Abstract
Background: Data about the global, regional, and country-specific variations in the levels and trends of colorectal cancer are required to understand the impact of this disease and the trends in its burden to help policy makers allocate resources. Here we provide a status report on the incidence, mortality, and disability caused by colorectal cancer in 195 countries and territories between 1990 and 2017. Methods: Vital registration, sample vital registration, verbal autopsy, and cancer registry data were used to generate incidence, death, and disability-adjusted life-year (DALY) estimates of colorectal cancer at the global, regional, and national levels. We also determined the association between development levels and colorectal cancer age-standardised DALY rates, and calculated DALYs attributable to risk factors that had evidence of causation with colorectal cancer. All of the estimates are reported as counts and age-standardised rates per 100 000 person-years, with some estimates also presented by sex and 5-year age groups. Findings: In 2017, there were 1·8 million (95% UI 1·8–1·9) incident cases of colorectal cancer globally, with an age-standardised incidence rate of 23·2 (22·7–23·7) per 100 000 person-years that increased by 9·5% (4·5–13·5) between 1990 and 2017. Globally, colorectal cancer accounted for 896 000 (876 300–915 700) deaths in 2017, with an age-standardised death rate of 11·5 (11·3–11·8) per 100 000 person-years, which decreased between 1990 and 2017 (−13·5% [–18·4 to −10·0]). Colorectal cancer was also responsible for 19·0 million (18·5–19·5) DALYs globally in 2017, with an age-standardised rate of 235·7 (229·7–242·0) DALYs per 100 000 person-years, which decreased between 1990 and 2017 (−14·5% [–20·4 to −10·3]). Slovakia, the Netherlands, and New Zealand had the highest age-standardised incidence rates in 2017. Greenland, Hungary, and Slovakia had the highest age-standardised death rates in 2017. Numbers of incident cases and deaths were higher among males than females up to the ages of 80–84 years, with the highest rates observed in the oldest age group (≥95 years) for both sexes in 2017. There was a non-linear association between the Socio-demographic Index and the Healthcare Access and Quality Index and age-standardised DALY rates. In 2017, the three largest contributors to DALYs at the global level, for both sexes, were diet low in calcium (20·5% [12·9–28·9]), alcohol use (15·2% [12·1–18·3]), and diet low in milk (14·3% [5·1–24·8]). Interpretation: There is substantial global variation in the burden of colorectal cancer. Although the overall colorectal cancer age-standardised death rate has been decreasing at the global level, the increasing age-standardised incidence rate in most countries poses a major public health challenge across the world. The results of this study could be useful for policy makers to carry out cost-effective interventions and to reduce exposure to modifiable risk factors, particularly in countries with high incidence or increasing burden. Funding: Bill & Melinda Gates Foundation.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 913-933 |
| Number of pages | 21 |
| Journal | The Lancet Gastroenterology and Hepatology |
| Volume | 4 |
| Issue number | 12 |
| DOIs | |
| State | Published - Dec 1 2019 |
ASJC Scopus subject areas
- Hepatology
- Gastroenterology
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The global, regional, and national burden of colorectal cancer and its attributable risk factors in 195 countries and territories, 1990–2017 : a systematic analysis for the Global Burden of Disease Study 2017. / GBD 2017 Colorectal Cancer Collaborators.
In: The Lancet Gastroenterology and Hepatology, Vol. 4, No. 12, 01.12.2019, p. 913-933.Research output: Contribution to journal › Article › peer-review
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TY - JOUR
T1 - The global, regional, and national burden of colorectal cancer and its attributable risk factors in 195 countries and territories, 1990–2017
T2 - a systematic analysis for the Global Burden of Disease Study 2017
AU - GBD 2017 Colorectal Cancer Collaborators
AU - Safiri, Saeid
AU - Sepanlou, Sadaf G.
AU - Ikuta, Kevin S.
AU - Bisignano, Catherine
AU - Salimzadeh, Hamideh
AU - Delavari, Alireza
AU - Ansari, Reza
AU - Roshandel, Gholamreza
AU - Merat, Shahin
AU - Fitzmaurice, Christina
AU - Force, Lisa M.
AU - Nixon, Molly R.
AU - Abbastabar, Hedayat
AU - Abegaz, Kedir Hussein
AU - Afarideh, Mohsen
AU - Ahmadi, Ayat
AU - Ahmed, Muktar Beshir
AU - Akinyemiju, Tomi
AU - Alahdab, Fares
AU - Ali, Raghib
AU - Alikhani, Mahtab
AU - Alipour, Vahid
AU - Aljunid, Syed Mohamed
AU - Almadi, Majid Abdulrahman Hamad
AU - Almasi-Hashiani, Amir
AU - Al-Raddadi, Rajaa M.
AU - Alvis-Guzman, Nelson
AU - Amini, Saeed
AU - Anber, Nahla Hamed
AU - Ansari-Moghaddam, Alireza
AU - Arabloo, Jalal
AU - Arefi, Zohreh
AU - Asghari Jafarabadi, Mohammad
AU - Azadmehr, Abbas
AU - Badawi, Alaa
AU - Baheiraei, Nafiseh
AU - Bärnighausen, Till Winfried
AU - Basaleem, Huda
AU - Behzadifar, Masoud
AU - Behzadifar, Meysam
AU - Belayneh, Yaschilal Muche
AU - Berhe, Kidanemaryam
AU - Bhattacharyya, Krittika
AU - Biadgo, Belete
AU - Bijani, Ali
AU - Biondi, Antonio
AU - Bjørge, Tone
AU - Borzì, Antonio M.
AU - Bosetti, Cristina
AU - Bou-Orm, Ibrahim R.
