Heart disease and cancer are the leading causes of disease-related deaths worldwide, collectively accounting for over 50% of global mortality[1–3]. Projections indicate that cancer will continue its upward trajectory over the next two decades[4–6]. In mainland China, the accelerating pace of population aging is contributing to the rising burden of chronic diseases, including cancer[7]. Cancer has become a significant public health challenge in the country, posing severe threats to both public health and the national economy, while also affecting social development[6, 8–10]. According to estimates from the Global Cancer Observatory (GLOBOCAN) in 2020, China reported more than 4.5 million new cancer cases, a figure that increased to over 4.8 million by 2022[11]. Simultaneously, over 3 million cancer-related deaths were recorded, highlighting the severity of the cancer burden. Both incidence and mortality rates—whether in absolute numbers or adjusted for age—show significant variation across different cancer types, sexes, and age groups[12, 13]. Furthermore, each cancer type is influenced by distinct risk factors. For instance, there is robust evidence linking exposure to PM_2.5 with lung cancer, and an association between nitrogen dioxide (NO2) exposure and breast cancer[14, 15].

China is currently undergoing rapid development. As the country continues to progress economically, its earlier model of rapid urbanization and industrialization—often at the expense of environmental quality—is being critically reassessed[16, 17]. There is now a growing national commitment to environmental protection and a clear shift toward more sustainable development practices[18]. In this context, it is essential to comprehensively investigate the influence of the aforementioned cancer-related factors on the Chinese population.[10]. A detailed understanding of these factors is crucial for shaping the development and implementation of a cancer prevention and control system that aligns with the evolving public health priorities of the country.

This study utilizes data from the Global Burden of Disease (GBD) database to systematically analyze the incidence and mortality of all cancer types in China, including a total of 35 neoplasms. In addition to evaluating the national cancer burden, we compare age-standardized incidence and mortality rates for all cancer types in China with those from the global dataset and regions categorized by the Sociodemographic Index (SDI), including high-SDI, high-middle SDI, middle-SDI, low-middle SDI, and low-SDI regions. A major advancement in GBD 2021, compared to GBD 2019, is the extension of cancer mortality estimates back to 1980, offering a richer dataset for assessing long-term trends in cancer burden[19]. Building upon this foundation, the present study focuses on the five leading cancer types in China in 2021, based on total deaths across all ages and both sexes. Through the use of decomposition analysis, Joinpoint regression, and Bayesian Age-Period-Cohort modeling, we conduct a comprehensive investigation of trends in incidence, mortality, and associated risk factors for these leading cancers. The findings aim to provide robust scientific evidence to inform policy-making and enhance the effectiveness of cancer prevention and control strategies in China.

We extracted the age-standardized incidence and deaths rates and employed the estimated annual percentage change (EAPC) method to evaluate temporal trends in cancer incidence and mortality. After logarithmic transformation of the age-standardized rates, the geometric mean for each year was calculated and treated as the dependent variable in a linear regression model[24, 25]. The EAPC was then computed using the formula 100 × (exp(β) − 1). The corresponding 95% confidence intervals (CIs) were derived from the regression model, allowing assessment of cancer trends across China.

Data from mainland China for the year 2021 were selected. All specific cancer types were included, excluding the overall category "Neoplasms". The age group was set to "All ages", with the metric specified as "Number", and the measures selected as both "Deaths" and "Incidence". Data were extracted for all three sex categories: both, female, and male. For each cancer type, the proportion of incidence and deaths relative to the total number of cancer incidence and deaths, respectively, was calculated to determine its percentage contribution to the overall cancer burden. The top five cancer types in terms of deaths number for both sexes and all ages in 2021 were: tracheal, bronchus, and lung cancer, stomach cancer, esophageal cancer, colon and rectum cancer, and liver cancer. All remaining cancer types with a percentage contribution of less than 5% were aggregated into a single category labeled “Other”. A proportional chart was then constructed to visualize the distribution. We further analyzed data on neoplasms for both males and females in China. From 1980 to 2021, we presented the number of deaths and the age-standardized deaths rate; from 1990 to 2021, we reported the number of incidence and the age-standardized incidence rate. Heatmaps were used to visualize the age-standardized deaths rate and age-standardized incidence rate across all cancer types, highlighting temporal trends and patterns. Additionally, for the year 2021, we stratified the number of deaths and incidence for males and females by age groups, and presented the corresponding results. Finally, we extracted data on the age-standardized incidence rate and age-standardized deaths rate for all cancer types from China, the global dataset, and regions classified by the SDI, including High-SDI, High-middle SDI, Middle SDI, Low-middle SDI, and Low SDI. Comparative analysis were performed across sex groups (both, female, and male) to assess variations in cancer burden among different regions.

