Summary
Background
Prevention, control, and treatment of respiratory tract cancers are important steps towards achieving target 3.4 of the UN Sustainable Development Goals (SDGs)—a one-third reduction in premature mortality due to non-communicable diseases by 2030. We aimed to provide global, regional, and national estimates of the burden of tracheal, bronchus, and lung cancer and larynx cancer and their attributable risks from 1990 to 2019.
Methods
Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 methodology, we evaluated the incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life-years (DALYs) of respiratory tract cancers (ie, tracheal, bronchus, and lung cancer and larynx cancer). Deaths from tracheal, bronchus, and lung cancer and larynx cancer attributable to each risk factor were estimated on the basis of risk exposure, relative risks, and the theoretical minimum risk exposure level input from 204 countries and territories, stratified by sex and Socio-demographic Index (SDI). Trends were estimated from 1990 to 2019, with an emphasis on the 2010–19 period.
Findings
Globally, there were 2·26 million (95{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} uncertainty interval 2·07 to 2·45) new cases of tracheal, bronchus, and lung cancer, and 2·04 million (1·88 to 2·19) deaths and 45·9 million (42·3 to 49·3) DALYs due to tracheal, bronchus, and lung cancer in 2019. There were 209 000 (194 000 to 225 000) new cases of larynx cancer, and 123 000 (115 000 to 133 000) deaths and 3·26 million (3·03 to 3·51) DALYs due to larynx cancer globally in 2019. From 2010 to 2019, the number of new tracheal, bronchus, and lung cancer cases increased by 23·3{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} (12·9 to 33·6) globally and the number of larynx cancer cases increased by 24·7{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} (16·0 to 34·1) globally. Global age-standardised incidence rates of tracheal, bronchus, and lung cancer decreased by 7·4{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} (−16·8 to 1·6) and age-standardised incidence rates of larynx cancer decreased by 3·0{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} (−10·5 to 5·0) in males over the past decade; however, during the same period, age-standardised incidence rates in females increased by 0·9{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} (−8·2 to 10·2) for tracheal, bronchus, and lung cancer and decreased by 0·5{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} (−8·4 to 8·1) for larynx cancer. Furthermore, although age-standardised incidence and death rates declined in both sexes combined from 2010 to 2019 at the global level for tracheal, bronchus, lung and larynx cancers, some locations had rising rates, particularly those on the lower end of the SDI range. Smoking contributed to an estimated 64·2{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} (61·9–66·4) of all deaths from tracheal, bronchus, and lung cancer and 63·4{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} (56·3–69·3) of all deaths from larynx cancer in 2019. For males and for both sexes combined, smoking was the leading specific risk factor for age-standardised deaths from tracheal, bronchus, and lung cancer per 100 000 in all SDI quintiles and GBD regions in 2019. However, among females, household air pollution from solid fuels was the leading specific risk factor in the low SDI quintile and in three GBD regions (central, eastern, and western sub-Saharan Africa) in 2019.
Interpretation
The numbers of incident cases and deaths from tracheal, bronchus, and lung cancer and larynx cancer increased globally during the past decade. Even more concerning, age-standardised incidence and death rates due to tracheal, bronchus, lung cancer and larynx cancer increased in some populations—namely, in the lower SDI quintiles and among females. Preventive measures such as smoking control interventions, air quality management programmes focused on major air pollution sources, and widespread access to clean energy should be prioritised in these settings.
Funding
Bill & Melinda Gates Foundation.
Introduction
Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
Larynx cancer is a less common but lethal cancer of the respiratory tract that shares some similar risk factors with tracheal, bronchus, and lung cancer.
- Steuer CE
- El-Deiry M
- Parks JR
- Higgins KA
- Saba NF
Members of the UN committed to a one-third reduction in premature mortality due to non-communicable diseases by 2030 as target 3.4 of the UN Sustainable Development Goals (SDGs).
Transforming our world: the 2030 agenda for sustainable development.
