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. 2022 Aug 20;400(10352):563-591.
doi: 10.1016/S0140-6736(22)01438-6.

The global burden of cancer attributable to risk factors, 2010-19: a systematic analysis for the Global Burden of Disease Study 2019

GBD 2019 Cancer Risk Factors Collaborators
Collaborators

The global burden of cancer attributable to risk factors, 2010-19: a systematic analysis for the Global Burden of Disease Study 2019

GBD 2019 Cancer Risk Factors Collaborators. Lancet. .

Abstract

Background: Understanding the magnitude of cancer burden attributable to potentially modifiable risk factors is crucial for development of effective prevention and mitigation strategies. We analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to inform cancer control planning efforts globally.

Methods: The GBD 2019 comparative risk assessment framework was used to estimate cancer burden attributable to behavioural, environmental and occupational, and metabolic risk factors. A total of 82 risk-outcome pairs were included on the basis of the World Cancer Research Fund criteria. Estimated cancer deaths and disability-adjusted life-years (DALYs) in 2019 and change in these measures between 2010 and 2019 are presented.

Findings: Globally, in 2019, the risk factors included in this analysis accounted for 4·45 million (95% uncertainty interval 4·01-4·94) deaths and 105 million (95·0-116) DALYs for both sexes combined, representing 44·4% (41·3-48·4) of all cancer deaths and 42·0% (39·1-45·6) of all DALYs. There were 2·88 million (2·60-3·18) risk-attributable cancer deaths in males (50·6% [47·8-54·1] of all male cancer deaths) and 1·58 million (1·36-1·84) risk-attributable cancer deaths in females (36·3% [32·5-41·3] of all female cancer deaths). The leading risk factors at the most detailed level globally for risk-attributable cancer deaths and DALYs in 2019 for both sexes combined were smoking, followed by alcohol use and high BMI. Risk-attributable cancer burden varied by world region and Socio-demographic Index (SDI), with smoking, unsafe sex, and alcohol use being the three leading risk factors for risk-attributable cancer DALYs in low SDI locations in 2019, whereas DALYs in high SDI locations mirrored the top three global risk factor rankings. From 2010 to 2019, global risk-attributable cancer deaths increased by 20·4% (12·6-28·4) and DALYs by 16·8% (8·8-25·0), with the greatest percentage increase in metabolic risks (34·7% [27·9-42·8] and 33·3% [25·8-42·0]).

Interpretation: The leading risk factors contributing to global cancer burden in 2019 were behavioural, whereas metabolic risk factors saw the largest increases between 2010 and 2019. Reducing exposure to these modifiable risk factors would decrease cancer mortality and DALY rates worldwide, and policies should be tailored appropriately to local cancer risk factor burden.

Funding: Bill & Melinda Gates Foundation.

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Conflict of interest statement