For risk factor analysis, we utilized Level 1–4 risk classifications provided by the Global Burden of Disease results tool (https://vizhub.healthdata.org/gbd-results/). Specifically, we focused on the top five cancer types in terms of number of deaths for both sexes and all ages in 2021: tracheal, bronchus, and lung cancer; stomach cancer; esophageal cancer; colon and rectum cancer; and liver cancer. For each of these cancer types, we extracted and analyzed the age-standardized death rate data from 1990 to 2021, stratified by sex (both, female, and male). Ultimately, we obtained data on risk factors for each cancer type, including 5 for liver cancer, 4 for esophageal cancer, 11 for colon and rectum cancer, 2 for stomach cancer, and 16 for tracheal, bronchus, and lung cancer. These data were subsequently subjected to downstream Joinpoint regression analysis.

The Joinpoint Regression Program (Version 5.3.0, https://surveillance.cancer.gov/joinpoint/), developed by the Division of Cancer Control and Population Sciences at the U.S. National Cancer Institute, is a statistical software designed to analyze temporal trends in time series data using joinpoint models[26, 27]. This method fits a series of linear segments connected at statistically determined points, known as "joinpoints," dividing the time series into distinct intervals. For each segment, the Annual Percent Change (APC) and its 95% confidence interval (CI) are estimated to quantify the rate of change. The Average Annual Percent Change (AAPC) is then computed to summarize the overall trend, with a statistically significant increase or decrease indicated when the entire 95% CI lies above or below zero, respectively. The model with the least complexity that best fits the data is selected, and statistical significance is assessed using the Monte Carlo permutation method[26]. In this study, the maximum number of joinpoints was set to five (max_joinpoints = 5).

Decomposition analysis provides a robust framework for quantifying the relative contributions of key factors to temporal changes in cancer-related deaths and incidence[28, 29]. In this study, changes in mortality and incidence for the selected five cancer types were decomposed into three components: population aging, population growth, and epidemiological changes. This approach enables a comprehensive assessment of how each factor contributes to the dynamics of cancer burden over the study period from 1990 to 2021. By disentangling the effects of demographic shifts from changes in disease risk, this method offers critical insights into the underlying drivers of cancer trends. Such information is essential for informing targeted public health interventions, as it helps determine whether efforts should prioritize risk factor modification, demographic adaptation, or a combination of both.

Using data from the Global Burden of Disease database, this study systematically analyzed cancer-related deaths and incidence across all cancer types in China, incorporating multiple analytical methods and stratifying by sex, age groups, and a broad spectrum of risk factors. In 2021, neoplasms in mainland China accounted for 24.07% (95% UI: 22.74–25.29) of all-cause deaths—substantially higher than the global rate of 14.57% (95% UI: 13.65–15.28)—with 13.66 million (95% UI: 11.79–15.85 million) new cases and 2.82 million (95% UI: 2.35–3.36 million) deaths reported. The ASDR for neoplasms in China was 137.48 (95% UI: 115.11–163.38) per 100,000 in 2021, reflecting a marked decline from 209.52 (95% UI: 179.16–246.87) in 1980 and indicating improved cancer-related mortality over time. In 2021, tracheal, bronchus, and lung; stomach; esophageal; colorectal; and liver cancers were the top five causes of cancer deaths in mainland China, accounting for 71.08% of total cancer mortality. Furthermore, for the major cancer types, we conducted a decomposition analysis to evaluate the respective contributions of aging, population growth, and epidemiological transitions to cancer trends. By integrating data on risk factors, we assessed the impact of high-risk exposures and highlighted the substantial health burden imposed by cancer in China. Based on BAPC model projections, we also illustrated future trends and underscored the urgent need for targeted interventions to mitigate the growing cancer burden.