N1 - Funding Information: From 1990 to 2017, the age-standardised incidence rates of colorectal cancer increased globally, with substantial regional and national heterogeneity. By contrast, the age-standardised death and DALY rates decreased across the study period. On the basis of our DALY estimates, colorectal cancer is the 36th leading cause of disease burden globally for 2017, and is the fourth leading cause of cancer burden, behind only lung cancer, liver cancer, and stomach cancer. The most recent GLOBOCAN report 3 in 2018 estimated that there were 1 800 977 incident cases and 861 663 deaths from colorectal cancer, which are relatively consistent with our 2017 estimates (1 833 451 [95% UI 1 791 865–1 873 464] incident cases and 896 040 [876 279–915 720] deaths). Similar to the GLOBOCAN report, 3 we found that the highest age-standardised incidence rates in 2017 were in Australasia, high-income Asia Pacific, and high-income North America, and the highest age-standardised death rates were found in central Europe, eastern Europe, and southern Latin America. We also investigated heterogeneous trends in age-standardised incidence, death, and DALY rates from 1990 to 2017 at the national level. Most countries showed an increase in the age-standardised incidence rate of colorectal cancer during 1990–2017, such that only Australasia and high-income North America experienced a decrease in age-standardised incidence rate at the regional level. One potential explanation for this global increase in age-standardised incidence is that the introduction of screening tests might have led to increased detection and thus increased incidence, but this increase might be short-lived because of the removal of precancerous polyps during colonoscopies. 5 Similarly, in countries where screening programmes were established two or three decades ago, reductions in death rates were observed that support the benefits attributable to screening interventions. 28 Improving survival by adopting the best practices in cancer treatment and management can also lead to reduced death rates. On the basis of the data from high-income countries, several factors might have contributed to the decrease in the number of deaths due to colorectal cancer, such as enhanced access to screening colonoscopy and early stage detection, as well as improved surgical techniques, radiotherapy, chemotherapy, targeted therapy, and palliative care. 29–32 Key interventions to decrease deaths from colorectal cancer include the removal of polyps and early detection interventions, such as colonoscopy, flexible sigmoidoscopy, faecal occult blood testing, and faecal immunochemical testing. Previous research has investigated the association between a country's development level and the incidence and mortality rates of colorectal cancer, using the Human Development Index. 7 Because one of the components of the Human Development Index is health related, it is not optimal to use this index when comparing the health outcomes of countries. To avoid this problem, we used the SDI, which does not contain any health-related measures. Our analysis of the association between the SDI and age-standardised DALY rate of colorectal cancer produced results that have not been previously reported. In some regions, such as Australasia and central Europe, the age-standardised DALY rates were higher than expected from 1990 to 2017, whereas in other regions they were lower than expected, such as in central Latin America and south Asia. Several regions also fluctuated between higher and lower than expected age-standardised DALY rates during the study period. Therefore, regional trends in age-standardised rates of deaths, DALYs, and incidence should not just be considered in isolation. Instead, their observed rates should be compared with their expected rates to determine whether regions have managed colorectal cancer better or worse than expected. Additionally, dividing regions or countries into developed and undeveloped regions to evaluate the association between development and colorectal cancer burden might be an oversimplification, since the findings from this study suggest that the association is complex and non-linear in nature. Furthermore, at the national level, age-standardised DALY rates of countries on both ends of the SDI range were at higher than expected levels based on the SDI, so countries at all development levels need to enhance their prevention programmes. Our report indicates that the colorectal cancer burden attributable to risk factors is different in males and females, and this difference should be considered in national policy makers' prevention programmes. Alcohol use, smoking, and diets low in calcium, milk, and fibre had considerable attributable colorectal cancer burden in males. By contrast, dietary risks, but not alcohol use or smoking, were found to have considerable attributable burden in females. The results of this study highlight the role of certain dietary risk factors, which are responsible for a greater burden than smoking or alcohol use globally. Specifically, diet low in calcium has been previously described as a risk factor for colorectal cancer. 33 However, the large burden attributable to this dietary risk factor has not been described before at the global level. This large burden attributable to a diet low in calcium is likely due in part to the high prevalence of this risk factor. The results of our study underscore the importance of improving diet through public health interventions. A previous study showed that alcohol use is responsible for nearly 10% of global deaths in the population aged 15–49 years and will lead to remarkable health loss in the absence of appropriate policy action. 34 The same study also reported that the safest level of alcohol consumption is zero, which is in contrast to current health guidelines. 34 Decreasing population-level alcohol consumption should be considered in prevention strategies to effectively minimise the corresponding health loss. 34 Smoking is another important risk factor. The global prevalence of smoking has decreased by 28% in males and 34% in females since 1990. 18 Taxation, advertising bans, and educational programmes about smoking and its toll on health are suggested as strategies to decrease smoking prevalence more substantially. 18 Diets low in calcium, milk, and fibre should also be addressed in colorectal cancer prevention strategies along with addressing low physical activity. To improve diet, increase physical activity, and reduce smoking, the American Heart Association suggests following population-based approaches, such as media and educational campaigns; labelling and consumer information; taxation, subsidies, and other economic incentives; school and workplace approaches; local environmental changes; and direct restrictions and mandates. 35 Our findings indicate that although high body-mass index was not among the top three risk factors for attributable DALYs, it is an important risk factor that has a higher attributable percentage of DALYs due to colorectal cancer in males than in females. One study showed that the prevalence of obesity has doubled in more than 70 countries and has continuously increased in most other countries since 1980. 