Declaration of interests R Ancuceanu reports consulting fees from AbbVie; payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing, or educational events from AbbVie, Sandoz, B Braun, and Laropharm; all outside the submitted work. J Conde reports grants or contracts from European Research Council Starting Grant (ERC-StG-2019-848325; funding of €1·5 million); patents planned, issued, or pending for functionalised nanoparticles and compositions for cancer treatment and methods (US application number 62/334538), and TRPV2 antagonists (US patent application 17/590,061); all outside the submitted work. S Das reports grants or contracts from a Department of Science and Technology Grant for COVID-19 research; support for attending meetings or travel through the American Society of Clinical Pathology Travel Grant (US$1500); leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid, with the American Association of Clinical Chemistry CME Committee, Personalised Division Committee, and as a HEA Committee member; all outside the submitted work. T R Driscoll reports leadership or fiduciary role in other board, society, committee, or advocacy group, unpaid, as Chair of the Occupational and Environmental Cancer Committee of Cancer Council Australia, Chair of the Australian Mesothelioma Registry Expert Advisory Group for the Australian Institute of Health and Welfare, and a member of the Research and Evaluation Committee of the Australian Safety and Eradication Agency, all outside the submitted work. H Elghazaly reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Roche, BMS, Lilly, Pfizer, AstraZeneca, Janssen, MSD, Novartis, and Sandoz, all as personal payments; payment for expert testimony from Roche as personal payments; participation on a data safety monitoring board or advisory board for Roche, BMS, Lilly, Pfizer, AstraZeneca, Janssen, MSD, Novartis, Sandoz, including personal payments; all outside the submitted work. L M Force reports support for the present manuscript from the Bill & Melinda Gates Foundation; grants or contracts from St Baldrick's Foundation, St Jude Children's Research Hospital, and National Institutes of Health (NIH) Loan Repayment Program; leadership or fiduciary role in other board, society, committee, or advocacy group, unpaid, with The Lancet Oncology International Advisory Board; all outside the submitted work. N Ghith reports their salary is covered by a grant from Novo Nordisk Foundation (NNF16OC0021856), outside the submitted work. C Herteliu reports grants from the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI (PN-III-P4-ID-PCCF-2016-0084, Oct, 2018, to Sep, 2022; and PN-III-P2-2.1-SOL-2020-2-0351, June–Oct, 2020), outside the submitted work. K Innos reports support for the present manuscript from Estonian Research Council, grant number PRG722 as payment to their institution. N E Ismail reports leadership or fiduciary role in other board, society, committee, or advocacy group, unpaid, as a Council Member for the Malaysian Academy of Pharmacy, outside the submitted work. J J Jozwiak reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Teva, Amgen, Synexus, Boehringer Ingelheim, ALAB Laboratories, Zentiva, all as personal payments outside the submitted work. M Klugar reports grants Czech-Norwegian Collaboration on Meta-Research and Critical Thinking Education in Healthcare (EHP-CZ-ICP-2-009), Evidence Implementation in Clinical Practice (2020-1-DE01-KA203-005669), Towards an International Network for Evidence-based Research in Clinical Health Research in the Czech Republic (LTC20031), and Strategic Partnership in Innovation and Development of Evidence-Based Healthcare (2019-1-CZ01-KA202-061350), all as payments to their institution; participation on a data safety monitoring board or advisory board as an unpaid member of Cochrane advisory board for Evidence Advocacy; other non-financial interest as Director of Cochrane, JBI and GRADE Centres of the Czech Republic; all outside the submitted work. K Krishan reports non-financial support from UGC Centre of Advanced Study, CAS II, Department of Anthropology, Panjab University, Chandigarh, India, outside the submitted work. J A Loureiro reports support for the present manuscript from Scientific Employment Stimulus (FCT; CEECINST/00049/2018) as support to their salary and from UIDB/00511/2020 of the LEPABE, funded by national funds through the FCT/MCTES (PIDDAC) as research support. M Mahmoudi reports other financial and non-financial interest with Academic Parity Movement, a non-profit organisation dedicated to addressing academic