Sex- and age-specific cancer burdens represent critical areas of concern with important implications for the formulation of effective public health policies and population-targeted interventions[33, 34]. In light of the physiological, behavioral, and occupational differences between males and females, we conducted a detailed analysis of sex-specific cancer data, moving general trends in ASDR and ASIR. From 1990 to 2021, females consistently exhibited higher ASIR and numbers of incident cases for all neoplasms, whereas males experienced significantly higher ASDR and cancer-related mortality. Although ASIR remained relatively stable, ASDR declined markedly—by 29.78% in males and 41.83% in females—over the past four decades, with male cancer mortality being 1.8 times that of females in 2021. The top five cancer types by mortality were identical for males and the overall population, while breast cancer accounted for 8.75% of all female cancer deaths. Given the heterogeneity of cancer burden across different age groups, age-specific patterns in incidence and mortality warrant closer examination to inform age-tailored prevention and control strategies[35–37]. Mortality peaked in the 70–74 age group for both sexes, with males showing higher death counts in nearly all age categories except for those aged 95 and above. Incidence was higher among females up to the 55–59 age group, while males exhibited greater incidence from age 60–64 onward. The peak incidence occurred at ages 50–54 in females and 65–69 in males.

Over the past three decades, the rapid industrialization and urbanization in China have led to significant advancements, but also resulted in severe environmental pollution—particularly due to high emissions of PM_2.5 and sulfur dioxide—which poses a major threat to the respiratory health of the population[38–40]. Correspondingly, the ASIR of tracheal, bronchus, and lung cancers increased from 33.11 (28.47–37.79) in 1990 to 44.01 (35.45–53.35) in 2021, with an EAPC of 1.03 (0.89–1.17). The ASDR also rose from 35.64 (28.88–44.65) in 1980 to 38.98 (31.40-47.06) in 2021. In 2021, tracheal, bronchus, and lung cancers were responsible for over 800,000 deaths, accounting for 28.9% of all cancer-related fatalities. Additionally, more than 900,000 new cases were reported that year. Prolonged exposure to tobacco and other environmental risk factors has significantly exacerbated the burden of respiratory system cancers[41, 42]. In the face of this growing challenge, there is an urgent need for molecular research to better understand and address the lung cancer burden in China. Such research should consider gender-specific differences in smoking behavior, occupational exposures, genetic susceptibility, health awareness, and preventive practices. At the same time, the Chinese government must further strengthen public health campaigns and educational initiatives, coupled with stringent regulatory measures—such as implementing comprehensive smoke-free policies in public places and increasing tobacco taxation. These efforts are crucial to enhancing awareness among younger populations about the harms of smoking, ultimately reducing both smoking prevalence and secondhand smoke exposure.

Chronic infections also play a critical role in cancer risk[43, 44]. Helicobacter pylori (H. pylori) infection is recognized as a major risk factor for gastric cancer[45, 46]. Although the ASIR of stomach cancer in China declined significantly from 48.03 (40.21, 56.69) to 29.05 (22.42, 36.20), with an EAPC of -1.64 (-1.81, -1.47), and the ASDR decreased from 56.46 (46.18, 67.60) to 21.51 (16.66, 26.61), with an EAPC of -2.31 (-2.45, -2.17), the overall number of cases and mortality rates remain high. These figures underscore the persistent significance of infection-related cancer risks in China. Chronic hepatitis B virus (HBV) infection has been firmly established as a major contributor to liver cancer in China[47–49]. Furthermore, China bears a disproportionately large share of the global esophageal cancer burden[50]. Esophageal cancer, which includes esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC), is dominated by ESCC, accounting for approximately 90% of all cases in China[51, 52]. The ASIR of esophageal cancer declined from 24.8 (20.71, 28.73) to 15.04 (12.04, 18.43), with an EAPC of -1.88 (-2.09, -1.67), and the ASDR dropped by more than 50%, from 29.77 (23.77, 36.01) to 14.13 (11.36, 17.18). Despite these improvements, more than half of the new esophageal cancer cases and related deaths worldwide occur in China. This disproportionate burden is largely driven by the high prevalence of modifiable risk factors, particularly tobacco use and alcohol consumption.

With rapid economic development, significant changes have occurred in lifestyle, dietary patterns, and population aging, all of which may contribute to an increased risk of colorectal cancer[53]. The rising consumption of high-calorie, high-fat, and high-protein foods, along with a reduction in the intake of fruits, whole grains, and vegetables, has become increasingly common. In addition, behavioral risk factors such as smoking, alcohol consumption, and obesity further exacerbate this risk. This trend is reflected in the epidemiological data: ASIR of colon and rectum cancer in China increased markedly from 19.04 (16.46, 21.81) to 31.44 (25.53, 37.97), with an EAPC of 1.75 (1.64, 1.86). In contrast, the ASDR showed a slight decline, from 16.69 (12.38, 20.95) to 13.64 (11.09, 16.31), indicating a complex but concerning epidemiological shift.

