacerbated by increasing risk factors associated with
globalization and a growing economy. Efforts to build a sustainable
infrastructure for the dissemination of cancer prevention measures and provision
of cancer care in transitioning countries is critical for global cancer control.
INTRODUCTION
Cancer ranks as a leading cause of death and an important barrier to increasing
life expectancy in every country of the world.1 According to estimates from the
World Health Organization (WHO) in 2019,2 cancer is the first or second leading
cause of death before the age of 70 years in 112 of 183 countries and ranks
third or fourth in a further 23 countries (Fig. 1). Cancer's rising prominence
as a leading cause of death partly reflects marked declines in mortality rates
of stroke and coronary heart disease, relative to cancer, in many countries.1
Figure 1
Open in figure viewerPowerPoint
National Ranking of Cancer as a Cause of Death at Ages <70 Years in 2019. The
numbers of countries represented in each ranking group are included in the
legend. Source: World Health Organization.
Overall, the burden of cancer incidence and mortality is rapidly growing
worldwide; this reflects both aging and growth of the population as well as
changes in the prevalence and distribution of the main risk factors for cancer,
several of which are associated with socioeconomic development.3, 4 The extent
to which the position of cancer as a cause of premature death reflects national
levels of social and economic development can be seen by comparing the maps in
Figure 1 and Figure 2A, the latter depicting the 4-tier Human Development Index
(HDI) based on the United Nation's 2019 Human Development Report.5
Figure 2
Open in figure viewerPowerPoint
(A) The 4-Tier Human Development Index (HDI) and (B) 20 Areas of the World. The
sizes of the respective populations are included in the legend. Source: United
Nations Procurement Division/United Nations Development Program.
In this article, we examine the cancer burden worldwide in 2020 based on the
GLOBOCAN estimates of cancer incidence and mortality produced by the
International Agency for Research on Cancer.6 The estimates provided herein do
not reflect the impact of severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19),7, 8
as they are based on extrapolations of cancer data collected in earlier years
before the pandemic. Although the full extent of the impact of the COVID-19
pandemic in different world regions is currently unknown, delays in diagnosis
and treatment associated with the concerns of individuals, health system
closures, including suspension of screening programs, and reduced availability
of and access to care are expected to cause a short-term decline in cancer
incidence followed by increases in advanced-stage diagnoses and cancer mortality
in some settings.9-13
As with previous reports,14-17 the primary focus is on a description of the
cancer incidence and mortality at the global level and an assessment of the
geographic variability observed across 20 predefined world regions (Fig. 2B). We
describe the magnitude and distribution of the disease overall and for the major
cancer types in 2020, commenting briefly on the associated risk factors and
prospects for prevention of the major cancers observed worldwide, and ending
with a prediction of the magnitude of the disease in 2040 on the basis of global
demographic projections.
DATA SOURCES AND METHODS
The sources and methods used in compiling the GLOBOCAN estimates for 2020 are
described online at the Global Cancer Observatory (GCO) (gco.iarc.fr).18 The GCO
website includes facilities for the tabulation and graphic visualization of the
GLOBOCAN database for 185 countries and 36 cancers (as well as all cancers
combined), by age and sex. The profile of cancer, globally and by world region,
is built up using the best available sources of cancer incidence and mortality
data within a given country. Therefore, the validity of the national estimates
depends on the degree of representativeness and quality of the source
information. The methods used to compile the 2020 estimates are largely based on
those developed previously, with an emphasis on the use of short-term
predictions and the use of modelled mortality-to-incidence ratios, where
applicable.19 The estimates are available in the GCO for 36 cancer types, based
on codes from International Statistical Classification of Diseases and Related
Health Problems 10th Revision (ICD-10), including nonmelanoma skin cancer (NMSC)
(C44, excluding basal cell carcinomas for incidence).19 Together with all
cancers combined, cancer-specific estimates are provided for 185 countries or
territories worldwide by sex and by 18 age groups (ages 0-4, 5-9, …, 80-84, and
≥85 years).
The number of new cancer cases and cancer deaths were extracted from the
GLOBOCAN 2020 database for all cancers combined (ICD-10 codes C00-C97) and for
36 cancer types: lip, oral cavity (C00-C06), salivary glands (C07-C08),
oropharynx (C09-C10), nasopharynx (C11), hypopharynx (C12-C13), esophagus (C15),
stomach (C16), colon (C18), rectum (C19-C20), anus (C21), liver (C22, including
intrahepatic bile ducts), gallbladder (C23), pancreas (C25), larynx (C32), lung
(C33-C34, including trachea and bronchus), melanoma of skin (C43), NMSC (C44,
excluding basal cell carcinoma for incidence), mesothelioma (C45), Kaposi
sarcoma (C46), female breast (C50), vulva (C51), vagina (C52), cervix uteri
(C53), corpus uteri (C54), ovary (C56), penis (C60), prostate (C61), testis
(C62), kidney (C64-C65, including renal pelvis), bladder (C67), brain, central
nervous system (C70-C72), thyroid (C73), Hodgkin lymphoma (C81), non-Hodgkin
lymphoma (C82-C86, C96), multiple myeloma (C88 and C90, including
immunoproliferative diseases), and leukemia (C91-C95). For the purposes of
consistency with previous exercises,6 we combine colon, rectum, and anus as
colorectal cancer (C18-C21); NMSC (C44, excluding basal cell carcinoma for
incidence) is included in the overall estimation of the total cancer burden,
unless otherwise stated, and is included within the other category when making
comparisons of the relative magnitude of different cancer types.
Further details of definitions and methods are provided in the Supporting
Materials. In brief, we present age-standardized incidence or mortality rates
(ASR) per 100,000 person-years based on the 1966 Segi-Doll World standard
population20 and the cumulative risk of developing or dying from cancer before
age 75 years, assuming the absence of competing causes of death, expressed as a
percentage. These indicators allow comparisons between populations that are not
influenced by differences in their age structures, and they are presented for
the major cancer types globally and across 20 aggregated regions, as defined by
the United Nations Population Division (Fig. 2B). We also characterize the
burden according to the 4-tier HDI (Fig. 2A) to further assess the cancer burden
according to a binary proxy of development (low and medium HDI vs high and very
high HDI). Finally, we also provide a prediction of the future burden of cancer
in 2040 based on demographic projections, assuming that national rates estimated
in 2020 remain constant. Throughout, we use the terms transitioning, emerging,
and lower HDI countries/economies as synonyms for nations classified as low or
medium HDI, and we use transitioned or higher HDI countries/economies for those
classified as high or very high HDI.
RESULTS
DISTRIBUTION OF CASES AND DEATHS BY WORLD REGION AND CANCER TYPES
There were an estimated 19.3 million new cases (18.1 million excluding NMSC,
except basal cell carcinoma) and 10 million cancer deaths (9.9 million excluding
NMSC, except basal cell carcinoma) worldwide in 2020 (Table 1). Figure 3
presents the distribution of all-cancer incidence and mortality according to
world region for both sexes combined and separately for men and women. For both
sexes combined, one-half of all cases and 58.3% of cancer deaths are estimated
to occur in Asia in 2020 (Fig. 3A), where 59.5% of the global population resides
(Fig. 2B). Europe accounts for 22.8% of the total cancer cases and 19.6% of the
cancer deaths, although it represents 9.7% of the global population, followed by
the Americas' 20.9% of incidence and 14.2% of mortality worldwide. In contrast
to other regions, the share of cancer deaths in Asia (58.3%) and Africa (7.2%)
are higher than the share of incidence (49.3% and 5.7%, respectively) because of
the different distribution of cancer types and higher case fatality rates in
these regions.
TABLE 1. New Cases and Deaths for 36 Cancers and All Cancers Combined in 2020
CANCER SITE NO. OF NEW CASES (% OF ALL SITES) NO. OF NEW DEATHS (% OF ALL SITES)
Female breast 2,261,419 (11.7) 684,996 (6.9) Lung 2,206,771 (11.4) 1,796,144
(18.0) Prostate 1,414,259 (7.3) 375,304 (3.8) Nonmelanoma of skina a New cases
exclude basal cell carcinoma, whereas deaths include all types of nonmelanoma
skin cancer.
1,198,073 (6.2) 63,731 (0.6) Colon 1,148,515 (6.0) 576,858 (5.8) Stomach
1,089,103 (5.6) 768,793 (7.7) Liver 905,677 (4.7) 830,180 (8.3) Rectum 732,210
(3.8) 339,022 (3.4) Cervix uteri 604,127 (3.1) 341,831 (3.4) Esophagus 604,100
(3.1) 544,076 (5.5) Thyroid 586,202 (3.0) 43,646 (0.4) Bladder 573,278 (3.0)
212,536 (2.1) Non-Hodgkin lymphoma 544,352 (2.8) 259,793 (2.6) Pancreas 495,773
(2.6) 466,003 (4.7) Leukemia 474,519 (2.5) 311,594 (3.1) Kidney 431,288 (2.2)
179,368 (1.8) Corpus uteri 417,367 (2.2) 97,370 (1.0) Lip, oral cavity 377,713
(2.0) 177,757 (1.8) Melanoma of skin 324,635 (1.7) 57,043 (0.6) Ovary 313,959
(1.6) 207,252 (2.1) Brain, nervous system 308,102 (1.6) 251,329 (2.5) Larynx
184,615 (1.0) 99,840 (1.0) Multiple myeloma 176,404 (0.9) 117,077 (1.2)
Nasopharynx 133,354 (0.7) 80,008 (0.8) Gallbladder 115,949 (0.6) 84,695 (0.9)
Oropharynx 98,412 (0.5) 48,143 (0.5) Hypopharynx 84,254 (0.4) 38,599 (0.4)
Hodgkin lymphoma 83,087 (0.4) 23,376 (0.2) Testis 74,458 (0.4) 9334 (0.1)
Salivary glands 53,583 (0.3) 22,778 (0.2) Anus 50,865 (0.3) 19,293 (0.2) Vulva
45,240 (0.2) 17,427 (0.2) Penis 36,068 (0.2) 13,211 (0.1) Kaposi sarcoma 34,270
(0.2) 15,086 (0.2) Mesothelioma 30,870 (0.2) 26,278 (0.3) Vagina 17,908 (0.1)
7995 (0.1) All sites excluding nonmelanoma skin 18,094,716 9,894,402 All sites
19,292,789 9,958,133
* a New cases exclude basal cell carcinoma, whereas deaths include all types of
nonmelanoma skin cancer.
Source: GLOBOCAN 2020.