discrimination, violence, and incivility as co-founder and director, Partners in Global Wound Care as founding partner, and receiving royalties or honoraria for his published books, plenary lectures, and licensed patent, all outside the submitted work. A-F A Mentis reports grants or contracts from “MilkSafe: a novel pipeline to enrich formula milk using omics technologies”, a research cofinanced by the European Regional Development Fund of the European Union and Greek national funds through the Operational Program Competitiveness, Entrepreneurship and Innovation, under the call RESEARCH—CREATE—INNOVATE (project code T2EDK-02222), as well as from ELIDEK (Hellenic Foundation for Research and Innovation, MIMS-860); stock or stock options in a family winery; other financial or non-financial interests as a scientific officer with BGI group; all outside the submitted work. S Mohammed reports support for the present manuscript from the Gates Foundation; a fellowship grant from Alexander von Humboldt Foundation, outside the submitted work. N Moka reports leadership or fiduciary role in other board, society, committee, or advocacy group, unpaid, with Kentucky Society of Clinical Oncology as treasurer, outside the submitted work. S B Munro reports stock or stock options in Invitae, and other financial or non-financial interests as an employee of Invitae, a genetics testing company. O O Odukoya reports support for the present manuscript from the Fogarty International Center of the National Institutes of Health under award number K43TW010704. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. R G Pestell reports support for the present manuscript from W81XWH1810605 Breast Cancer Research Breakthrough Grant and R21 CA235139-01. NIH grant; patents issued and pending in the area of cancer diagnostics and treatment; participation on a data safety monitoring board or advisory board as a member of the VGI Health Technology Scientific Advisory Board, Chair Scientific Advisory Board for MD Anderson, and Cancer Center Breast Cancer SPORE Program; leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid, as Founder and CEO of biotechnology companies LightSeed, EcoGenome and StromaGenesis; stock or stock options in CytoDyn and VGI Health Technology; all outside the submitted work. M J Postma reports stock or stock options in Health-Ecore (25%) and Pharmacoeconomics Advice Groningen (100%) outside the submitted work. A Radfar and I Filip report other financial or non-financial interest with Avicenna Medical and Clinical Research Institute, outside the submitted work. T J Roberts reports support for attending meetings or travel from Conquer Cancer Foundation; leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid, with Biocon Biologics; all outside the submitted work. S Shrestha reports other financial or non-financial interests in the School of Pharmacy, Monash University Malaysia by receiving Graduate Research Merit Scholarship. L M L R Silva reports grants or contracts with the project code CENTRO-04-3559-FSE-000162, Fundo Social Europeu (FSE), outside the submitted work. J A Singh reports consulting fees from Crealta/Horizon, Medisys, Fidia, PK Med, Two Labs, Adept Field Solutions, Clinical Care options, Clearview healthcare partners, Putnam associates, Focus forward, Navigant consulting, Spherix, MedIQ, Jupiter Life, UBM, Trio Health, Medscape, WebMD, and Practice Point communications, and the National Institutes of Health and the American College of Rheumatology; payment or honoraria for participating in the speakers bureau for Simply Speaking; support for attending meetings or travel from the steering committee of OMERACT, to attend their meeting every 2 years; participation on a data safety monitoring board or advisory board as an unpaid member of the FDA Arthritis Advisory Committee; leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid, as a member of the steering committee of OMERACT, an international organisation that develops measures for clinical trials and receives arms length funding from 12 pharmaceutical companies, with the Veterans Affairs Rheumatology Field Advisory Committee as Chair, and with the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis as a director and editor; stock or stock options in TPT Global Tech, Vaxart pharmaceuticals, Atyu Biopharma, Adaptimmune Therapeutics, GeoVax Labs, Pieris Pharmaceuticals, Enzolytics, Series Therapeutics, Tonix Pharmaceuticals, and Charlotte's Web Holdings and previously owned stock options in Amarin, Viking, and Moderna pharmaceuticals; all outside the submitted work.