36 Effective prevention programmes are needed to decrease exposure to this important risk factor through appropriate strategies, such as restricting the advertisement of unhealthy foods, using taxation to reduce consumption of unhealthy foods, providing subsidies to increase intake of healthy foods, and using supply-chain incentives to increase the production of healthy foods. 37 Fasting plasma glucose can also be controlled mainly through physical activity and healthy diets. 38 This study had several limitations, including the fact that some of the variations in age-standardised incidence and mortality rates might be due to detection biases as well as changes in screening protocols. For example, the low age-standardised incidence and death rates in Iraq might be due to low detection rates. In addition, a major limitation of cancer burden research is the scarcity of data for many countries. Although different data sources, such as cancer registries, vital registration systems, and verbal autopsies, are used to produce cancer estimates, some countries do not have any of these sources available so their estimates are based on predictive covariates or trends from neighbouring countries. Moreover, estimates for the most recent years are usually based on past trends and covariates because there is a lag in data availability. As GBD is an iterative study, additional data sources for different locations will be added in future rounds and make the estimates more data driven, particularly in data-sparse locations. This study found large country and regional variations in the burden of colorectal cancer in 2017. Whereas age-standardised incidence rates increased in most countries and territories over the measurement period, age-standardised death rates decreased at the global level, and in particular in high SDI countries, possibly due to fast improvement in diagnostics and interventions in these countries. Further research is required to expand our knowledge of additional factors associated with colorectal cancer incidence and to improve early detection and treatment of this disease, especially in developing countries. Clearly, colorectal cancer remains a substantial public health challenge across the globe. The results of GBD 2017 can be valuable for policy makers to implement cost-effective interventions and address modifiable risk factors and for researchers to design and carry out further research on proper modalities for prevention, early detection, and treatment of colorectal cancer. GBD 2017 Colorectal Cancer Collaborators Saeid Safiri, Sadaf G Sepanlou, Kevin S Ikuta, Catherine Bisignano, Hamideh Salimzadeh, Alireza Delavari, Reza Ansari, Gholamreza Roshandel, Shahin Merat, Christina Fitzmaurice, Lisa M Force, Molly R Nixon, Hedayat Abbastabar, Kedir Hussein Abegaz, Mohsen Afarideh, Ayat Ahmadi, Muktar Beshir Ahmed, Tomi Akinyemiju, Fares Alahdab, Raghib Ali, Mahtab Alikhani, Vahid Alipour, Syed Mohamed Aljunid, Majid Abdulrahman Hamad Almadi, Amir Almasi-Hashiani, Rajaa M Al-Raddadi, Nelson Alvis-Guzman, Saeed Amini, Nahla Hamed Anber, Alireza Ansari-Moghaddam, Jalal Arabloo, Zohreh Arefi, Mohammad Asghari Jafarabadi, Abbas Azadmehr, Alaa Badawi, Nafiseh Baheiraei, Till Winfried Bärnighausen, Huda Basaleem, Masoud Behzadifar, Meysam Behzadifar, Yaschilal Muche Belayneh, Kidanemaryam Berhe, Krittika Bhattacharyya, Belete Biadgo, Ali Bijani, Antonio Biondi, Tone Bjørge, Antonio M Borzì, Cristina Bosetti, Ibrahim R Bou-Orm, Hermann Brenner, Andrey Nikolaevich Briko, Nikolay Ivanovich Briko, Giulia Carreras, Félix Carvalho, Carlos A Castañeda-Orjuela, Ester Cerin, Peggy Pei-Chia Chiang, Onyema Greg Chido-Amajuoyi, Ahmad Daryani, Dragos Virgil Davitoiu, Alireza Delavari, Gebre Teklemariam Demoz, Rupak Desai, Mostafa Dianati Nasab, Aziz Eftekhari, Iman El Sayed, Iffat Elbarazi, Mohammad Hassan Emamian, Aman Yesuf Endries, Firooz Esmaeilzadeh, Alireza Esteghamati, Arash Etemadi, Farshad Farzadfar, Eduarda Fernandes, João C Fernandes, Irina Filip, Florian Fischer, Masoud Foroutan, Mohamed M Gad, Silvano Gallus, Fatemeh Ghaseni-Kebria, Ahmad Ghashghaee, Giuseppe Gorini, Nima Hafezi-Nejad, Arvin Haj-Mirzaian, Arya Haj-Mirzaian, Susan Hasanpour-Heidari, Amir Hasanzadeh, Soheil Hassanipour, Simon I Hay, Chi Linh Hoang, Mihaela Hostiuc, Mowafa Househ, Olayinka Stephen Ilesanmi, Milena D Ilic, Kaire Innos, Seyed Sina Naghibi Irvani, Farhad Islami, Anelisa Jaca, Nader Jafari Balalami, Nastaran Jafari Delouei, Morteza Jafarinia, Mohammad Ali Jahani, Mihajlo Jakovljevic, Spencer L James, Mehdi Javanbakht, Ensiyeh Jenabi, Ravi Prakash Jha, Farahnaz Joukar, Amir Kasaeian, Tesfaye Dessale Kassa, Mesfin Wudu Kassaw, Andre Pascal Kengne, Yousef Saleh Khader, Mojtaba Khaksarian, Rovshan Khalilov, Ejaz Ahmad Khan, Maryam Khayamzadeh, Maryam Khazaee-Pool, Salman Khazaei, Fatemeh Khosravi Shadmani, Jagdish Khubchandani, Daniel Kim, Adnan Kisa, Sezer Kisa, Jonathan M Kocarnik, Hamidreza Komaki, Jacek A Kopec, Ai Koyanagi, Ernst J Kuipers, Vivek Kumar, Carlo La Vecchia, Faris Hasan Lami, Alan D Lopez, Platon D Lopukhov, Raimundas Lunevicius, Azeem Majeed, Maryam Majidinia, Amir Manafi, Navid Manafi, Ana-Laura Manda, Fariborz Mansour-Ghanaei, Lorenzo Giovanni Mantovani, Dhruv Mehta, Toni Meier, Hagazi Gebre Meles, Walter Mendoza, Tomislav Mestrovic, Bartosz Miazgowski, Tomasz Miazgowski, Seyed Mostafa Mir, Hamed Mirzaei, Karzan Abdulmuhsin Mohammad, Naser Mohammad Gholi Mezerji, Abdollah Mohammadian-Hafshejani, Milad Mohammadoo-Khorasani, Shafiu Mohammed, Farnam Mohebi, Ali H Mokdad, Lorenzo Monasta, Maryam Moossavi, Ghobad Moradi, Farhad Moradpour, Rahmatollah Moradzadeh, Azin Nahvijou, Gurudatta Naik, Farid Najafi, Javad Nazari, Ionut Negoi, Serban Negru, Cuong Tat Nguyen, Trang Huyen Nguyen, Dina Nur Anggraini Ningrum, Felix Akpojene Ogbo, Andrew T Olagunju, Tinuke O Olagunju, Adrian Pana, David M Pereira, Majid Pirestani, Akram Pourshams, Hossein Poustchi, Mostafa Qorbani, Mohammad Rabiee, Navid Rabiee, Amir Radfar, Marveh Rahmati, Fatemeh Rajati, Samira Raoofi, David Laith Rawaf, Salman Rawaf, Robert C Reiner Jr, Andre M N Renzaho, Nima Rezaei, Aziz Rezapour, Anas M Saad, Seyedmohammad Saadatagah, Basema Saddik, Farkhonde Salehi, Saleh Salehi Zahabi, Inbal Salz, Abdallah M Samy, Juan Sanabria, Milena M Santric Milicevic, Arash Sarveazad, Maheswar Satpathy, Ione J C Schneider, Mario Sekerija, Faramarz Shaahmadi, Hosein Shabaninejad, Morteza Shamsizadeh, Zeinab Sharafi, Mehdi Sharif, Amrollah Sharifi, Sara Sheikhbahaei, Reza Shirkoohi, Sudeep K Siddappa Malleshappa, Diego Augusto Santos Silva, Mekonnen Sisay, Catalin-Gabriel Smarandache, Moslem Soofi, Kjetil Soreide, Sergey Soshnikov, Vladimir I Starodubov, Rafael Tabarés-Seisdedos, Mark Sullman, Amir Taherkhani, Berhe Etsay Tesfay, Roman Topor-Madry, Eugenio Traini, Bach Xuan Tran, Khanh Bao Tran, Irfan Ullah, Olalekan A Uthman, Marco Vacante, Amir