Figure 3
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Distribution of Cases and Deaths by World Area in 2020 for (A) Both Sexes, (B)
Men, and (C) Women. For each sex, the area of the pie chart reflects the
proportion of the total number of cases or deaths. Source: GLOBOCAN 2020.
Figure 4 shows the top 10 cancer types for estimated cases and deaths worldwide
for men and women, combined and separately, with NMSC included within the other
category. For both sexes combined, the top 10 cancer types account for >60% of
the newly diagnosed cancer cases and >70% of the cancer deaths. Female breast
cancer is the most commonly diagnosed cancer (11.7% of total cases), closely
followed by lung (11.4%), colorectal (10.0%), prostate (7.3%), and stomach
(5.6%) cancers. Lung cancer is the leading cause of cancer death (18.0% of the
total cancer deaths), followed by colorectal (9.4%), liver (8.3%), stomach
(7.7%), and female breast (6.9%) cancers. Lung cancer is the most frequently
occurring cancer and the leading cause of cancer death in men, followed by
prostate and colorectal cancer for incidence and liver and colorectal cancer for
mortality. In women, breast cancer is the most commonly diagnosed cancer and the
leading cause of cancer death, followed by colorectal and lung cancer for
incidence, and vice versa for mortality.
Figure 4
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Distribution of Cases and Deaths for the Top 10 Most Common Cancers in 2020 for
(A) Both Sexes, (B) Men, and (C) Women. For each sex, the area of the pie chart
reflects the proportion of the total number of cases or deaths; nonmelanoma skin
cancers (excluding basal cell carcinoma for incidence) are included in the
“other” category. Source: GLOBOCAN 2020.
GLOBAL CANCER PATTERNS
Figures 5 and 6 show the most commonly diagnosed cancers and leading causes of
cancer death, respectively, by sex at the national level. The maps reveal
substantial global diversity in leading cancer types, particularly for incidence
in men (8 different cancer types) and for mortality in both men (8 types) and
women (7 types). In men, prostate cancer is the most frequently diagnosed cancer
in 112 countries, followed by lung cancer in 36 countries, and colorectal cancer
and liver cancer each in 11 countries (Fig. 5A). With regard to mortality (Fig.
6A), lung cancer is the leading cause of cancer death in men in 93 countries, in
part because of its high fatality rate,21 followed by prostate cancer (48
countries) and liver cancer (23 countries). In contrast to men, the most
commonly diagnosed cancer in women is dominated by 2 cancer sites: breast cancer
(159 countries) and cervical cancer (23 of 26 remaining countries) (Fig. 5B).
The mortality profile in women is more heterogeneous (Fig. 6B), with breast and
cervical cancer the leading causes of cancer death in 110 and 36 countries,
respectively, followed by lung cancer in 25 countries.
Figure 5
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Most Common Type of Cancer Incidence in 2020 in Each Country Among (A) Men and
(B) Women. The numbers of countries represented in each ranking group are
included in the legend. However, nonmelanoma skin cancer (excluding basal cell
carcinoma), the most common type of cancer in Australia and New Zealand among
men and women and in the United States among men, was excluded when constructing
the global maps. Source: GLOBOCAN 2020.
Figure 6
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Most Common Type of Cancer Mortality by Country in 2020 Among (A) Men and (B)
Women. The numbers of countries represented in each ranking group are included
in the legend. Source: GLOBOCAN 2020.
CANCER INCIDENCE AND MORTALITY PATTERNS BY THE 4-TIER HDI
Incidence rates increased with increasing HDI level, ranging from 104.3 and
128.0 per 100,000 in low HDI countries to 335.3 and 267.6 per 100,000 in very
high HDI countries for men and women, respectively (Table 2). Mortality rates
are about 2-fold higher in higher HDI countries (122.9-141.1 per 100,000) versus
lower HDI countries (76.7-78.0 per 100,000) in men, whereas little variation
exists across HDI levels (67.0-88.4 per 100,000) in women (Table 2).
TABLE 2. Incidence and Mortality Rates (Age-Standardized Rate, Cumulative Risk)
for 24 World Areas and Sex for All Cancers Combined (Including Nonmelanoma Skin
Cancera a Incidence excludes basal cell carcinoma, whereas mortality includes
all types of nonmelanoma skin cancer.
) in 2020
WORLD AREA INCIDENCE MORTALITY MALES FEMALES MALES FEMALES AGE-STANDARDIZED RATE
(WORLD) CUMULATIVE RISK, AGES 0-74 YEARS, % AGE-STANDARDIZED RATE (WORLD)
CUMULATIVE RISK, AGES 0-74 YEARS, % AGE-STANDARDIZED RATE (WORLD) CUMULATIVE
RISK, AGES 0-74 YEARS, % AGE-STANDARDIZED RATE (WORLD) CUMULATIVE RISK, AGES
0-74 YEARS, % Eastern Africa 112.9 11.91 148.1 15.12 82.5 8.71 102.4 11.02
Middle Africa 109.5 11.70 115.8 11.83 79.2 8.25 79.9 8.54 Northern Africa 145.7
15.14 140.1 14.17 104.6 10.43 77.6 8.06 Southern Africa 232.7 22.74 189.0 18.22
128.8 13.38 98.7 10.22 Western Africa 100.6 10.67 123.2 12.71 74.8 7.89 83.6
8.99 Caribbean 213.9 22.35 174.6 17.44 120.7 11.85 89.2 9.24 Central America
140.9 14.71 141.1 14.01 70.2 7.15 63.1 6.72 South America 217.1 22.09 192.2
18.79 104.9 10.59 82.1 8.51 Northern America 397.9 37.05 332.6 31.10 98.9 10.31
77.7 8.23 Eastern Asia 242.3 24.47 196.4 19.34 157.4 16.34 93.0 9.88 All but
China 304.8 30.09 239.2 22.70 112.0 10.76 64.4 6.12 China 225.4 23.25 188.2
18.78 163.9 17.28 98.1 10.59 South-Eastern Asia 159.2 16.46 149.3 15.03 114.1
11.82 80.8 8.55 South Central Asia 103.2 11.13 102.5 10.78 71.2 7.88 63.1 6.95
All but India 122.8 12.97 110.7 11.60 86.2 9.25 68.5 7.49 India 95.7 10.44 99.3
10.47 65.4 7.37 61.0 6.74 Western Asia 198.3 20.77 162.3 16.38 123.5 13.09 79.1
8.38 Eastern Europe 293.8 30.47 220.9 22.18 165.6 18.24 88.7 9.79 Northern
Europe 343.7 32.91 296.5 28.19 115.1 11.39 87.9 9.2 Southern Europe 317.8 31.31
249.9 23.85 126.9 13.19 76.3 8.07 Western Europe 365.3 34.90 294.3 27.85 127.1
13.00 83.9 8.84 Australia/New Zealand 494.2 44.37 405.2 36.45 100.7 9.76 73.1
7.38 Melanesia 192.6 20.62 202.5 19.59 125.3 13.21 118.3 12.12
Micronesia/Polynesia 239.5 25.18 206.5 20.62 152.3 16.24 109.4 11.58 Low HDI
104.3 11.04 128.0 13.10 78.0 8.14 88.4 9.46 Medium HDI 109.2 11.75 108.7 11.35
76.7 8.45 67.0 7.32 High HDI 207.7 21.49 178.0 17.79 141.1 14.90 90.3 9.69 Very
high HDI 335.3 32.64 267.6 25.75 122.9 12.67 80.0 8.37 World 222.0 22.60 186.0
18.55 120.8 12.59 84.2 8.86
* a Incidence excludes basal cell carcinoma, whereas mortality includes all
types of nonmelanoma skin cancer.
* Abbreviation: HDI, Human Development Index.
Source: GLOBOCAN 2020.
Figures 7A and 7B show cancer incidence and mortality ASRs in higher HDI versus
lower HDI countries for men and women, respectively, in 2020. For incidence in
men (Fig. 7A), lung cancer ranks first (39 per 100,000) and prostate cancer
ranks second (37.5 per 100,000) in higher HDI countries, and vice versa for
lower HDI countries (11.3 per 100,000 for prostate cancer and 10.3 per 100,000
for lung cancer). These cancers were followed by colorectal cancer (29 per
100,000) in higher HDI countries, largely reflecting the substantial
contribution by the United States,22 and lip and oral cavity cancer (10.2 per
100,000) in lower HDI countries because of the high burden of the disease in
India.23 In women (Fig. 7B), incidence rates for breast cancer far exceed those
of other cancers in both transitioned (55.9 per 100,000) and transitioning (29.7
per 100,000) countries, followed by colorectal cancer (20 per 100,000) in
transitioned countries and cervical cancer (18.8 per 100,000) in transitioning
countries.
Figure 7
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Incidence and Mortality Age-Standardized Rates in High/Very High Human
Development Index (HDI) Countries Versus Low/Medium HDI Countries Among (A) Men
and (B) Women in 2020. The 15 most common cancers in the world (W) are shown in
descending order of the overall age-standardized rate for both sexes combined.
Source: GLOBOCAN 2020.
CANCER INCIDENCE AND DEATH RATES BY SEX AND WORLD REGION
Worldwide, the incidence rate for all cancers combined was 19% higher in men
(222.0 per 100,000) than in women (186 per 100,000) in 2020, although rates
varied widely across regions. Among men, incidence rates ranged almost 5-fold,
from 494.2 per 100,000 in Australia/New Zealand to 100.6 per 100,000 in Western
Africa (Table 2); among women, rates varied nearly 4-fold, from 405.2 per
100,000 in Australia/New Zealand to 102.5 per 100,000 in South Central Asia.
These variations largely reflect differences in exposure to risk factors and
associated cancers (cancer mix) and barriers to high-quality cancer prevention
and early detection. For example, the highest overall incidence rates in
Australia/New Zealand are caused in part by an elevated risk of NMSC because
most of the population is light-skinned, and excessive sun exposure is
prevalent, in conjunction with increased detection of the disease.
The gender gap for overall cancer mortality worldwide is twice that for
incidence, with death rates 43% higher in men than in women (120.8 and 84.2 per
100,000, respectively) (Table 2), partly because of differences in the
distribution of the cancer types. Death rates per 100,000 persons varied from
165.6 per 100,000 in Eastern Europe to 70.2 per 100,000 in Central America among
men and from 118.3 per 100,000 in Melanesia to 63.1 per 100,000 in Central
America and South Central Asia among women. Notably, the cumulative risk of
dying from cancer among women in 2020 was higher in Eastern Africa (11.0%) than
in Northern America (8.2%), Western Europe (8.8%), and Australia/New Zealand
(7.4%).