In addition, comparisons with global trends and regions at different SDI levels—including High SDI, High-middle SDI, Middle SDI, Low-middle SDI, and Low SDI—can help contextualize the recent progress made by China in cancer prevention and control, as well as highlight areas that require further improvement. Regarding the overall ASIR of neoplasms, there has been no significant change in China or in most SDI regions, except for a notable increase observed in High SDI regions. Interestingly, the ASDR has demonstrated a marked decline globally, as well as in China and in the High, High-middle, and Middle SDI regions. This trend may largely be attributed to advances in medical technologies and improvements in healthcare systems.

Moreover, the socioeconomic development of China has led to profound changes in both demographic characteristics—such as population aging and growth—and cancer-related risk factors, including environmental exposures, lifestyle, and behavioral patterns[54]. Therefore, it is essential to assess the distinct contributions of these risk factors and demographic shifts to the development and incidence trends of different cancer types[19, 55–58]. The GBD 2021 analysis generated comprehensive, data-driven estimates linking 88 risk factors to 631 health outcomes across multiple demographic and geographic dimensions[20]. Given this, in addition to analyzing the disease burden of various cancer types in China, we further investigated five major cancers by incorporating data on three major categories of risk factors—behavioral, environmental/occupational, and metabolic risks—as provided by the GBD database[20]. However, due to limitations in the availability and completeness of cancer-specific risk factor data, our analysis offers only a partial interpretation based on currently accessible information. Using data from the GBD database, this study analyzed the association between risk factors and the ASDR of the five leading cancers in China from 1990 to 2021. Tracheal, bronchus, and lung cancer exhibited the highest ASDR attributable to tobacco use and air pollution. At more granular levels, smoking and ambient particulate matter pollution were identified as the predominant contributors. Although ambient particulate matter pollution-related ASDR increased significantly over time, household air pollution from solid fuels showed a marked decline. For liver and colorectal cancers, high body-mass index demonstrated the most significant upward trend, while in colorectal cancer, dietary risks, particularly low fiber intake, exhibited a consistent decline. In contrast, stomach and esophageal cancers showed no risk factors with increasing trends; their burden declined primarily due to improvements in dietary patterns, including reduced sodium intake and increased vegetable consumption. Joinpoint regression analysis further confirmed these temporal shifts, highlighting the changing risk landscape for major cancers in China and underscoring the need for targeted prevention strategies. Meanwhile, despite the declines in ASIR, ASDR, and EAPC for stomach, liver, and esophageal cancers, the absolute number of cases continues to rise. This increase is likely driven by population aging, which was identified as the most significant positive contributor to the rise in cancer-related mortality among the top five cancer types in China in 2021. Cancer-related deaths peaked in the 70–74 age group for both sexes. Decomposition analysis revealed that the shifting cancer burden in China is primarily influenced by demographic changes; however, different cancer types exhibited distinct epidemiological trends, highlighting the need for more tailored prevention and control strategies. Although population aging significantly influences cancer incidence, a large proportion of cancers remain preventable through prevention strategies, especially in low- and middle-income countries[59].

This study employed multiple analytical approaches to conduct a comprehensive investigation of cancer-related data in China from the Global Burden of Disease database; however, several aspects warrant further exploration and refinement. First, data incompleteness—particularly in risk factor categories—may introduce estimation bias for certain cancer types or risk burdens. Given the vast geographic and demographic diversity within mainland China, future analysis should aim to disaggregate data into more granular and representative subregions and populations. Second, the integration of multi-omics data—such as genomics, transcriptomics, and proteomics—would allow for a deeper understanding of the molecular mechanisms underlying cancer susceptibility among different groups, facilitating more precise insights into cancer pathogenesis. Finally, as the current dataset extends only through 2021, updated analysis incorporating more recent data are needed to capture ongoing epidemiological trends and inform timely public health interventions.

In summary, cancer ranks as the second leading cause of disease-related mortality worldwide and represents a major public health challenge in China. In 2021, neoplasms accounted for 24.07% of all-cause deaths across all age groups and both sexes in mainland China. The ASDR declined substantially from 209.52 per 100,000 in 1980 to 137.48 in 2021, while ASIR showed a slight increase from 718.73 per 100,000 in 1990 to 790.17 in 2021. The top five cancer types in terms of number of deaths for both sexes and all ages in 2021 were tracheal, bronchus, and lung cancer; stomach cancer; esophageal cancer; colon and rectum cancer; and liver cancer. As China undergoes a critical phase of socioeconomic transition, understanding the sex-specific and age-related patterns of high-risk cancers, the contribution of key risk factors, and the impact of population aging is essential for developing effective, locally adapted control strategies and targeted interventions.