Vahedian-Azimi, Alessandro Valli, Elena Varavikova, Isidora S Vujcic, Ronny Westerman, Vahid Yazdi-Feyzabadi, Engida Yisma, Chuanhua Yu, Vesna Zadnik, Telma Zahirian Moghadam, Leila Zaki, Hamed Zandian, Zhi-Jiang Zhang, Christopher J L Murray, Mohsen Naghavi*, and Reza Malekzadeh*. *These authors jointly supervised the study. Affiliations Aging Research Institute (S Safiri PhD), Department of Community Medicine (S Safiri PhD), Department of Pharmacology and Toxicology (A Eftekhari PhD), Department of Biostatistics and Epidemiology (Prof M Asghari Jafarabadi PhD), Tabriz University of Medical Sciences, Tabriz, Iran; Cancer Biology Research Center (M Rahmati PhD, R Shirkoohi PhD), Cancer Research Center (A Nahvijou PhD), Cancer Research Institute (R Shirkoohi PhD), Department of Cardiology (S Saadatagah MD), Department of Health Promotion and Education (Z Arefi PhD), Department of Microbiology (A Hasanzadeh PhD), Department of Pharmacology (Arv Haj-Mirzaian MD, Ary Haj-Mirzaian MD), Digestive Diseases Research Institute (S G Sepanlou MD, H Salimzadeh PhD, Prof A Delavari MD, R Ansari MD, G Roshandel PhD, Prof S Merat MD, Prof A Pourshams MD, H Poustchi PhD, Prof R Malekzadeh MD), Endocrinology and Metabolism Research Center (M Afarideh MD, Prof A Esteghamati MD, S Sheikhbahaei MD), Hematologic Malignancies Research Center (A Kasaeian PhD), Hematology-Oncology and Stem Cell Transplantation Research Center (A Kasaeian PhD), Iran National Institute of Health Research (F Mohebi MD), Iranian Center of Neurological Research (H Abbastabar PhD), Knowledge Utilization Research Center (A Ahmadi PhD), Non-communicable Diseases Research Center (F Farzadfar MD, F Mohebi MD), Research Center for Immunodeficiencies (Prof N Rezaei PhD), Department of Internal Medicine (Prof A Delavari MD), School of Medicine (N Hafezi-Nejad MD), Tehran University of Medical Sciences, Tehran, Iran (A Etemadi PhD); Department of Epidemiology (M Dianati Nasab MSc), Non-communicable Diseases Research Center (S G Sepanlou MD, Prof R Malekzadeh MD), Shiraz University of Medical Sciences, Shiraz, Iran; Department of Health Metrics Sciences, School of Medicine (Prof S I Hay FMedSci, Prof A H Mokdad PhD, R C Reiner Jr PhD, Prof C J L Murray DPhil, Prof M Naghavi PhD), Division of Allergy and Infectious Diseases (K S Ikuta MD), Division of Hematology (C Fitzmaurice MD), Institute for Health Metrics and Evaluation (K S Ikuta MD, C Bisignano MPH, C Fitzmaurice MD, L M Force MD, M R Nixon PhD, Prof S I Hay FMedSci, S L James MD, J M Kocarnik PhD, Prof A D Lopez PhD, Prof A H Mokdad PhD, R C Reiner Jr PhD, Prof C J L Murray DPhil, Prof M Naghavi PhD), University of Washington, Seattle, WA, USA; Golestan Research Center of Gastroenterology and Hepatology (G Roshandel PhD, F Ghaseni-Kebria MSc, S Hasanpour-Heidari MSc, N Jafari Delouei MSc, A Sharifi PhD), Golestan University of Medical Sciences, Gorgan, Iran (S Mir MSc); Department of Oncology (L M Force MD), Department of Global Pediatric Medicine (L M Force MD), St Jude Children's Research Hospital, Memphis, TN, USA; Biostatistics and Health Informatics Department (K H Abegaz MPH), Madda Walabu University, Bale Robe, Oromia, Ethiopia; Radiotherapy Center (K H Abegaz MPH), School of Allied Health Sciences (E Yisma MPH), Addis Ababa University, Addis Ababa, Ethiopia (G T Demoz MPharm); Department of Epidemiology (M B Ahmed MPH), Jimma University, Jimma, Oromia, Ethiopia; Department of Population Health Sciences (T Akinyemiju PhD), Duke Global Health Institute (T Akinyemiju PhD), Duke University, Durham, North Carolina, USA; Evidence Based Practice Center (F Alahdab MD), Mayo Clinic Foundation for Medical Education and Research, Rochester, MN, USA; Public Health Research Center (R Ali MPH), New York University Abu Dhabi, Abu Dhabi, United Arab Emirates; Nuffield Department of Population Health (R Ali MPH), University of Oxford, Oxford, UK; Colorectal Research Center (A Sarveazad PhD), Department of Health Policy (H Shabaninejad PhD), Department of Health Services Management (M Alikhani PhD, A Ghashghaee BSc, S Raoofi MSc), Health Economics Department (V Alipour PhD), Health Management and Economics Research Center (V Alipour PhD, J Arabloo PhD, A Rezapour PhD, T Zahirian Moghadam PhD), Ophthalmology Department (N Manafi MD), Iran University of Medical Sciences, Tehran, Iran; Department of Health Policy and Management (Prof S M Aljunid PhD), Kuwait University, Safat, Kuwait City, Kuwait; International Centre for Casemix and Clinical Coding (Prof S M Aljunid PhD), National University of Malaysia, Bandar Tun Razak, Malaysia; College of Medicine (M A H Almadi FRCPC), King Saud University, Riyadh, Central, Saudi Arabia; Division of Gastroenterology & Hepatology (M A H Almadi FRCPC), McGill University, Montreal, QC, Canada; Department of Epidemiology (A Almasi-Hashiani PhD, R Moradzadeh PhD), Department of Pediatrics (J Nazari PhD), Health Services Management Department (S Amini PhD), Arak University of Medical Sciences, Arak, Iran; Department of Family and Community Medicine (Prof R M Al-Raddadi PhD), King Abdulaziz University, Jeddah, Saudi Arabia; Research Group in Health Economics (Prof N Alvis-Guzman PhD), University of Cartagena, Cartagena, Colombia; Research Group in Hospital Management and Health Policies (Prof N Alvis-Guzman PhD), University of the Coast, Barranquilla, Colombia; Faculty of Medicine (N H Anber PhD), Mansoura University, Mansoura, Egypt (N H Anber PhD); Department of Epidemiology and Biostatistics (Prof A Ansari-Moghaddam PhD), Health Promotion Research Center, Zahedan, Iran; Department of Biostatistics and Epidemiology (Prof M Asghari Jafarabadi PhD), Zanjan University of Medical Sciences, Zanjan, Iran; Cellular and Molecular Biology Research Center (A Azadmehr PhD), Clinical Biochemistry (S Mir MSc), Faculty of Medicine (M Jahani PhD), Social Determinants of Health Research Center (A Bijani PhD), Babol University of Medical Sciences, Babol, Iran; Public Health Risk Sciences Division (A Badawi PhD), Public Health Agency of Canada, Toronto, ON, Canada; Department of Nutritional Sciences (A Badawi PhD), University of Toronto, Toronto, ON, Canada; Department of Clinical Biochemistry (M Mohammadoo-Khorasani PhD), Department of Parasitology and Entomology (M Pirestani PhD, L Zaki PhD), Tissue Engineering and Applied Cell Sciences Division (N Baheiraei PhD), Tarbiat Modares University, Tehran, Iran; Division of Diseases (N Baheiraei PhD), Advanced Technologies Research Group, Tehran, Iran; Heidelberg Institute of Global Health (HIGH) (Prof T W Bärnighausen MD), Institute of Public Health (S Mohammed PhD), Heidelberg University, Heidelberg, Germany; Department of Medicine Brigham and Women's Hospital (V Kumar MD), T.H. Chan School of Public Health (Prof T W Bärnighausen MD), Harvard University, Boston, MA, USA; University of Aden, Aden, Yemen (H Basaleem PhD); Department of Physiology (M Khaksarian PhD), Hepatitis Research Center (Me Behzadifar MS), Razi Herbal Medicines Research Center (Z Sharafi PhD), Social Determinants of Health Research Center (Ma Behzadifar