Table 3 shows the number of newly diagnosed cancer cases and deaths, the
incidence and mortality ASR, and the cumulative risk of developing and dying
from cancer overall and for the 36 cancer types separately in men and women. One
in 5 men or women develop the disease, and 1 in 8 men and 1 in 11 women die from
it. Below, we describe and discuss the variations in sex-specific incidence and
mortality rates by world region for 16 of these cancer types.
TABLE 3. Incidence (Cases, Age-Standardized Rate, Cumulative Risk) and Mortality
(Deaths, Age-Standardized Rate, Cumulative Risk) for 36 Cancers and All Cancers
Combined by Sex in 2020
CANCER SITE INCIDENCE MORTALITY MALES FEMALES MALES FEMALES CASES
AGE-STANDARDIZED RATE (WORLD) CUMULATIVE RISK, AGES 0-74 YEARS, % CASES
AGE-STANDARDIZED RATE (WORLD) CUMULATIVE RISK, AGES 0-74 YEARS, % CASES
AGE-STANDARDIZED RATE (WORLD) CUMULATIVE RISK, AGES 0-74 YEARS, % CASES
AGE-STANDARDIZED RATE (WORLD) CUMULATIVE RISK, AGES 0-74 YEAR S, % Lip, oral
cavity 264,211 6.0 0.68 113,502 2.3 0.26 125,022 2.8 0.32 52,735 1.0 0.12
Salivary glands 29,694 0.7 0.07 23,889 0.5 0.05 13,353 0.3 0.03 9425 0.2 0.02
Oropharynx 79,045 1.8 0.22 19,367 0.4 0.05 39,590 0.9 0.11 8553 0.2 0.02
Nasopharynx 96,371 2.2 0.24 36,983 0.8 0.09 58,094 1.3 0.16 21,914 0.5 0.05
Hypopharynx 70,254 1.6 0.19 14,000 0.3 0.03 32,303 0.7 0.09 6296 0.1 0.01
Esophagus 418,350 9.3 1.15 185,750 3.6 0.44 374,313 8.3 1.01 169,763 3.2 0.38
Stomach 719,523 15.8 1.87 369,580 7.0 0.79 502,788 11.0 1.29 266,005 4.9 0.55
Colon 600,896 13.1 1.49 547,619 10.0 1.12 302,117 6.4 0.66 274,741 4.6 0.45
Rectum 443,358 9.8 1.18 288,852 5.6 0.65 204,104 4.4 0.50 134,918 2.4 0.26 Anus
21,706 0.5 0.06 29,159 0.6 0.07 9416 0.2 0.02 9877 0.2 0.02 Liver 632,320 14.1
1.65 273,357 5.2 0.60 577,522 12.9 1.49 252,658 4.8 0.55 Gallbladder 41,062 0.9
0.10 74,887 1.4 0.16 30,265 0.7 0.07 54,430 1.0 0.11 Pancreas 262,865 5.7 0.66
232,908 4.1 0.45 246,840 5.3 0.62 219,163 3.8 0.41 Larynx 160,265 3.6 0.45
24,350 0.5 0.06 85,351 1.9 0.23 14,489 0.3 0.03 Lung 1,435,943 31.5 3.78 770,828
14.6 1.77 1,188,679 25.9 3.08 607,465 11.2 1.34 Melanoma of skin 173,844 3.8
0.42 150,791 3.0 0.33 32,385 0.7 0.07 24,658 0.4 0.05 Nonmelanoma of skina a
Incidence excludes basal cell carcinoma, whereas mortality includes all types of
nonmelanoma skin cancer.
722,348 15.1 1.40 475,725 7.9 0.75 37,596 0.8 0.07 26,135 0.4 0.04 Mesothelioma
21,560 0.5 0.05 9310 0.2 0.02 18,681 0.4 0.04 7597 0.1 0.02 Kaposi sarcoma
23,413 0.5 0.05 10,857 0.3 0.02 9929 0.2 0.02 5157 0.1 0.01 Breast 2,261,419
47.8 5.20 684,996 13.6 1.49 Vulva 45,240 0.9 0.09 17,427 0.3 0.03 Vagina 17,908
0.4 0.04 7995 0.2 0.02 Cervix uteri 604,127 13.3 1.39 341,831 7.3 0.82 Corpus
uteri 417,367 8.7 1.05 97,370 1.8 0.22 Ovary 313,959 6.6 0.73 207,252 4.2 0.49
Penis 36,068 0.8 0.09 13,211 0.3 0.03 Prostate 1,414,259 30.7 3.86 375,304 7.7
0.63 Testis 74,458 1.8 0.14 9334 0.2 0.02 Kidney 271,249 6.1 0.70 160,039 3.2
0.36 115,600 2.5 0.28 63,768 1.2 0.12 Bladder 440,864 9.5 1.05 132,414 2.4 0.26
158,785 3.3 0.30 53,751 0.9 0.08 Brain, nervous system 168,346 3.9 0.40 139,756
3.0 0.31 138,277 3.2 0.34 113,052 2.4 0.26 Thyroid 137,287 3.1 0.33 448,915 10.1
1.02 15,906 0.3 0.04 27,740 0.5 0.05 Hodgkin lymphoma 48,981 1.2 0.10 34,106 0.8
0.07 14,288 0.3 0.03 9088 0.2 0.02 Non-Hodgkin lymphoma 304,151 6.9 0.73 240,201
4.8 0.52 147,217 3.3 0.33 112,576 2.1 0.21 Multiple myeloma 98,613 2.2 0.25
77,791 1.5 0.17 65,197 1.4 0.15 51,880 0.9 0.10 Leukemia 269,503 6.3 0.59
205,016 4.5 0.41 177,818 4.0 0.38 133,776 2.7 0.26 All sites excluding
nonmelanoma of skin 9,342,957 206.9 21.50 8,751,759 178.1 17.94 5,491,214 120.0
12.53 4,403,188 83.7 8.83 All sites 10,065,305 222.0 22.60 9,227,484 186.0 18.55
5,528,810 120.8 12.59 4,429,323 84.2 8.86
* a Incidence excludes basal cell carcinoma, whereas mortality includes all
types of nonmelanoma skin cancer.
Source: GLOBOCAN 2020
Figure 8
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Region-Specific Incidence and Mortality Age-Standardized Rates for Female Breast
Cancer in 2020. Rates are shown in descending order of the world (W)
age-standardized incidence rate, and the highest national age-standardized rates
for incidence and mortality are superimposed. Source: GLOBOCAN 2020.
Figure 9
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Region-Specific Incidence Age-Standardized Rates by Sex for Lung Cancer Among
Men and Women in 2020. Rates are shown in descending order of the world (W)
age-standardized rate in men, and the highest national rates among men and women
are superimposed. Source: GLOBOCAN 2020.
Figure 10
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Region-Specific Incidence Age-Standardized Rates by Sex for Cancers of the (A)
Colon and (B) Rectum (Including Anus) in 2020. Rates are shown in descending
order of the world (W) age-standardized rate among men, and the highest national
rates among men and women are superimposed. Source: GLOBOCAN 2020.
Figure 11
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Region-Specific Incidence and Mortality Age-Standardized Rates for Prostate
Cancer in 2020. Rates are shown in descending order of the world (W)
age-standardized incidence rate, and the highest national age-standardized rates
for incidence and mortality are superimposed. Source: GLOBOCAN 2020.
Figure 12
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Region-Specific Incidence Age-Standardized Rates by Sex for Stomach Cancer in
2020. Rates are shown in descending order of the world (W) age-standardized rate
among men, and the highest national rates among men and women are superimposed.
Source: GLOBOCAN 2020.
Figure 13
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Region-Specific Incidence Age-Standardized Rates by Sex for Liver Cancer in
2020. Rates are shown in descending order of the world (W) age-standardized rate
among men, and the highest national rates among men and women are superimposed.
Source: GLOBOCAN 2020.
Figure 14
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Region-Specific Incidence Age-Standardized Rates by Sex for Esophageal Cancer in
2020. Rates are shown in descending order of the world (W) age-standardized rate
among men, and the highest national rates among men and women are superimposed.
Source: GLOBOCAN 2020.
Figure 15
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Region-Specific Incidence and Mortality Age-Standardized Rates for Cervical
Cancer in 2020. Rates are shown in descending order of the world (W)
age-standardized incidence rate, and the highest national age-standardized rates
for incidence and mortality are superimposed. Source: GLOBOCAN 2020.
Figure 16
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Region-Specific Incidence Age-Standardized Rates by Sex for Thyroid Cancer in
2020. Rates are shown in descending order of the world (W) age-standardized rate
among men, and the highest national rates among men and women are superimposed.
Source: GLOBOCAN 2020.
Figure 17
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Region-Specific Incidence Age-Standardized Rates by Sex for Bladder Cancer in
2020. Rates are shown in descending order of the world (W) age-standardized rate
among men, and the highest national rates among men and women are superimposed.
Source: GLOBOCAN 2020.
Figure 18
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Region-Specific Incidence Age-Standardized Rates by Sex for nonmelanoma Skin
Cancer (Excluding Basal Cell Carcinoma). Rates are shown in descending order of
the world (W) age-standardized rate among men, and the highest national rates
among men and women are superimposed. Source: GLOBOCAN 2020.
Figure 19
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Region-Specific Incidence Age-Standardized Rates by Sex for Pancreatic Cancer in
2020. Rates are shown in descending order of the world (W) age-standardized rate
among men, and the highest national rates among men and women are superimposed.
Source: GLOBOCAN 2020.
Figure 20
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Region-Specific Incidence Age-Standardized Rates by sex for Non-Hodgkin Lymphoma
in 2020. Rates are shown in descending order of the world (W) age-standardized
rate among men, and the highest national rates among men and women are
superimposed. Source: GLOBOCAN 2020.
Figure 21
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Region-Specific Incidence and Mortality Age-Standardized Rates for Uterine
Corpus Cancer in 2020. Rates are shown in descending order of the world (W)
age-standardized incidence rate, and the highest national age-standardized rates
for incidence and mortality are superimposed. Source: GLOBOCAN 2020.
Figure 22
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Region-Specific Incidence Age-Standardized Rates by Sex for Kaposi Sarcoma in
2020. Rates are shown in descending order of the world (W) age-standardized rate
among men, and the highest national rates in men and women are superimposed.
Source: GLOBOCAN 2020.