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Goal 3: ensure health lives and promote well-being for all at all ages.
To realise this goal, the 17th World Health Assembly did a comprehensive review and assessment of the progress achieved in the prevention and control of cancers worldwide.
Global action plan for the prevention and control of NCDs 2013–2020.
Prevention, control, and treatment of respiratory tract cancers, which include both tracheal, bronchus, and lung cancer and larynx cancer, are important steps towards achieving this SDG target.
Evidence before this study
Available datasets, registries, and the scientific literature were searched for information about tracheal, bronchus, lung, and larynx cancer, without any language restrictions. A 2019 report by the Global Burden of Disease Cancer Collaboration based on estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 showed that, despite decreasing age-standardised death rates, tracheal, bronchus, and lung cancer was still the leading cause of death due to cancer worldwide. The Global Cancer Incidence, Mortality and Prevalence (GLOBOCAN) project provides estimates about lung cancer mortality, but without identifying the attributable risk factors or showing the trend of estimates from past to present. The UN committed to a one-third reduction in premature mortality due to non-communicable diseases by 2030 as part of the UN Sustainable Development Goals (SDGs). Reducing mortality from tracheal, bronchus, and lung cancer would help countries to meet this SDG target by 2030. Considerable efforts have been made to decrease mortality rates of tracheal, bronchus, and lung cancer, including through expansion of smoking control programmes around the world, enactment and enforcement of air pollution regulations (although efforts have been limited in low-income and middle-income countries), implementation of low-dose CT screening strategies in certain countries for high-risk patients, and improvement of available therapies for patients with identifiable lesions.
Added value of this study
As part of GBD 2019, this study expands on the estimation of the incidence, mortality, and disability from respiratory tract cancers and their attributable risk factors in GBD 2019. This study provides estimates of the burden of respiratory tract cancers and attributable risk factors from 1990 to 2019, with an emphasis on trends from 2010 to 2019, in 204 countries and territories, and by socio-demographic status. It identifies the top risk factors associated with mortality from tracheal, bronchus, and lung cancer and larynx cancer in different populations worldwide and highlights disparate trends in the incidence of and mortality from tracheal, bronchus, and lung cancer and larynx cancer over the past decade. The findings from this study could encourage policy makers to identify populations with a disproportionately large burden of respiratory tract cancer and implement targeted strategies to reduce the risk and burden of this disease.
Implications of all the available evidence
Although the age-standardised death and incidence rates of tracheal, bronchus, and lung cancer and larynx cancer for both sexes combined decreased globally over the past decade, rates trended upwards for some populations, particularly females in certain countries lower on the Socio-demographic Index (SDI). This changing trend is important for researchers and policy makers to understand how comparative risk assessment, prevention, and cancer surveillance can be prioritised in low SDI countries. Smoking is still the single most important risk factor for mortality from larynx cancer and tracheal, bronchus, and lung cancer worldwide. However, the contribution of household air pollution from solid fuels to mortality from tracheal, bronchus, and lung cancer was even higher than that of smoking among females in many low SDI countries. Preventive measures, including smoking control programmes and clean energy for cooking and heating, should be prioritised in these settings to reduce the incidence of and mortality from larynx cancer and tracheal, bronchus, and lung cancer. The high SDI quintile had the highest age-standardised incidence rate of tracheal, bronchus, and lung cancer in 2019, but the fastest rate of decline over the past decade, so these countries should continue preventive measures and further optimise them to maintain their declines. In high SDI countries, screening in high-risk populations and early targeted treatment might help further decrease mortality from larynx cancer and tracheal, bronchus, and lung cancer. Our results on the relative contribution of various risk factors to tracheal, bronchus, and lung cancer mortality are not only helpful to guide risk reduction measures but also important to identify high-risk populations that might benefit from intensified strategies for prevention and treatment.
Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
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- Malvezzi M
- Bosetti C
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- et al.
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- Zuo J-J
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- et al.