PhD), Lorestan University of Medical Sciences, Khorramabad, Iran; Department of Pharmacy (Y M Belayneh MSc), Wollo University, Dessie, Ethiopia; Clinical Pharmacy Unit (T D Kassa MSc), Department of Nutrition and Dietetics (K Berhe MPH), Mekelle University, Mekelle, Ethiopia (H G Meles MPH); Department of Statistical and Computational Genomics (K Bhattacharyya MSc), National Institute of Biomedical Genomics, Kalyani, West Bengal, India; Department of Statistics (K Bhattacharyya MSc), University of Calcutta, Kolkata, India; Department of Clinical Chemistry (B Biadgo MSc), University of Gondar, Gondar, Ethiopia; Department of Clinical and Molecular Biomedicine (MEDBIO) (A M Borzì MD), Department of General Surgery and Medical-Surgical Specialties (Prof A Biondi PhD, M Vacante PhD, A Valli PhD), University of Catania, Catania, Italy; Department of Clinical Medicine (Prof K Soreide PhD), Department of Global Public Health and Primary Care (Prof T Bjørge PhD), University of Bergen, Bergen, Norway; Cancer Registry of Norway, Oslo, Norway (Prof T Bjørge PhD); Department of Environmental Health Science (S Gallus DSc), Department of Oncology (C Bosetti PhD), Mario Negri Institute for Pharmacological Research, Milan, Italy; Ministry of Public Health, Beirut, Lebanon (I R Bou-Orm MD); Division of Clinical Epidemiology and Aging Research (Prof H Brenner MD), German Cancer Research Center, Heidelberg, Germany; Biomedical Technologies (A N Briko MSc), Bauman Moscow State Technical University, Moscow, Russia; Department of Epidemiology and Evidence-Based Medicine (P D Lopukhov Cand of Sci [Med]), Epidemiology and Evidence Based Medicine (Prof N I Briko DSc), I.M. Sechenov First Moscow State Medical University, Moscow, Russia; Institute for Cancer Research, Prevention and Clinical Network, Florence, Italy (G Carreras PhD); Applied Molecular Biosciences Unit (Prof F Carvalho PhD), Institute of Public Health (Prof F Carvalho PhD), REQUIMTE/LAQV (Prof E Fernandes PhD, Prof D M Pereira PhD), University of Porto, Porto, Portugal; Colombian National Health Observatory (C A Castañeda-Orjuela MD), National Institute of Health, Bogota, Colombia; Epidemiology and Public Health Evaluation Group (C A Castañeda-Orjuela MD), National University of Colombia, Bogota, Colombia; Mary MacKillop Institute for Health Research (Prof E Cerin PhD), Australian Catholic University, Melbourne, VIC, Australia; School of Public Health (Prof E Cerin PhD), University of Hong Kong, Hong Kong, China; Clinical Governance (P P Chiang PhD), Gold Coast Health, Gold Coast, QLD, Australia; Department of Epidemiology, Human Genetics, and Environmental Sciences (O G Chido-Amajuoyi MD), University of Texas, Houston, Texas, USA; Department of Public Health (M Khazaee-Pool PhD), Toxoplasmosis Research Center (Prof A Daryani PhD), Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran; Department of General Surgery (D V Davitoiu PhD, M Hostiuc PhD), Emergency Hospital of Bucharest (I Negoi PhD), General Surgery Department (I Negoi PhD), Surgery 2nd Department-SUUB (C Smarandache MD), Carol Davila University of Medicine and Pharmacy, Bucharest, 2nd sector, Romania; Department of Surgery (D V Davitoiu PhD), Clinical Emergency Hospital Sf. Pantelimon, Bucharest, Romania; School of Pharmacy (G T Demoz MPharm), Aksum University, Aksum, Ethiopia; Division of Cardiology (R Desai MBBS), Atlanta Veterans Affairs Medical Center, Decatur, Georgia, USA; Department of Microbiology (A Hasanzadeh PhD), Pharmacology and Toxicology Department (A Eftekhari PhD), Maragheh University of Medical Sciences, Maragheh, Iran (F Esmaeilzadeh PhD); Biomedical Informatics and Medical Statistics (I El Sayed PhD), Alexandria University, Alexandria, Egypt; Institute of Public Health (I Elbarazi DrPH), United Arab Emirates University, Al Ain, United Arab Emirates; Ophthalmic Epidemiology Research Center (M Emamian PhD), Shahroud University of Medical Sciences, Shahroud, Semnan, Iran; Public Health Department (A Y Endries MPH), Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia; Division of Cancer Epidemiology and Genetics (A Etemadi PhD), National Cancer Institute, Bethesda, MD, USA; Center for Biotechnology and Fine Chemistry (J C Fernandes PhD), Catholic University of Portugal, Porto, Portugal; Psychiatry Department (I Filip MD), Kaiser Permanente, Fontana, CA, USA; College of Graduate Health Sciences (A Radfar MD), Department of Health Sciences (I Filip MD), A.T. Still University, Mesa, AZ, USA; Department of Public Health Medicine (F Fischer PhD), Bielefeld University, Bielefeld, Germany; Abadan School of Medical Sciences, Abadan, Iran (M Foroutan PhD); Department of Cardiovascular Medicine (M M Gad MD), Cleveland Clinic, Cleveland, OH, USA; Gillings School of Global Public Health (M M Gad MD), University of North Carolina Chapel Hill, Chapel Hill, NC, USA; Occupational and Environmental Epidemiology Section (G Gorini MD), Cancer Prevention and Research Institute, Florence, Italy; Department of Radiology (N Hafezi-Nejad MD, A Haj-Mirzaian MD), Department of Radiology and Radiological Sciences (S Sheikhbahaei MD), Johns Hopkins University, Baltimore, MD, USA; Cancer Research Center (M Khayamzadeh MD), Obesity Research Center (A Haj-Mirzaian MD), Research Institute for Endocrine Sciences (S N Irvani MD), Shahid Beheshti University of Medical Sciences, Tehran, Iran; Gastrointestinal and Liver Disease Research Center (S Hassanipour PhD, F Joukar PhD, Prof F Mansour-Ghanaei PhD), Guilan University of Medical Sciences, Rasht, Guilan, Iran (S Hassanipour PhD); Center of Excellence in Behavioral Medicine (C L Hoang BMedSc, T H Nguyen BMedSc), Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam; Department of Internal Medicine (M Hostiuc PhD), Surgery 2nd Department (C Smarandache MD), Bucharest Emergency Hospital, Bucharest, Romania; Division of Information and Computing Technology (Prof M Househ PhD), Hamad Bin Khalifa University, Doha, Qatar; Qatar Foundation for Education, Science, and Community Development, Doha, Qatar (Prof M Househ PhD); Department of Community Medicine (O S Ilesanmi PhD), University of Ibadan, Ibadan, Nigeria; Department of Epidemiology (Prof M D Ilic PhD), Department of Global Health, Economics, and Policy (Prof M Jakovljevic PhD), University of Kragujevac, Kragujevac, Serbia; Department of Epidemiology and Biostatistics (K Innos PhD), National Institute for Health Development, Tallinn, Estonia; Surveillance and Health Services Research (F Islami PhD), American Cancer Society, Atlanta, GA, USA; Cochrane South Africa (A Jaca PhD), Non-communicable Diseases Research Unit (Prof A P Kengne PhD), Medical Research Council South Africa, Cape Town, Western Cape, South Africa; Centre for Evidence Based Health Care (A Jaca PhD), Stellenbosch University, Cape Town, Western Cape, South Africa; Department of Psychosis (N Jafari Balalami PhD), Babol Nushirvani University of Technology, Babol, Iran; Clinical Medicine and Community Health (Prof C La Vecchia MD), Department of Immunology (M Jafarinia MSc), A.C.S. Medical College and Hospital, Isfahan, Iran; Newcastle