Figure 23
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Region-Specific Incidence Age-Standardized Rates by Sex for Cancers of the Lip
and Oral Cavity in 2020. Rates are shown in descending order of the world (W)
age-standardized rate among men, and the highest national rates among men and
women are superimposed. Source: GLOBOCAN 2020.
FEMALE BREAST CANCER
Female breast cancer has now surpassed lung cancer as the leading cause of
global cancer incidence in 2020, with an estimated 2.3 million new cases,
representing 11.7% of all cancer cases (Table 1, Fig. 4). It is the fifth
leading cause of cancer mortality worldwide, with 685,000 deaths. Among women,
breast cancer accounts for 1 in 4 cancer cases and for 1 in 6 cancer deaths,
ranking first for incidence in the vast majority of countries (159 of 185
countries) (Fig. 5B) and for mortality in 110 countries (Fig. 6B). There are
exceptions, most notably in terms of deaths, with the disease preceded by lung
cancer in Australia/New Zealand, Northern Europe, Northern America, and China
(part of Eastern Asia) and by cervical cancer in many countries in sub-Saharan
Africa.
Incidence rates are 88% higher in transitioned countries than in transitioning
countries (55.9 and 29.7 per 100,000, respectively) (Fig. 7B), with the highest
incidence rates (>80 per 100,000) in Australia/New Zealand, Western Europe
(Belgium has the world's highest incidence), Northern America, and Northern
Europe and the lowest rates (<40 per 100,000) in Central America, Eastern and
Middle Africa, and South Central Asia (Fig. 8). However, women living in
transitioning countries have 17% higher mortality rates compared with women in
transitioned countries (15.0 and 12.8 per 100,000, respectively) (Fig. 7B)
because of high fatality rates, with the highest mortality rates found in
Melanesia, Western Africa, Micronesia/Polynesia, and the Caribbean (Barbados has
the world's highest mortality) (Fig. 8).
The elevated incidence rates in higher HDI countries reflect a longstanding
higher prevalence of reproductive and hormonal risk factors (early age at
menarche, later age at menopause, advanced age at first birth, fewer number of
children, less breastfeeding, menopausal hormone therapy, oral contraceptives)
and lifestyle risk factors (alcohol intake, excess body weight, physical
inactivity), as well as increased detection through organized or opportunistic
mammographic screening.24 An exceptionally high prevalence of mutations in
high-penetrance genes, such as BRCA1 and BRCA2 among women of Ashkenazi Jewish
heritage (range, 1%-2.5%), in part accounts for the high incidence in Israel and
in certain European subpopulations.25
Breast cancer incidence rates uniformly increased rapidly during the 1980s and
1990s in many countries in Northern America, Oceania, and Europe, likely
reflecting changes in the prevalence of risk factors coupled with increased
detection through widespread uptake of mammographic screening. Then, during the
early 2000s, incidence dropped or stabilized,26 which was largely attributed to
a reduction in the use of menopausal hormone therapy and also possibly a plateau
in screening participation.27, 28 Since 2007, there has been a slow upturn in
incidence rates in the United States of <0.5% annually,29 and moderate but
significant increases have also been reported in many other countries in Europe
and Oceania.30 Findings from studies in the United States,31, 32 Denmark,33
Ireland,34 and Scotland35 using cancer registry data supplemented with tumor
maker information have found that increasing incidence is confined to estrogen
receptor-positive cancer, and the rates are falling for estrogen
receptor-negative cancers. Explanations include the obesity epidemic, given the
stronger and more consistent association of excess body weight with estrogen
receptor-positive cancer,36-39 and the impact of mammographic screening, which
preferentially detects slow-growing estrogen receptor-positive cancers.40, 41
Countries in historically high-risk regions have benefited most from progress
through several breakthroughs in effective treatment, with mortality rates
decreasing since the late 1980s and the early 1990s.42, 43
Incidence rates of breast cancer are rising fast in transitioning countries in
South America, Africa,44 and Asia45 as well as in high-income Asian countries
(Japan and the Republic of Korea),30 where rates are historically low. Dramatic
changes in lifestyle, sociocultural, and built environments brought about by
growing economies and an increase in the proportion of women in the industrial
workforce have had an impact on the prevalence of breast cancer risk factors—the
postponement of childbearing and having fewer children, greater levels of excess
body weight and physical inactivity—and have resulted in a convergence toward
the risk factor profile of western countries and narrowing international gaps in
breast cancer morbidity.
Some of the most rapid increases are occurring in sub-Saharan Africa. Between
the mid-1990s and the mid-2010s, incidence rates increased by >5% per year in
Malawi (Blantyre), Nigeria (Ibadan), and the Seychelles and by 3% to 4% per year
in South Africa (Eastern Cape) and Zimbabwe (Harare).44 Mortality rates in
sub-Saharan African regions have increased simultaneously and rank now in the
world highest (Fig. 8), reflecting weak health infrastructure and subsequently
poor survival outcomes. The 5-year age-standardized relative survival in 12
sub-Saharan African countries was 66% for cases diagnosed during 2008 through
2015, sharply contrasting with 85% to 90% for cases diagnosed in high-income
countries during 2010 through 2014.46 The country-specific estimate was as low
as 12% in Uganda (Kyadondo) and 20% to 60% in South Africa (Eastern Cape), Kenya
(Eldoret), and Zimbabwe (Harare),47 comparable to 55% in the US state of
Connecticut and 57% in Norway during the late 1940s,48 3 decades before the
introduction of mammography screening and modern therapies.
Low survival rates in sub-Saharan Africa are largely attributable to late-stage
presentation. According to a report summarizing 83 studies across 17 sub-Saharan
African countries, 77% of all staged cases were stage III/IV at diagnosis.49
Because organized, population-based mammography screening programs may not be
cost effective or feasible in low-resource settings,50 efforts to promote early
detection through improved breast cancer awareness and clinical breast
examination by skilled health providers,51, 52 followed by timely and
appropriate treatment, are essential components to improving survival.53 A
recent study conducted in 5 sub-Saharan African countries estimated that 28% to
37% of breast cancer deaths in these countries could be prevented through
earlier diagnosis of symptomatic disease and adequate treatment, with a fairly
equal contribution of each.54 The Breast Health Global Initiative has
established a series of evidence-based, resource-stratified guidelines that
supports phased implementation into real-world practice.55-57
Establishing primary prevention programs for breast cancer remains a challenge.
Nevertheless, efforts to decrease excess body weight and alcohol consumption and
to encourage physical activity and breastfeeding may have an impact in stemming
the incidence of breast cancer worldwide. Population-wide breast cancer
screening programs aim to reduce breast cancer mortality through early detection
and effective treatment.58-61 The WHO recommends organized, population-based
mammography screening every 2 years for women at average risk for breast cancer
aged 50 to 69 years in well resourced settings.50 The current guidelines from
the American Cancer Society recommend that women aged 45 to 54 years should be
screened annually, women aged 40 to 44 years should have the opportunity to
begin annual screening, women aged ≥55 years should transition to biennial
screening or have the opportunity to continue screening annually, and women
should continue screening as long as their overall health is good and they have
a life expectancy ≥10 years.62 Mammographic screening, however, has limitations,
such as overdiagnosis and overtreatment.63-65 There are opportunities to improve
the cost effectiveness and benefit-to-harm ratio of screening by adopting a
risk-stratified screening strategy using existing and evolving risk prediction
models.66-69 Ongoing screening trials are evaluating the clinical acceptability
and utility of risk-stratified screening programs in the general population.70,
71
LUNG CANCER
With an estimated 2.2 million new cancer cases and 1.8 million deaths, lung
cancer is the second most commonly diagnosed cancer and the leading cause of
cancer death in 2020, representing approximately one in 10 (11.4%) cancers
diagnosed and one in 5 (18.0%) deaths (Table 1, Fig. 4). Lung cancer is the
leading cause of cancer morbidity and mortality in men, whereas, in women, it
ranks third for incidence, after breast and colorectal cancer, and second for
mortality, after breast cancer. Incidence and mortality rates are roughly 2
times higher in men than in women, although the male-to-female ratio varies
widely across regions, ranging from 1.2 in Northern America to 5.6 in Northern
Africa (Fig. 9). Lung cancer incidence and mortality rates are 3 to 4 times
higher in transitioned countries than in transitioning countries (Fig. 7); this
pattern may well change as the tobacco epidemic evolves given that 80% of
smokers aged ≥15 years resided in low-income and middle-income countries (LMICs)
in 2016.72
Among men, lung cancer is the most commonly diagnosed cancer in 36 countries
(Fig. 5A), while it is the leading cause of cancer death in 93 countries (Fig.