Figures

Figure 1
Figure 1
Cancer DALYs attributable to 11 Level 2 risk factors globally in 2019 (A) Absolute cancer DALYs for males. (B) Proportional cancer DALYs for males. (C) Absolute cancer DALYs for females. (D) Proportional cancer DALYs for females. Air pollution includes ambient particulate matter pollution and household air pollution from solid fuels. Other environmental risks include residential radon. Occupational risks include exposure to 13 specific carcinogens. Dietary risks include nine specific risk factors relevant to cancer. Tobacco includes smoking, chewing tobacco, and second-hand smoke. See appendix (pp 157–60) for details and definitions of each Level 2 risk factor on the y-axis. See appendix (p 161) for further details about global absolute and proportional cancer deaths attributable to Level 2 risk factors. DALYs=disability-adjusted life-years.
Figure 2
Figure 2
Global deaths from cancers attributable to risk factors in 2019 by sex and SDI Non-high SDI countries include low, low-middle, middle, and high-middle SDI countries. Cancer types are listed from left to right in order of greatest to least risk-attributable deaths. See appendix (pp 213–14, 217–18) for estimates for risk-attributable cancer deaths in high and non-high SDI locations by sex. See appendix (p 162) for further details about DALYs from cancers attributable to risk factors in 2019 by sex and SDI. For additional versions of this figure showing age-standardised mortality and DALY rates see appendix (pp 163–64). DALYs=disability-adjusted life-years. SDI=Socio-demographic Index.
Figure 3
Figure 3
Global map of age-standardised DALY rate quintiles for risk-attributable cancer burden, both sexes combined, 2019 (A) Environmental and occupational risks. (B) Behavioural risks. (C) Metabolic risks. Each map represents estimates at the national level. Quintiles are based on age-standardised DALY rates per 100 000 person-years. See appendix (pp 165–68, 234–39) for further details of risk-attributable cancer deaths and DALYs for each country and territory. DALYs=disability-adjusted life-years.
Figure 3
Figure 3
Global map of age-standardised DALY rate quintiles for risk-attributable cancer burden, both sexes combined, 2019 (A) Environmental and occupational risks. (B) Behavioural risks. (C) Metabolic risks. Each map represents estimates at the national level. Quintiles are based on age-standardised DALY rates per 100 000 person-years. See appendix (pp 165–68, 234–39) for further details of risk-attributable cancer deaths and DALYs for each country and territory. DALYs=disability-adjusted life-years.
Figure 4
Figure 4
Estimates of age-specific rates of risk-attributable cancer DALYs, SDI quintiles, both sexes combined, 2019 (A) Environmental and occupational risks. (B) Behavioural risks. (C) Metabolic risks. Rates are expressed per 100 000 person-years. See appendix (pp 146–47) for details and definitions of the SDI regions. DALYs=disability-adjusted life-years. SDI=Socio-demographic Index.
Figure 5
Figure 5
Percentage change of risk-attributable cancer DALY counts and age-standardised DALY rates for Level 1 risk factors by SDI quintile, both sexes combined, 2010–19 (A) Percentage change of risk-attributable cancer DALY counts by SDI quintile. (B) Percentage change of risk-attributable age-standardised cancer DALY rates by SDI quintile. See appendix (pp 146–47) for more information on SDI quintiles. See appendix (p172) for further information about the percentage change of risk-attributable cancer DALYs and age-standardised DALY rates for risk factors by GBD world super-region. See appendix (p 173) for percentage change of risk-attributable cancer deaths and age-standardised mortality rates by SDI quintile and GBD world super-region. DALYs=disability-adjusted life-years. GBD=Global Burden of Disease, Injuries, and Risk Factors Study. SDI=Socio-demographic Index. *95% uncertainty intervals that do not include zero.
Figure 6
Figure 6
Leading risk factors at the most detailed level for risk-attributable cancer age-standardised DALY rates globally, both sexes combined, 2010–19 Top ten risk factors for age-standardised rates of cancer DALYs and risk factors moving in or out of the top ten between 2010 and 2019 are displayed for the global level. Dashed lines indicate decrease in rank. Solid lines indicate increase or no change in rank. Data in parentheses are 95% uncertainty intervals. Risk factors at the most detailed level reflect the GBD hierarchy in which these categories of risks fall, ranging from Levels 2 to 4 (see appendix p 152 for more information on risk factor levels in the GBD hierarchy). See appendix (pp 175–80) for an expanded version of this figure, which contains the top ten risk factors for risk-attributable cancer age-standardised DALY rates in males, females, and both sexes combined globally and by SDI quintile. See appendix (pp 181–87) for further details about the top ten risk factors for risk-attributable cancer age-standardised death rates for males, females, and both sexes combined globally and by SDI quintile. DALYs=disability-adjusted life-years. GBD=Global Burden of Disease, Injuries, and Risk Factors Study. SDI=Socio-demographic Index.
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