University, Tyne, UK (M Javanbakht PhD); Autism Spectrum Disorders Research Center (E Jenabi PhD), Chronic Diseases (Home Care) Research Center (M Shamsizadeh MSc), Department of Biostatistics (N Mohammad Gholi Mezerji MSc), Department of Epidemiology (S Khazaei PhD), Neurophysiology Research Center (H Komaki MD), Research Center for Molecular Medicine (A Taherkhani PhD), Hamadan University of Medical Sciences, Hamadan, Iran; Department of Community Medicine (R P Jha MSc), Banaras Hindu University, Varanasi, Uttar Pradesh, India; Department of Nursing (M W Kassaw MSc), Woldia University, Woldia, Amhara, Ethiopia; Amhara Public Health Institute, Bair Dar, Amhara, Ethiopia (M W Kassaw MSc); Department of Medicine (Prof A P Kengne PhD), University of Cape Town, Cape Town, Western Cape, South Africa; Department of Public Health and Community Medicine (Prof Y S Khader PhD), Jordan University of Science and Technology, Ramtha, Irbid, Jordan; Department of Physiology (R Khalilov PhD), Baku State University, Baku, Azerbaijan; Epidemiology and Biostatistics Department (E A Khan MPH), Health Services Academy, Islamabad, Islamabad Capital Territory, Pakistan; Department of Community and Family Medicine (F H Lami PhD), Academy of Medical Science, Tehran, Iran (M Khayamzadeh MD); Department of Epidemiology & Biostatistics (F Khosravi Shadmani PhD, Prof F Najafi PhD), Department of Health Education & Promotion (F Rajati PhD), Radiology and Nuclear Medicine (S Salehi Zahabi PhD), Social Development and Health Promotion Research Center (M Soofi PhD), Taleghani Hospital (F Salehi MA), Kermanshah University of Medical Sciences, Kermanshah, Iran; Department of Nutrition and Health Science (Prof J Khubchandani PhD), Ball State University, Muncie, IN, USA; Department of Health Sciences (Prof D Kim DrPH), Northeastern University, Boston, Massachusetts, USA; Department of Health Management and Health Economics (Prof A Kisa PhD), Kristiania University College, Oslo, Norway; Department of Health Services Policy and Management (Prof A Kisa PhD), University of South Carolina, Columbia, SC, USA; Department of Nursing and Health Promotion (S Kisa PhD), Oslo Metropolitan University, Oslo, Norway; Public Health Sciences Division (J M Kocarnik PhD), Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Brain Engineering Research Center (H Komaki MD), Institute for Research in Fundamental Sciences, Tehran, Iran; University of British Columbia, Vancouver, BC, Canada (J A Kopec PhD); Arthritis Research Canada, Richmond, BC, Canada (J A Kopec PhD); CIBERSAM (A Koyanagi MD), San Juan de Dios Sanitary Park, Sant Boi de Llobregat, Barcelona, Spain; Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain (A Koyanagi MD); Department of Gastroenterology and Hepatology (Prof E J Kuipers MD), Erasmus University Medical Center, Rotterdam, Netherlands; University of Melbourne, Melbourne, QLD, Australia (Prof A D Lopez PhD); General Surgery Department (R Lunevicius PhD), Aintree University Hospital National Health Service (NHS) Foundation Trust, Liverpool, Merseyside, UK; Surgery Department (R Lunevicius PhD), University of Liverpool, Liverpool, Merseyside, UK; Department of Primary Care and Public Health (Prof A Majeed MD, Prof S Rawaf MD), WHO Collaborating Centre for Public Health Education and Training (D L Rawaf MD), Imperial College London, London, England, UK; Solid Tumor Research Center (M Majidinia PhD), Urmia University of Medical Science, Urmia, Iran; Department of Surgery (A Manafi MD), University of Virginia, Charlottesville, Virginia, USA; Ophthalmology Department (N Manafi MD), University of Manitoba, Winnipeg, Manitoba, Canada; Surgery Department (A Manda MD), Emergency University Hospital Bucharest, Bucharest, 5th sector, Romania; School of Medicine and Surgery (Prof L G Mantovani DSc), University of Milan Bicocca, Monza, MB, Italy; Division of Gastroenterology and Hepatobiliary Disease (D Mehta MD), New York Medical College, Valhalla, New York, USA; Institute for Agricultural and Nutritional Sciences (T Meier PhD), Martin Luther University Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany; Innovation Office (T Meier PhD), Competence Cluster for Nutrition and Cardiovascular Health (nutriCARD), Halle, Sachsen-Anhalt, Germany; Peru Country Office (W Mendoza MD), United Nations Population Fund (UNFPA), Lima, Lima, Peru; Clinical Microbiology and Parasitology Unit (T Mestrovic PhD), Dr. Zora Profozic Polyclinic, Zagreb, Croatia; University Centre Varazdin (T Mestrovic PhD), University North, Varazdin, Croatia; Center for Innovation in Medical Education (B Miazgowski MD), Department of Propedeutics of Internal Diseases & Arterial Hypertension (Prof T Miazgowski MD), Pomeranian Medical University, Szczecin, Zachodniopomorskie, Poland (B Miazgowski MD); Research Center for Biochemistry and Nutrition in Metabolic Diseases (H Mirzaei PhD), Kashan University of Medical Sciences, Kashan, Isfahan, Iran; Department of Biology (K A Mohammad PhD), Salahaddin University, Erbil, Iraq; ISHIK University, Erbil, Iraq (K A Mohammad PhD); Department of Epidemiology and Biostatistics (A Mohammadian-Hafshejani PhD), Shahrekord University of Medical Sciences, Shahrekord, Iran; Health Systems and Policy Research Unit (S Mohammed PhD), Ahmadu Bello University, Zaria, Nigeria; Clinical Epidemiology and Public Health Research Unit (L Monasta DSc, E Traini MSc), Burlo Garofolo Institute for Maternal and Child Health, Trieste, Italy; Department of Molecular Medicine (M Moossavi PhD), Birjand University of Medical Sciences, Birjand, Iran; Department of Epidemiology and Biostatistics (G Moradi PhD), Social Determinants of Health Research Center (G Moradi PhD, F Moradpour PhD), Kurdistan University of Medical Sciences, Sanandaj, Kurdistan, Iran; Department of Epidemiology (G Naik MPH), University of Alabama at Birmingham, Birmingham, AL, USA; Iranian Ministry of Health and Medical Education, Tehran, Iran (J Nazari PhD); Department of Oncology (S Negru MD), University of Medicine and Pharmacy, Timisoara, Romania; Institute for Global Health Innovations (C T Nguyen MPH), Duy Tan University, Hanoi, Vietnam; Public Health Science Department (D N A Ningrum MPH), State University of Semarang, Kota Semarang, Indonesia; Graduate Institute of Biomedical Informatics (D N A Ningrum MPH), Taipei Medical University, Taipei City, Taiwan; School of Social Sciences and Psychology (Prof A M N Renzaho PhD), Translational Health Research Institute (F A Ogbo PhD), Western Sydney University, Penrith, NSW, Australia; Department of Pathology and Molecular Medicine (T O Olagunju MD), Department of Psychiatry and Behavioural Neurosciences (A T Olagunju MD), McMaster University, Hamilton, ON, Canada; Department of Psychiatry (A T Olagunju MD), University of Lagos, Lagos, Nigeria; Department of Statistics and Econometrics (A Pana MD), Bucharest University of Economic Studies, Bucharest, Romania; Center for Health Outcomes & Evaluation, Bucharest, Romania (A Pana MD); Cartagena University, Cartagena, Colombia (Prof D M Pereira PhD); Department of