6A). The highest incidence rates are observed in Micronesia/Polynesia, Eastern
and Southern Europe, Eastern Asia, and Western Asia, where Turkey has the
highest rate among men globally (Fig. 9). Incidence rates remain generally low
in Africa, although they range from intermediate to high in both Southern and
Northern regions. Among women, lung cancer is the leading cause of cancer death
in 25 countries in Northern America, Oceania, and parts of Europe (Fig. 6B). The
highest incidence rates are in Northern America, Northern and Western Europe,
Micronesia/Polynesia, and Australia/New Zealand, with Hungary having the highest
country-specific rates (Fig. 9). Rates are also high in Eastern Asia, largely
reflecting the high burden among Chinese women, which is thought to reflect high
outdoor ambient air pollution and exposures to other inhalable agents, such as
household burning of solid fuels for heating and cooking given their low smoking
prevalence.73, 74 The global proportion of lung cancer deaths attributable to
outdoor ambient PM2.5 (known as fine particulate matter) air pollution was 14%
in 2017, ranging from 4.7% in the United States to 20.5% in China.74
International variation in lung cancer rates and trends largely reflects the
maturity of the tobacco epidemic,75 with patterns in mortality paralleling those
in incidence because of the high fatality rate. Smoking was first established
among men in several high-income countries, including the United Kingdom, the
United States, Finland, Australia, New Zealand, the Netherlands, Singapore, and,
more recently, Germany, Uruguay, and the remaining Nordic countries and was
followed by a steep increase in lung cancer.76, 77 Subsequent declines in lung
cancer followed peak smoking prevalence by several decades and were first
observed in young birth cohorts.78
In contrast, among women, the tobacco epidemic is less advanced and defined,75
and most countries are still observing a rising incidence of lung cancer.79 Only
a relatively few populations, eg, the United States and Switzerland, show signs
of a peak and stabilization or decline, albeit at a slower pace compared with
those in men.79, 80 As a result of this sex-specific trend, incidence rates
among women are approaching or equaling those among men in several countries in
Europe and Northern America.79 From 2006 to 2008, female incidence rates were
even higher than male incidence (ages 35-64 years) in Denmark, Iceland, and
Sweden.79 More recent studies revealed a higher female-to-male incidence ratio
in successively younger birth cohorts in the United States81 and subsequently in
more countries, including Canada, Denmark, Germany, New Zealand, the
Netherlands,82 because of increasing incidence rates among women in contrast to
steep declines among men. The increasing female-to-male incidence ratio,
however, was not fully explained by sex-specific differences in smoking
behaviour.81, 82 In countries where the epidemic is at an earlier stage,
including China, Indonesia, and several African countries, smoking has either
peaked recently or continues to increase,83 hence lung cancer rates will likely
increase for at least the next few decades barring interventions to accelerate
smoking cessation or reduce initiation.84
With about two-thirds of lung cancer deaths worldwide attributable to smoking,
the disease can be largely prevented through effective tobacco-control policies
and regulations. To assist the country-level implementation of effective
interventions to reduce the demand of tobacco, the WHO Framework Convention on
Tobacco Control introduced the MPOWER package, consisting of 6 policy
intervention strategies: Monitor tobacco use and prevention policies, Protect
people from tobacco smoke, Offer help to quit tobacco use, Warn about the
dangers of tobacco, Enforce bans on tobacco advertising, promotion and
sponsorship, and Raise taxes on tobacco.85 Since its introduction by the WHO,
progress has been substantial. In 2018, 65% of the world's population in 136
countries was covered by at least one select measure at a comprehensive level
compared with 15% of the population in 43 countries in 2007.86 Furthermore, the
prevalence of tobacco use has declined in 116 countries, especially those with
stronger implementation measures. In 2018, for the first time, the number of men
using tobacco globally began to decline despite population growth, with the
decline in the number of female tobacco users continuing since 2000.87 However,
progress is uneven, and there are 59 countries that have yet to adopt a single
MPOWER measure, 49 of which are LMICs.86
The survival of patients with lung cancer at 5 years after diagnosis is only 10%
to 20% in most countries among those diagnosed during 2010 through 2014,
although rates are higher in Japan (33%), Israel (27%), and the Republic of
Korea (25%).46 Screening with low-dose computed tomography (CT) for high-risk
individuals (current and former heavy smokers) can help diagnose cancer early,
when successful treatment is more likely. The efficacy of annual low-dose CT
screening in reducing lung cancer mortality has been confirmed in several
independent, international, randomized controlled clinical trials.88-91
Recently, the Dutch-Belgian lung cancer screening trial reported that volume CT
screening, with the introduction of growth-rate assessment as an imaging
biomarker for indeterminate tests, resulted in a lung cancer mortality reduction
at 10 years of follow-up of 24% in men and 33% in women compared with no
screening.91 This outcome was also accompanied by low referral rates for
additional assessments, resulting in significant reductions in false-positive
tests and unnecessary workup procedures.91 However, the translation of this
benefit to the general population has proven challenging, likely impeding the
implementation of lung cancer screening as part of a global strategy to reduce
the disease burden, at least in the near term.
COLORECTAL CANCER
More than 1.9 million new colorectal cancer (including anus) cases and 935,000
deaths were estimated to occur in 2020, representing about one in 10 cancer
cases and deaths (Table 1). Overall, colorectal ranks third in terms of
incidence, but second in terms of mortality (Fig. 4). Incidence rates are
approximately 4-fold higher in transitioned countries compared with
transitioning countries, but there is less variation in the mortality rates
because of higher fatality in transitioning countries (Fig. 7). There is an
approximately 9-fold variation in colon cancer incidence rates by world regions,
with the highest rates in European regions, Australia/New Zealand, and Northern
America, with Hungary and Norway ranking first in men and women, respectively
(Fig. 10A). Rectal cancer incidence rates have a similar regional distribution,
although rates in Eastern Asia rank among the highest (Fig. 10B). Rates of both
colon and rectal cancer incidence tend to be low in most regions of Africa and
in South Central Asia.
Colorectal cancer can be considered a marker of socioeconomic development, and,
in countries undergoing major transition, incidence rates tend to rise uniformly
with increasing HDI.92, 93 Incidence rates have been steadily rising in many
countries in Eastern Europe, South Eastern and South Central Asia, and South
America.22, 94 The increase in formerly low-risk and lower HDI countries likely
reflects changes in lifestyle factors and diet, ie, shifts toward an increased
intake of animal-source foods and a more sedentary lifestyle, leading to
decreased physical activity and increased prevalence of excess body weight,
which are independently associated with colorectal cancer risk.95 Additional
risk factors include heavy alcohol consumption, cigarette smoking, and
consumption of red or processed meat, whereas calcium supplements and adequate
consumption of whole grains, fiber, and dairy products appear to decrease
risk.96 Primary prevention remains the key strategy to reduce the increasing
global burden of colorectal cancer. The expense of mounting a mass screening
effort in most LMICs is not currently justified given the significant costs of
colonoscopy and inadequate implementation of diagnostic and treatment services.
Some evidence, however, suggests that colorectal cancer screening with more
affordable and less invasive methods (guaiac testing and fecal immunochemical
tests) may be cost-effective, at least in some settings of emerging economies,
and offer options for control of the growing burden of the disease.97, 98
Declines in colorectal cancer incidence in some high-incidence countries have
been attributed to population-level changes toward healthier lifestyle choices
(eg, declines in smoking) and the uptake of screening,94, 99 although
accelerated progress since the early 2000s is chiefly attributed to increased
colonoscopy screening and the removal of precursor lesions.100-102 However,
favorable trends for adults aged ≥50 years mask increasing rates of early-onset
colorectal cancer (age at diagnosis <50 years) in many countries, including the
United States, Canada, Australia, and 6 other high-income countries, with
incidence rising by 1% to 4% per year.103-105 Although rising incidence in young
birth cohorts points to the influence of dietary patterns, excess body weight,
and lifestyle factors, further research is needed to elucidate specific
underlying causal factors because information on risk factors is currently based
almost exclusively on data from older cohorts. To mitigate the rising burden of
early- onset colorectal cancer, the American Cancer Society lowered the
recommended age for screening initiation for individuals at average risk from 50
to 45 years in 2018,106 and, in October 2020, the US Preventive Services Task
Force concurred in a draft recommendation statement.107
PROSTATE CANCER
With an estimated almost 1.4 million new cases and 375,000 deaths worldwide
(Table 1), prostate cancer is the second most frequent cancer and the fifth
leading cause of cancer death among men in 2020 (Fig. 4B). Incidence rates are
3-fold higher in transitioned than in transitioning countries (37.5 and 11.3 per
100,000, respectively), whereas mortality rates are less variable (8.1 and 5.9
per 100,000, respectively) (Fig. 7A). It is the most frequently diagnosed cancer
in men in over one-half (112 of 185) of the countries of the world (Fig. 5A).
Incidence rates vary from 6.3 to 83.4 per 100,000 men across regions, with the
highest rates found in Northern and Western Europe, the Caribbean, Australia/New
Zealand, Northern America, and Southern Africa and the lowest rates in Asia and
Northern Africa (Fig. 11). Regional patterns of mortality rates do not follow
those of incidence, with the highest mortality rates in the Caribbean,
sub-Saharan Africa, and Micronesia/Polynesia. Prostate cancer is the leading
cause of cancer death among men in 48 countries, including many countries in
sub-Saharan Africa, the Caribbean, and Central and South America (eg, Ecuador,
Chile, and Venezuela), as well as Sweden (Fig. 6A).
For a disease as common as prostate cancer, relatively little is known about its
etiology. Established risk factors are limited to advancing age, family history
of this malignancy, and certain genetic mutations (eg, BRCA1 and BRCA2) and
conditions (Lynch syndrome). Black men in the United States and the Caribbean
have the highest incidence rates globally, supporting the role of Western
African ancestry in modulating prostate cancer risk.108 There have been few
lifestyle and environmental factors identified to date for which the evidence is
convincing, although this may be accumulating for smoking, excess body weight,
and some nutritional factors that may increase the risk of advanced prostate
cancer.109
International differences in prostate cancer diagnostic practices are likely the
greatest contributor to the variation in prostate cancer incidence rates
worldwide.110 In the United States, Canada, and Australia, there were rapid
increases in incidence rates in the late 1980s and early 1990s as a result of
the widespread introduction of prostate-specific antigen (PSA) testing, allowing
the detection of preclinical cancers.111 The dramatic increases were followed by
sharp reductions within a few years, likely reflecting a depletion of prevalent
latent cancers in the general population. Further declines in the late 2000s are
attributed to a reduction in the use of PSA testing,110-112 reflecting changes
in the recommendations concerning PSA-based screening of asymptomatic
men.113-116 In many countries in Northern and Western European, alongside a few
in Southern and Central America and Asia, less marked but similar patterns were
observed, reflecting the later and more gradual adoption of PSA testing.110,
111, 117, 118 In contrast, incidence rates continue to increase in China and
countries in Eastern Europe (Belarus, Bulgaria, Slovakia).118 Rapidly increasing
trends have been also found in sub-Saharan Africa, with annual increases ranging
from 2% to 10% reported in 9 countries (eg, South Africa, Kenya, Uganda,
Mozambique, Zimbabwe) over the time period examined between 1995 and 2018.119
Reasons for the uniform rise are unclear but are thought to primarily reflect
increased awareness and improvements in the health care system, enabling a
broader use of PSA testing and possibly increased use of transurethral
resections.119
Mortality rates for prostate cancer have decreased in most high-income countries
since the mid-1990s, including those in Northern America, Oceania, and Northern
and Western Europe,111, 117, 120 likely reflecting advancements in treatment and
earlier detection through increased screening.121, 122 During the same period,
rates increased in many countries in Central and Eastern Europe, Asia, and
Africa111 and continued until recently in some countries (eg, Thailand,
Bulgaria, and Ukraine),118 which may partly reflect an underlying rise in
incidence trends combined with limited access to PSA testing and effective
treatment. A more contemporary trend (2009-2013) in high-resource countries
signals stabilization of mortality declines (eg, the United States, Denmark,
Norway, Switzerland, Spain, Argentina, New Zealand, Israel, and Japan), whereas
decreasing trends continue in some countries (eg, the United Kingdom, Greece,
Italy, Austria, France, Germany, the Netherlands, Brazil, Canada, and
Australia).118 In the United States, there has been an increase in regional and
advanced-stage cancer diagnoses since around 2010123 and a concomitant increase
in advanced-stage death rates during 2012 through 2017.124 The current guideline
from the American Cancer Society recommends informed/shared decision-making (ie,
an individual choice of men with their health care provider after receiving
information about the uncertainties, risks, and potential benefits associated
with the screening) for PSA testing in men at average risk, beginning at age 50
years.125 In 2018, the US Preventive Services Task Force upgraded its
recommendation to informed decision for men aged 55 to 69 years126; the impact
of this change on cancer rates is yet to be determined.
STOMACH CANCER
Stomach cancer remains an important cancer worldwide and is responsible for over
one million new cases in 2020 and an estimated 769,000 deaths (equating to one
in every 13 deaths globally), ranking fifth for incidence and fourth for
mortality globally (Table 1, Fig. 4A). Rates are 2-fold higher in men than in
women. In men, it is the most commonly diagnosed cancer and the leading cause of
cancer death in several South Central Asian countries, including Iran,
Afghanistan, Turkmenistan, and Kyrgyzstan (Figs. 5A and 6A). Incidence rates are
highest in Eastern Asia (Japan and Mongolia, the countries with the highest
incidence in men and women, respectively) and Eastern Europe,18 whereas rates in
Northern America and Northern Europe are generally low and equivalent to those
seen across the African regions (Fig. 12).
Although stomach cancer is often reported as a single entity, it can generally
be classified into two topographical subsites, the cardia (upper stomach) and
noncardia (lower stomach). These entities differ in terms of risk factors,
carcinogenesis, and epidemiologic patterns. Chronic Helicobacter pylori
infection is considered the principal cause of noncardia gastric cancer, with
almost all cases attributed to this bacterium.127, 128 The prevalence of H.
pylori infection is extraordinarily high, infecting 50% of the world's
population,129 and its geographic variation correlates reasonably with that of
stomach cancer incidence. However, <5% of infected hosts will develop cancer,
likely because of differences in bacterial genetics, host genetics, age of
infection acquisition, and environmental factors.130 Established risk factors
beyond H. pylori for noncardia gastric cancer include alcohol consumption,
tobacco smoking, and foods preserved by salting.96 Low fruit intake and the high
consumption of processed meat and of grilled or barbecued meat and fish may
increase the risk.96 Although cancers of the gastric cardia in the presence of
H. pylori infection show an association with gastric atrophy, cardia cancer is
not generally associated with H. pylori infection131 and may even be inversely
associated in some populations.132 Emerging evidence suggests a dual etiology
for cardia gastric cancer, with some cancers linked to H. pylori infection and
some linked to excess body weight and gastroesophageal reflux disease injury,
resembling characteristics of esophageal adenocarcinoma (AC).133
Incidence and mortality rates of noncardia gastric cancer have been steadily
declining over the last one-half century in most populations. The trends are
attributed to the unplanned triumph of prevention, including a decreased
prevalence of H. pylori and improvements in the preservation and storage of
foods.134 The historical trends in the incidence of gastric cardia were largely
reported in low-risk populations, in which the contribution of cardia versus
noncardia gastric cancer to the overall burden tends to be greatest; incidence
rates increased from the 1960s to the 1980s in the United Kingdom135 and the
United States136 and appeared to stabilize during the more recent period in the
United States137 and the Netherlands.138
Recent notable findings are the increase in the incidence of stomach cancer
(cardia and noncardia gastric cancers combined) among young adults (aged <50
years) in both low-risk and high-risk countries, including the United States,
Canada, the United Kingdom, Chile, and Belarus.139, 140 A previous US study
focusing on noncardia gastric cancer reported that increases among young
individuals was largely confined to non-Hispanic Whites and people living in
more affluent counties.141, 142 It has been postulated that the rising
prevalence of autoimmune gastritis and dysbiosis of the gastric microbiome,
possibly relevant to increased use of antibiotics and acid suppressants, may
have contributed to the paradoxical increase of stomach cancer among younger
generations.141, 142
LIVER CANCER
Primary liver cancer is the sixth most commonly diagnosed cancer and the third
leading cause of cancer death worldwide in 2020, with approximately 906,000 new
cases and 830,000 deaths (Table 1, Fig. 4A). Rates of both incidence and
mortality are 2 to 3 times higher among men than among women in most regions
(Fig. 13), and liver cancer ranks fifth in terms of global incidence and second
in terms of mortality for men (Fig. 4B). Incidence rates among men are 2.4-fold
greater in transitioned countries (Fig. 7), but the highest rates are observed
mainly in transitioning countries, with the disease being the most common cancer
in 11 geographically diverse countries in Eastern Asia (Mongolia, which has
rates far exceeding any other country), South-Eastern Asia (eg, Thailand,
Cambodia, and Viet Nam), and Northern and Western Africa (eg, Egypt and Niger)
(Figs. 5A). Liver cancer is the leading cause of cancer death in Mongolia,
Thailand, Cambodia, Egypt, Guatemala among both men and women and in an
additional 18 countries among men (Fig. 6).
Primary liver cancer includes hepatocellular carcinoma (HCC) (comprising 75%-85%
of cases) and intrahepatic cholangiocarcinoma (10%-15%), as well as other rare
types. The main risk factors for HCC are chronic infection with hepatitis B
virus (HBV) or hepatitis C virus (HCV), aflatoxin-contaminated foods, heavy
alcohol intake, excess body weight, type 2 diabetes, and smoking.143 The major
risk factors vary from region to region. In most high-risk HCC areas (China, the
Republic of Korea, and sub-Saharan Africa), the key determinants are chronic HBV
infection, aflatoxin exposure, or both; whereas, in other countries (Japan,
Italy, and Egypt), HCV infection is likely the predominant cause. In Mongolia,
HBV and HCV and co-infections of HBV carriers with HCV or hepatitis delta
viruses, as well as alcohol consumption, all contribute to the high burden.144
Although risk factors tend to vary substantially by geographic region, major
risk factors for cholangiocarcinoma include liver flukes (eg, in the Northeast
region of Thailand, where Opisthorchis viverrini is endemic),145 metabolic
conditions (including obesity, diabetes, and nonalcoholic fatty liver disease),
excess alcohol consumption, and HBV or HCV infection.146-148
Incidence and mortality rates of liver cancer have decreased in many high-risk
countries in Eastern and South-Eastern Asia, including China, Taiwan, the
Republic of Korea, the Philippines, since the late 1970s and in Japan since the
1990s.94, 149 Rates in Italy have also declined since 1995.94, 149 These trends
likely reflect declines in the population seroprevalence of HBV and HCV as well
as a reduction in aflatoxin exposure. Vaccination against HBV, which has been a
major public health success, dramatically reduced the prevalence of HBV
infection and the incidence of HCC in high-risk countries in Eastern Asia, where
it was first introduced in the early 1980s.150 Although primary liver cancer
trends largely reflect those of HCC, there are notable exceptions; in Thailand,
where HCC accounts for <30% of liver cancer, HCC incidence rates have sharply
decreased since 2000, whereas primary liver cancer continues to rise.149
The major risk factors appear to be in transition, with the prevalence of HBV
and HCV declining and excess body weight and diabetes increasing in many
regions.151 In China, the rates of liver cancer have begun to plateau in recent
birth cohorts, potentially offsetting the gains achieved for the last 3
decades.149 Furthermore, incidence rates in formerly low-risk countries—most
countries across Europe, Northern America, Australia/New Zealand, and South
America—have increased or stabilized at a higher level in recent years,149, 152
possibly caused in part by the changing prevalence of excess body weight and
diabetes.
Although the relevance of nonviral risk factors is becoming more important on
the burden of liver cancer, elimination of viral hepatitis remains the key
strategy for primary prevention of liver cancer globally, as HBV infection and
HCV infection account for 56% and 20% of liver cancer deaths worldwide,
respectively.153 By the end of 2019, 189 countries had introduced the HBV
vaccine into their national infant immunization programs, and global coverage
with 3 doses of hepatitis B vaccine was estimated at 85%.154 The global coverage
of HBV birth-dose, however, was low at 43%, varying up to 84% in the WHO Western
Pacific region and falling to only 6% in the WHO African region,155 where HBV
predominates as a cause of liver cancer.153 Countries with the highest HCV
prevalence are mainly LMICs in which a large proportion of infections occur in
the health care settings through unsafe injections and other invasive
procedures.156 Enhancing infection control through safety measures, such as
screening of transfusions, prevention of mother-to-child transmission, the
provision of clean needles, and infection control in health care facilities, is
a key aspect of HCV control.156 Currently, there is no vaccine available to
prevent HCV infection, although an 8-week to 12-week course of orally
administered, direct-acting antiviral agents appears to cure HCV infection in
most instances.157 Yet chronic infections are usually asymptomatic, and many
infected persons remain undiagnosed; as of 2015, an estimated 290 million
individuals remained undiagnosed worldwide.158 A policy shift toward treating
all individuals with HCV is expected to have the potential to decrease
hepatitis-associated morbidity and mortality.158 However, challenges to ensuring
widespread access to treatment in different settings vary.156 In most LMICs,
affordability of viral testing and treatment is a major barrier,158, 159
underscoring the need for concerted and coordinated efforts by local
governments, private and nonprivate public health organizations, and industries
to scale up screen-and-treat interventions for viral hepatitis.160 In
high-income countries, those most at risk are often vulnerable populations,
including undocumented immigrants, injection drug users, those who have been
incarcerated, and homeless and poor people, who experience many barriers to
health care access.158, 159
ESOPHAGEAL CANCER
Esophageal cancer ranks seventh in terms of incidence (604,000 new cases) and
sixth in mortality overall (544,000 deaths), the latter signifying that
esophageal cancer is responsible for one in every 18 cancer deaths in 2020 (Fig.
4, Table 1). Approximately 70% of cases occur in men, and there is a 2-fold to
3-fold difference in incidence and mortality rates between the sexes (Table 3).
Rates are higher in transitioned versus transitioning countries for men but
comparable for women (Fig. 7).18, 94 Eastern Asia exhibits the highest regional
incidence rates for both men and women, in part because of the large burden in
China, followed by Southern Africa, Eastern Africa, Northern Europe, and South
Central Asia (Fig. 14). Cape Verde and Malawi have the highest incidence rates
globally in men and women, respectively (Fig. 14). Esophageal cancer is the
leading cause of cancer death among Bangladeshi men and women and among Malawian
men (Fig. 6).