Health Promotion and Education (F Shaahmadi PhD), Non-communicable Diseases Research Center (M Qorbani PhD), Alborz University of Medical Sciences, Karaj, Alborz, Iran; Biomedical Engineering Department (Prof M Rabiee PhD), Amirkabir University of Technology, Tehran, Iran; Department of Chemistry (N Rabiee PhD), Sharif University of Technology, Tehran, Iran; Medichem, Barcelona, Spain (A Radfar MD); University College London Hospitals, London, UK (D L Rawaf MD); Academic Public Health (Prof S Rawaf MD), Public Health England, London, UK; Network of Immunity in Infection, Malignancy, and Autoimmunity (NIIMA) (Prof N Rezaei PhD), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Department of Entomology (A M Samy PhD), Faculty of Medicine (A M Saad MBBCh), Ain Shams University, Cairo, Egypt; Medical Department (B Saddik PhD), University of Sharjah, Sharjah, United Arab Emirates; Research Deputy (S Salehi Zahabi PhD), Taleghani Hospital, Kermanshah, Iran; Health and Disability Intelligence Group (I Salz MD), Ministry of Health, Wellington, New Zealand; Department of Surgery (Prof J Sanabria MD), Marshall University, Huntington, WV, USA; Department of Nutrition and Preventive Medicine (Prof J Sanabria MD), Case Western Reserve University, Cleveland, OH, USA; Centre School of Public Health and Health Management (Prof M M Santric Milicevic PhD), Faculty of Medicine Institute of Epidemiology (I S Vujcic PhD), University of Belgrade, Belgrade, Serbia; UGC Centre of Advanced Study in Psychology (M Satpathy PhD), Utkal University, Bhubaneswar, India; Udyam-Global Association for Sustainable Development, Bhubaneswar, Odisha, India (M Satpathy PhD); School of Health Sciences (Prof I J C Schneider PhD, Prof D A S Silva PhD), Federal University of Santa Catarina, Ararangua, Brazil; Department of Medical Statistics, Epidemiology and Medical Informatics (M Sekerija PhD), University of Zagreb, Zagreb, Croatia; Division of Epidemiology and Prevention of Chronic Non-communicable Diseases (M Sekerija PhD), Croatian Institute of Public Health, Zagreb, Croatia; Department of Basic Sciences (Prof M Sharif PhD), Department of Laboratory Sciences (Prof M Sharif PhD), Islamic Azad University, Sari, Iran; Department of Hematology-Oncology (S K Siddappa Malleshappa MD), Baystate Medical Center, Springfield, MA, USA; School of Pharmacy (M Sisay MSc), Haramaya University, Harar, Ethiopia; Department of Gastrointestinal Surgery (Prof K Soreide PhD), Stavanger University Hospital, Stavanger, Rogaland, Norway; Research Development (S Soshnikov PhD), Central Research Institute of Cytology and Genetics (E Varavikova PhD), Federal Research Institute for Health Organization and Informatics of the Ministry of Health (FRIHOI), Moscow, Russia (Prof V I Starodubov DSc); Department of Social Sciences (Prof M Sullman PhD), University of Nicosia, Nicosia, Cyprus; Department of Medicine (Prof R Tabarés-Seisdedos PhD), University of Valencia, Valencia, Spain; Carlos III Health Institute (Prof R Tabarés-Seisdedos PhD), Biomedical Research Networking Center for Mental Health Network (CiberSAM), Madrid, Spain; Department of Public Health (B E Tesfay MPH), Adigrat University, Adigrat, Ethiopia; Faculty of Health Sciences (R Topor-Madry PhD), Jagiellonian University Medical College, Krakow, Poland; The Agency for Health Technology Assessment and Tariff System, Warsaw, Poland (R Topor-Madry PhD); Department of Health Economics (B X Tran PhD), Hanoi Medical University, Hanoi, Vietnam; Molecular Medicine and Pathology (K B Tran MD), University of Auckland, Auckland, New Zealand; Clinical Hematology and Toxicology (K B Tran MD), Military Medical University, Hanoi, Vietnam; Gomal Center of Biochemistry and Biotechnology (I Ullah PhD), Gomal University, Dera Ismail Khan, Pakistan; TB Culture Laboratory (I Ullah PhD), Mufti Mehmood Memorial Teaching Hospital, Dera Ismail Khan, Pakistan; Division of Health Sciences (O A Uthman PhD), University of Warwick, Coventry, UK; Baqiyatallah University of Medical Sciences, Tehran, Iran (A Vahedian-Azimi PhD); Competence Center of Mortality-Follow-Up, German National Cohort (R Westerman DSc), Federal Institute for Population Research, Wiesbaden, Hesse, Germany; Department of Health Management, Policy and Economics (V Yazdi-Feyzabadi PhD), Health Services Management Research Center (V Yazdi-Feyzabadi PhD), Kerman University of Medical Sciences, Kerman, Iran; Department of Epidemiology and Biostatistics (Prof C Yu PhD), Department of Preventive Medicine (Z Zhang PhD), Global Health Institute (Prof C Yu PhD), Wuhan University, Wuhan, Hubei Province, China; Epidemiology and Cancer Registry Sector (Prof V Zadnik PhD), Institute of Oncology Ljubljana, Ljubljana, Slovenia; and Department of Community Medicine (H Zandian PhD), Social Determinants of Health Research Center (T Zahirian Moghadam PhD, H Zandian PhD), Ardabil University of Medical Science, Ardabil, Iran. Contributors SS, SGS, HS, GR, CF, MN, and CJLM prepared the first draft. RM, AD, RA, SM, CF, MN, and CJLM provided overall guidance. RM, SGS, SS, CF, MN, and CJLM managed the project. SGS, SS, HS, and CF analysed data. RM, SGS, SS, SM, HS, CF, MN, and CJLM finalised the manuscript on the basis of comments from other authors and reviewer feedback. All other authors provided data, developed models, reviewed results, provided guidance on methods, or reviewed and contributed to the manuscript. Declaration of interests SLJ reports grants from Sanofi Pasteur, outside the submitted work. All other authors declare no competing interests. Acknowledgments This study was funded by the Bill & Melinda Gates Foundation. AB is supported by the Public Health Agency of Canada . TB was supported by the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award, funded by the German Federal Ministry of Education and Research . AMS was supported by a fellowship from the Egyptian Fulbright Mission Program . FC and EF acknowledge support from UID/MULTI/04378/2019 and UID/QUI/50006/2019 with funding from Fundação para a Ciência e a Tecnologia/Ministério da Ciência, Tecnologia e Ensino Superior through Portuguese national funds. TM acknowledges institutional support from the Competence Cluster for Nutrition and Cardiovascular Health (nutriCARD), Jena-Halle-Leipzig (Germany). WM is Program Analyst Population and Development at the UN Population Fund-UNFPA Country Office in Peru, which does not necessarily endorse this study. MJ's contribution to this GBD study was co-financed by the Serbian Ministry of Education Science and Technological Development through grant OI 175 014. MSM acknowledges the support from the Serbian Ministry of Education, Science and Technological Development (contract number 175087). SA acknowledges International Centre for Casemix and Clinical Coding, Faculty of Medicine, National University of Malaysia, and Department of Health Policy and Management, Faculty of Public Health, Kuwait University, for the approval and support to participate in this research project. Editorial note: The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.