The geographic variation in esophageal cancer incidence substantially differs
between the 2 most common histologic subtypes (squamous cell carcinoma [SCC] and
adenocarcinoma [AC]), which have quite different etiologies. The incidence of
esophageal SCC in certain high-risk areas in Asia (eg, China) is broadly in
decline and may have been preceded by economic gains and dietary improvements,
whereas, in several high-income countries (eg, the United States, Australia,
France, and the United Kingdom), the reductions are considered primarily due to
declines in cigarette smoking.161 Heavy drinking and smoking and their
synergistic effects are the major risk factors for SCC in western settings.161
However, in lower income countries, including parts of Asia and sub-Saharan
Africa, the major risk factors for SCC—which usually comprises over 90% of all
esophageal cancer cases—have yet to be elucidated, although dietary components
(eg, nutritional deficiencies, nitrosamines) have been suspected.162 Additional
suspected risk factors for SCC include betel quid chewing in the Indian
subcontinent and consumption of pickled vegetables (eg, in China) and very hot
food and beverages (eg, in Uruguay, Iran, and Tanzania).161
AC represents roughly two-thirds of esophageal cancer cases in high-income
countries, with excess body weight, gastroesophageal reflux disease, and
Barrett's esophagus among the key risk factors.161 Across high-income countries,
incidence rates of AC are thus rising rapidly in part because of increased
excess body weight and increasing gastroesophageal reflux disease and possibly
because of decreasing levels of chronic infection with H. pylori, which has been
inversely associated with AC.163 These trends are predicted to continue in the
near future, with AC surpassing SCC in many high-income countries; excess body
weight is likely to be an increasingly important contributor to the future
burden of esophageal cancer.163
CERVICAL CANCER
Cervical cancer is the fourth most frequently diagnosed cancer and the fourth
leading cause of cancer death in women, with an estimated 604,000 new cases and
342,000 deaths worldwide in 2020 (Table 1, Fig. 4). Cervical cancer is the most
commonly diagnosed cancer in 23 countries (Fig. 5B) and is the leading cause of
cancer death in 36 countries (Fig. 6B), with the vast majority of these
countries found in sub-Saharan Africa, Melanesia, South America, and
South-Eastern Asia. The highest regional incidence and mortality is in
sub-Saharan Africa (Fig. 15), with rates elevated in Eastern Africa (Malawi has
the world's highest incidence and mortality rate), Southern Africa, and Middle
Africa. Incidence rates are 7 to 10 times lower in Northern America,
Australia/New Zealand, and Western Asia (Saudi Arabia and Iraq), with mortality
rates varying up to 18 times.18
Human papillomavirus (HPV) is a necessary but not sufficient cause of cervical
cancer,164 with 12 oncogenic types classified as group 1 carcinogens by the
International Agency for Research on Cancer Monographs.165 Other important
cofactors include some sexually transmittable infections (HIV and Chlamydia
trachomatis), smoking, a higher number of childbirths, and long-term use of oral
contraceptives.166 Rates remain disproportionately high in transitioning versus
transitioned countries (18.8 vs 11.3 per 100,000 for incidence; 12.4 vs 5.2 per
100,000 for mortality) (Fig. 7B). The HDI and poverty rates have been shown to
account for >52% of global variance in mortality.167 This disparity exists even
within high-income countries like the United States, where the cervical cancer
death rate is 2-fold higher among women residing in high-poverty versus
low-poverty areas.168
Incidence and mortality rates have declined in most areas of the world for the
past few decades. The declines are ascribed to factors linked to either
increasing average socioeconomic levels or a diminishing risk of persistent
infection with high-risk HPV, resulting from improvements in genital hygiene,
reduced parity, and a diminishing prevalence of sexually transmitted disease.169
Cervical cancer screening programs hastened the declines upon their
implementation in many countries in Europe, Oceania, and Northern America,
despite the observations of increasing risk among younger generations of women
in some of these countries170, 171 and also in Japan,172 which may in part
reflect changing sexual behavior and increased transmission of HPV that is
insufficiently compensated by cytologic screening.173, 174 Rates have also
decreased in countries in the Caribbean and Central and South America (eg,
Argentina, Chile, Costa Rica, Brazil, and Colombia) during the 2000s, although
incidence rates remain high.175 In the absence of effective screening, as in
Eastern Europe and Central Asia, there have been rapid increases in premature
cervical cancer mortality in recent generations.176 Perhaps most concerning are
the uniform rises recently reported in 7 of 8 sub-Saharan African countries,
including the Gambia, Kenya, Malawi, the Seychelles, South Africa, Uganda, and
Zimbabwe.177
Cervical cancer is considered nearly completely preventable because of the
highly effective primary (HPV vaccine) and secondary (screening) prevention
measures. However, these measures have not been equitably implemented across and
within countries. As of May 2020, <30% of LMICs had implemented national HPV
vaccination programs compared with >80% of high-income countries.178 Only 44% of
women in LMICs have ever been screened for cervical cancer, with the lowest
prevalence among women in sub-Saharan Africa (country-level median, 16.9%;
range, 0.9%-50.8%),179 compared with >60% in high-income countries.
In such regions, of critical importance is ensuring that resource-dependent
programs of screening and vaccination are implemented to transform the
situation.180 HPV vaccination programs can reduce the long-term future burden of
cervical cancer under the assumption of reasonable uptake,181, 182 and the WHO
currently recommends 2-dose vaccination of girls aged 9 to 13 years as a best
buy (ie, efficacious and cost-effective interventions).183 High-quality
screening programs are also important to prevent cervical cancer among
unvaccinated women and for oncogenic subtypes not covered by the vaccine. The
WHO recommends the screening of women aged 30 to 49 years—either through visual
inspection with acetic acid in low-resource settings, a Papanicolaou test
(cervical cytology) every 3 to 5 years, or HPV testing every 5 years—coupled
with timely and efficacious treatment of precancerous lesions.183, 184
Accumulated evidence supports the use of HPV-based tests for the detection of
precancerous lesions as a preferred test for primary screening,185 which can
also offer opportunities of self-sampling to women who live in remote areas or
who are reluctant to undergo gynecologic examination.186 Studies suggested that
self-sampled HPV testing can be cost effective, either as an addition to
existing screening programs or as a primary screening strategy, by increasing
the level of screening attendance, lowering the cost of testing, and attracting
more never-screened or long-term underscreened women.187, 188 Efforts are also
needed to increase access to treatment and palliative care among patients with
invasive tumors, particularly in transitioning countries.189, 190
In 2018, given the substantial global burden of cervical cancer and the
increasing inequity, the WHO Director-General made a call for global action
toward the elimination of cervical cancer (≤4 per 100,000 women worldwide)
through the triple-intervention strategy of: 1) vaccinating 90% of all girls by
age 15 years, 2) screening 70% of women twice in the age range of 35 to 45
years, and 3) treating at least 90% of all precancerous lesions detected during
screening.191 A modelling exercise predicts that implementing this strategy will
result in more than 74 million cases and more than 62 million deaths averted
over the course of the next century.192 This goal is projected to be achieved by
2055 to 2059 in very high HDI countries, whereas, in low HDI countries, it might
take until the end of the 21st century,193 mirroring the glaring gap in
underlying incidence rates and resources required to achieve the goal. Findings
from recent studies, however, suggest opportunities to prevent cervical cancer
in resource-limited settings by adopting the combined vaccination and screening
strategy, which has proven to be cost effective across several LMICs194-196 and
is expected to expedite the realization of the goal within 11 to 31 years in low
HDI countries.192, 193 The 2020 guideline update from the American Cancer
Society recommends that women initiate cervical cancer screening at age 25 years
and undergo primary HPV testing every 5 years through age 65 years as a
preferred option.197
THYROID CANCER
Thyroid cancer is responsible for 586,000 cases worldwide, ranking in 9th place
for incidence in 2020. The global incidence rate in women of 10.1 per 100,000 is
3-fold higher than that in men (Table 3), and the disease represents one in
every 20 cancers diagnosed among women (Fig. 4C). Mortality rates from the
disease are much lower, with rates of 0.5 per 100,000 in women and 0.3 per
100,000 in men and an estimated 44,000 deaths in both sexes combined. Incidence
rates are higher in transitioned countries than in transitioning countries, 4.0
times for men18 and 5.5 times for women, although mortality rates, in contrast,
are rather similar (Fig. 7). The highest incidence rates are found in Northern
America, Australia/New Zealand, Eastern Asia, and Southern Europe for both sexes
and also in Micronesia/Polynesia, and South America for women (Fig. 16). The
highest global rates are estimated in Cyprus for both men and women.
The etiology of thyroid cancer is not well understood. The only well established
risk factor for thyroid cancer is ionizing radiation, particularly when exposure
is in childhood, although there is evidence that other factors (excess body
weight, greater height, hormonal exposures, and certain environmental
pollutants) may play a role.198 Since the 1980s, rapid rises in incidence rates
and comparatively stable or even declining mortality rates have been observed in
much of the world.198, 199 The rapid increase of thyroid cancer, particularly
papillary thyroid cancer, has been largely attributed to the progressively
available and sensitive use of ultrasonography, along with increased use of
other diagnostic imaging modalities,200, 201 which have likely led to a massive
detection and diagnosis of a large reservoir of subclinical, indolent lesions of
the thyroid that are known to exist in the general population.202, 203 Among
women, overdiagnosis was estimated to account for 80% to 95% of newly diagnosed
cases from 2008 to 2012 in the Republic of Korea, Belarus, China, Italy,
Croatia, Slovakia, and France and from 50% to 70% in Denmark, Norway, Ireland,
the United Kingdom, and Japan.204 Patterns similar to those observed in women,
although of a lower magnitude were observed in men (ie, the proportion
attributable to overdiagnosis was approximately 10% lower in men than in women
in each country).204
A growing understanding of the substantial impact of overdiagnosis and the
indolent nature of small thyroid cancers has led to modifications of national
and international clinical practice guidelines,205, 206 which recommend against
screening for thyroid cancer and advocate active surveillance for
microcarcinoma.207, 208 The global impact of changing guidelines needs to be
determined, although the significant decline in thyroid cancer incidence rates
observed in the Republic of Korea since 2010203, 209 and in the United States
since 2015210, 211 suggest that greater acceptance of guidelines and adoption of
active surveillance may already be mitigating some of the harms related to
overdiagnosis.
In addition, the change in the prevalence of risk factors may also have partly
contributed to the observed trend.212 A study from the United States showed an
increase in distant-stage thyroid cancer diagnoses during 1993 through 2013,
coinciding with a slow increase in overall mortality.213 A study linking secular
trends of thyroid cancer incidence in the United States to those of the
prevalence of obesity estimated that 16% of overall cancers and 63% of
large-size tumors diagnosed from 2013 to 2015 were attributable to obesity,214
suggesting that controlling obesity might help to prevent the development of
thyroid cancer.