PY - 2019/12/1
Y1 - 2019/12/1
N2 - Background: Data about the global, regional, and country-specific variations in the levels and trends of colorectal cancer are required to understand the impact of this disease and the trends in its burden to help policy makers allocate resources. Here we provide a status report on the incidence, mortality, and disability caused by colorectal cancer in 195 countries and territories between 1990 and 2017. Methods: Vital registration, sample vital registration, verbal autopsy, and cancer registry data were used to generate incidence, death, and disability-adjusted life-year (DALY) estimates of colorectal cancer at the global, regional, and national levels. We also determined the association between development levels and colorectal cancer age-standardised DALY rates, and calculated DALYs attributable to risk factors that had evidence of causation with colorectal cancer. All of the estimates are reported as counts and age-standardised rates per 100 000 person-years, with some estimates also presented by sex and 5-year age groups. Findings: In 2017, there were 1·8 million (95% UI 1·8–1·9) incident cases of colorectal cancer globally, with an age-standardised incidence rate of 23·2 (22·7–23·7) per 100 000 person-years that increased by 9·5% (4·5–13·5) between 1990 and 2017. Globally, colorectal cancer accounted for 896 000 (876 300–915 700) deaths in 2017, with an age-standardised death rate of 11·5 (11·3–11·8) per 100 000 person-years, which decreased between 1990 and 2017 (−13·5% [–18·4 to −10·0]). Colorectal cancer was also responsible for 19·0 million (18·5–19·5) DALYs globally in 2017, with an age-standardised rate of 235·7 (229·7–242·0) DALYs per 100 000 person-years, which decreased between 1990 and 2017 (−14·5% [–20·4 to −10·3]). Slovakia, the Netherlands, and New Zealand had the highest age-standardised incidence rates in 2017. Greenland, Hungary, and Slovakia had the highest age-standardised death rates in 2017. Numbers of incident cases and deaths were higher among males than females up to the ages of 80–84 years, with the highest rates observed in the oldest age group (≥95 years) for both sexes in 2017. There was a non-linear association between the Socio-demographic Index and the Healthcare Access and Quality Index and age-standardised DALY rates. In 2017, the three largest contributors to DALYs at the global level, for both sexes, were diet low in calcium (20·5% [12·9–28·9]), alcohol use (15·2% [12·1–18·3]), and diet low in milk (14·3% [5·1–24·8]). Interpretation: There is substantial global variation in the burden of colorectal cancer. Although the overall colorectal cancer age-standardised death rate has been decreasing at the global level, the increasing age-standardised incidence rate in most countries poses a major public health challenge across the world. The results of this study could be useful for policy makers to carry out cost-effective interventions and to reduce exposure to modifiable risk factors, particularly in countries with high incidence or increasing burden. Funding: Bill & Melinda Gates Foundation.
AB - Background: Data about the global, regional, and country-specific variations in the levels and trends of colorectal cancer are required to understand the impact of this disease and the trends in its burden to help policy makers allocate resources. Here we provide a status report on the incidence, mortality, and disability caused by colorectal cancer in 195 countries and territories between 1990 and 2017. Methods: Vital registration, sample vital registration, verbal autopsy, and cancer registry data were used to generate incidence, death, and disability-adjusted life-year (DALY) estimates of colorectal cancer at the global, regional, and national levels. We also determined the association between development levels and colorectal cancer age-standardised DALY rates, and calculated DALYs attributable to risk factors that had evidence of causation with colorectal cancer. All of the estimates are reported as counts and age-standardised rates per 100 000 person-years, with some estimates also presented by sex and 5-year age groups. Findings: In 2017, there were 1·8 million (95% UI 1·8–1·9) incident cases of colorectal cancer globally, with an age-standardised incidence rate of 23·2 (22·7–23·7) per 100 000 person-years that increased by 9·5% (4·5–13·5) between 1990 and 2017. Globally, colorectal cancer accounted for 896 000 (876 300–915 700) deaths in 2017, with an age-standardised death rate of 11·5 (11·3–11·8) per 100 000 person-years, which decreased between 1990 and 2017 (−13·5% [–18·4 to −10·0]). Colorectal cancer was also responsible for 19·0 million (18·5–19·5) DALYs globally in 2017, with an age-standardised rate of 235·7 (229·7–242·0) DALYs per 100 000 person-years, which decreased between 1990 and 2017 (−14·5% [–20·4 to −10·3]). Slovakia, the Netherlands, and New Zealand had the highest age-standardised incidence rates in 2017. Greenland, Hungary, and Slovakia had the highest age-standardised death rates in 2017. Numbers of incident cases and deaths were higher among males than females up to the ages of 80–84 years, with the highest rates observed in the oldest age group (≥95 years) for both sexes in 2017. There was a non-linear association between the Socio-demographic Index and the Healthcare Access and Quality Index and age-standardised DALY rates. In 2017, the three largest contributors to DALYs at the global level, for both sexes, were diet low in calcium (20·5% [12·9–28·9]), alcohol use (15·2% [12·1–18·3]), and diet low in milk (14·3% [5·1–24·8]). Interpretation: There is substantial global variation in the burden of colorectal cancer. Although the overall colorectal cancer age-standardised death rate has been decreasing at the global level, the increasing age-standardised incidence rate in most countries poses a major public health challenge across the world. The results of this study could be useful for policy makers to carry out cost-effective interventions and to reduce exposure to modifiable risk factors, particularly in countries with high incidence or increasing burden. Funding: Bill & Melinda Gates Foundation.
UR - http://www.scopus.com/inward/record.url?scp=85074240207&partnerID=8YFLogxK
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U2 - 10.1016/S2468-1253(19)30345-0
DO - 10.1016/S2468-1253(19)30345-0
M3 - Article
C2 - 31648977
AN - SCOPUS:85074240207
VL - 4
SP - 913
EP - 933
JO - The Lancet Gastroenterology and Hepatology
JF - The Lancet Gastroenterology and Hepatology
SN - 2468-1253
IS - 12
ER -