BLADDER CANCER
Bladder cancer is the 10th most commonly diagnosed cancer worldwide, with
approximately 573,000 new cases and 213,000 deaths (Table 1). It is more common
in men than in women, with respective incidence and mortality rates of 9.5 and
3.3 per 100,000 among men, which are approximately 4 times those among women
globally (Table 3). Thus the disease ranks higher among men, for whom it is the
6th most common cancer and the 9th leading cause of cancer death (Fig. 4B).
Incidence rates in both sexes are highest in Southern Europe (Greece [with the
highest incidence rate among men globally], Spain, and Italy), Western Europe
(Belgium and the Netherlands), and Northern America, although the highest global
rates are in Hungary among women (Fig. 17).18
The observed geographic and temporal patterns of bladder cancer incidence
worldwide appear to reflect the prevalence of tobacco smoking, although
infection with Schistosoma haematobium (parts of Northern and sub-Saharan
Africa) and other risk factors (occupational exposures to aromatic amines and
other chemicals affecting workers in the painting, rubber, or aluminum
industries and arsenic contamination in drinking water) may be major causes in
some populations.215, 216
Diverging incidence trends were observed by sex in many countries from the 1990s
and the early 2010s, with stabilizing or declining rates in men but some
increasing trends seen for women (eg, Spain, the Netherlands, Germany, and
Belarus).216, 217 With the rising smoking prevalence among women, 39% of bladder
cancer cases among women were estimated to be attributable to smoking in 2014 in
the United States, compared with 49% among men.218 Mortality rates have been in
decline mainly in the most developed settings due in part to improvements in
treatment (eg, endoscopic resection, adjuvant instillation of chemotherapy, and
intravesical immunotherapy)219; the exceptions are countries undergoing rapid
economic transition, including in Central and South America; some Central,
Southern, and Eastern European countries; and the Baltic countries.216 Of note,
differences in coding and registration practices need to be considered in terms
of inclusion or otherwise of noninvasive cancers.216, 220, 221 Because
noninvasive cancers reflect a large proportion of all bladder cancers222 and are
commonly associated with a good prognosis, mortality rates may be of greater
utility when comparing international and temporal variations and assessing
overall progress in controlling the disease.216, 220
OTHER CANCERS COMMON IN CERTAIN REGIONS
Nonmelanoma skin cancer is responsible for over one million new cases (excluding
basal cell carcinoma) and 64,000 deaths globally (Table 1), with incidence rates
approximately 2 times higher among men than among women (Table 3). It is the
most frequently diagnosed cancer in Australia/New Zealand where the rates are
the world highest in both men and women (Fig. 18). The overall melanoma
incidence in Australia has been decreasing since 2005 (−0.7% per year),223 in
part reflecting some successes in mass media campaigns,224 accompanied by
policies, supportive environments such as shade, and access to quality
sun-protection products governed by national standards.225 Although incidence
rates in New Zealand increased until the early 2010s, they are projected to
decline in the future,223 reflecting birth cohort effects in younger
generations.226 A rapid decline in death rates for melanoma has been reported in
the United States by 6.4% per year since 2013 through 2017 after the
introduction of new therapies, including immune checkpoint inhibitors and
targeted therapies for metastatic melanoma.227, 228
Pancreatic cancer accounts for almost as many deaths (466,000) as cases
(496,000) because of its poor prognosis and is the seventh leading cause of
cancer death in both sexes (Fig. 4). Rates are from 4-fold to 5-fold higher in
higher HDI countries (Fig. 7), with the highest incidence rates in Europe,
Northern America, and Australia/New Zealand (Fig. 19). Both incidence and
mortality rates either have been stable or have slightly increased in many
countries, likely reflecting the increasing prevalence of obesity, diabetes, and
alcohol consumption, although improvements in diagnostic and cancer registration
practices may also be in play in some countries.94 Given that the rates of this
disease are rather stable relative to the declining rates of breast cancer, it
has been projected that pancreatic cancer will surpass breast cancer as the
third leading cause of cancer death by 2025 in a study of 28 European
countries.229
Non-Hodgkin lymphoma is responsible for 544,000 new cases and 260,000 deaths in
2020 (Table 1). Incidence rates are approximately 2-fold higher in transitioned
countries than in transitioning countries (Fig. 7). The highest incidence rates
are found in Australia/New Zealand, Northern America, and Europe, with Israel
and Slovenia ranking first for men and women, respectively (Fig. 20). In many
countries in the high-risk regions, increasing incidence rates during the 1980s
and 1990s have plateaued in recent years.230 In the United States, this trend
appeared in a similar fashion for both HIV-infected and HIV-uninfected
individuals, and reasons for the long-term increase in non-Hodgkin lymphoma
incidence in the general population remain unknown.231
Uterine corpus cancer is the sixth most commonly diagnosed cancer in women, with
417,000 new cases and 97,000 deaths in 2020 (Table 1). Incidence rates vary
10-fold across world regions with the highest rates seen in Northern America,
Europe, Micronesia/Polynesia, and Australia/New Zealand and the lowest incidence
rates in most African regions and South Central Asia (Fig. 21). Less regional
variation was seen for mortality rates, with the highest in Eastern Europe,
Micronesia/Polynesia, the Caribbean, and Northern America. Incidence rates have
increased or stabilized since the late 1990s in many countries across regions,
with South Africa and several countries in Asia showing the fastest increase.232
Birth cohort effects were most evident in Japan, the Philippines, Belarus,
Singapore, India, Belarus, Lithuania, Costa Rica, and New Zealand,232 possibly
in part reflecting increases in the prevalence of risk factors (eg, excess body
weight, physical inactivity) in subsequently younger generations.
There are several cancers that, although not featured among the top 10 cancers,
are major cancers within certain regions or specific countries. With
approximately 34,000 new cases and 15,000 deaths (Table 1), Kaposi sarcoma is a
relatively rare cancer worldwide but is endemic in several countries in Southern
and Eastern Africa (Fig. 22) and is the leading cause of both cancer incidence
and mortality among men in 2020 in Mozambique and Uganda (Figs. 5A and 6A);
rates are the highest worldwide in Mozambique for men and in Zambia for women
(Fig. 22). Cancers of the lip and oral cavity cancers are highly frequent in
South Central Asia (eg, India, Sri Lanka, and Pakistan)18 as well as Melanesia
(Papua New Guinea, with the highest incidence rate worldwide in both sexes)
(Fig. 23), reflecting the popularity of betel nut chewing.233 It is also the
leading cause of cancer death in India among men (Fig. 6A). Incidence rates are
also high in Eastern and Western Europe and in Australia/New Zealand and have
been linked to alcohol consumption, tobacco smoking, HPV infection for cancers
of the oropharyngeal region, and to ultraviolet radiation from sunlight exposure
for lip cancer.233-236
FUTURE BURDEN OF CANCER IN 2040
Worldwide, an estimated 28.4 million new cancer cases (including NMSC, except
basal cell carcinoma) are projected to occur in 2040, a 47% increase from the
corresponding 19.3 million cases in 2020, assuming that national rates estimated
in 2020 remain constant (Fig. 24). The relative magnitude of increase is most
striking in low HDI countries (95%) and in medium HDI countries (64%). In terms
of the absolute burden, the high HDI countries are expected to experience the
greatest increase in incidence, with 4.1 million new cases more in 2040 compared
with 2020. This projection is solely due to the growth and aging of the
population and may be further exacerbated by an increasing prevalence of risk
factors in many parts of the world.
Figure 24
Open in figure viewerPowerPoint
Projected Number of New Cases for All Cancers Combined (Both Sexes Combined) in
2040 According to the 4-Tier Human Development Index (HDI). Source: GLOBOCAN
2020.
Although the burden of cancer increases substantially at all HDI levels, the
epidemiologic transition of cancer in emerging HDI countries will likely to be
most affected, in which an increasing magnitude of the disease is paralleled by
a changing profile of common cancer types. Many countries classified with low
and medium HDI levels are experiencing a marked increase in the prevalence of
known cancer risk factors that prevail in high-income western countries (eg,
smoking, unhealthy diet, excess body weight, and physical inactivity).4, 92, 237
A recurring observation is the ongoing displacement of infection-related and
poverty-related cancers (eg, cervix, liver, stomach) with cancers that are
uniformly common in the most developed countries (eg, breast, lung, colorectum,
prostate), requiring changes in the priorities in national cancer control
strategies.93
Increases in the incidence of these cancers will likely be paralleled by
increases in mortality rates, which have been observed for breast and colorectal
cancer, unless resources are placed within health services to appropriately
treat and manage the growing number of cancers.238 In addition to a residual
burden of cancers associated with infections,84 the increasing burden of cancers
associated with social and economic transition may overwhelm health care systems
in many lower income countries if left unchecked.239 Primary prevention is a
particularly effective way to control cancer, up to half of all cancers are
preventable.240 However, much needs to be done to integrate current effective
interventions into existing health plans, while cultivating new interventions
that either tackle exposures that are increasing globally or cancers for which
prevention options remain limited.241
SUMMARY AND CONCLUSIONS
The GLOBOCAN 2020 estimates presented in this study indicate that there were
19.3 million new cases of cancer and almost 10 million deaths from cancer in
2020. The disease is an important cause of morbidity and mortality worldwide, in
every world region, and irrespective of the level of human development. It is
worth reiterating that, in Africa, the cumulative risk of death from cancer
among women in 2020 is broadly comparable to the risks observed among women in
Northern America and in the highest income countries of Europe. Therefore,
efforts to build a sustainable infrastructure for the dissemination of proven
cancer prevention measures and the provision of cancer care in transitioning
countries are critical for global cancer control.
The extraordinary diversity of cancer continues to offer clues to the underlying
causes but also reenforces the need for a global escalation of efforts to
control the disease. Packages of effective and resource-sensitive preventative
and curative interventions are available for cancer,183, 242 and their tailored
integration into health planning nationally can serve to reduce the future
burden and suffering from cancer worldwide, while narrowing the evident cancer
inequities between transitioning and transitioned countries observed today.
ACKNOWLEDGEMENTS
We thank cancer registries worldwide for their continued collaboration; without
their efforts, there would be no global cancer estimates.
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CITING LITERATURE
Volume71, Issue3
May/June 2021
Pages 209-249
This article also appears in:
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