Environmental exposures, including air pollution and occupational carcinogens, are other important risk factors for respiratory tract cancers that can also be reduced by appropriate regulations.
Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
Alcohol consumption is another risk factor for larynx cancer.
- Cao Y
- Willett WC
- Rimm EB
- Stampfer MJ
- Giovannucci EL
So far, considerable efforts have been made to decrease the incidence of and mortality from larynx cancer and tracheal, bronchus, and lung cancer in high-income countries through smoking control programmes.
- Malvezzi M
- Bosetti C
- Rosso T
- et al.
,
- Meza R
- Meernik C
- Jeon J
- Cote ML
The relative contribution of each risk factor to mortality from respiratory tract cancers varies by sex and geographical area, with different behavioural, environmental, and occupational exposures, and different methods might be required to effectively address these risk factors.
To develop a clear understanding of the policy importance of the incidence and mortality of larynx cancer and tracheal, bronchus, and lung cancer, it is important to identify populations at high risk by geographical location. By analysing data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we aimed to describe the burden of respiratory tract cancers (ie, tracheal, bronchus, and lung cancer and larynx cancer) and attributable risk factors, by sex and Socio-demographic Index (SDI), in 204 countries and territories from 1990 to 2019. We aimed to provide an overview of the current burden of tracheal, bronchus, and lung cancer and larynx cancer globally and regionally, as well as progress to reduce mortality and incidence over the past decade. We also aimed to shed light on risk factors for respiratory tract cancer so that policy makers can make informed decisions about the potential benefits of risk reduction policies, particularly in populations with high exposure to these risk factors.
Methods
Overview
Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
,
- Fitzmaurice C
- Akinyemiju TF
- Al Lami FH
- et al.
as well as in appendix 1 (pp 10–24). Here, we briefly review the methods for estimating the burden of respiratory tract cancers—tracheal, bronchus, and lung cancer and larynx cancer—and their attributable risk factors.
Estimation of mortality, incidence, and DALYs
- Fitzmaurice C
- Akinyemiju TF
- Al Lami FH
- et al.
,
- Foreman KJ
- Lozano R
- Lopez AD
- Murray CJ
Additionally, to ensure that all single-cause mortality estimates matched the separately modelled all-cause mortality estimates, CoDCorrect was used to scale single-cause mortality estimates to all-cause mortality estimates.
Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
The incidence of each cancer was calculated by dividing the cause-specific mortality estimates by the MIRs.
Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
Disability-adjusted life-years (DALYs) were calculated by summing the YLDs and YLLs.
Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
Risk factor estimation
Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
,
,
To model the attributable burden associated with a specific risk factor, four metrics were assessed: the metric of burden under study (deaths, YLDs, YLLs, or DALYs), the exposure level for the risk, the relative risk of outcomes caused by the exposure, and the counterfactual level of the risk factor exposure. For instance, in order to estimate the DALYs for tracheal, bronchus, and lung cancer attributable to a specific risk, these DALYs were multiplied by the population attributable fraction (PAF)—the proportion by which the DALYs would be decreased in a specific year if the exposure to a risk factor in the past was equal to the TMREL—for the tracheal, bronchus, and lung cancer risk–outcome pair for a given sex, age, year, and location.
Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
Specific risk factors associated with each cause were selected in accordance with the World Cancer Research Fund grades of convincing or probable evidence, and include smoking; secondhand smoke; ambient particulate matter pollution; household air pollution from solid fuels; diets low in fruits; high fasting plasma glucose; residential radon exposure; and occupational exposure to asbestos, arsenic, beryllium, cadmium, chromium, diesel engine exhaust, nickel, polycyclic aromatic hydrocarbons, and silica for tracheal, bronchus, and lung cancer; and smoking, alcohol use, and occupational exposure to asbestos and sulphuric acid for larynx cancer. The definition and input data for each exposure are summarised in appendix 1 (pp 32–34). Details about the modelling strategy and TMREL for each exposure are summarised in appendix 1 of the report by the GBD 2019 Risk Factors Collaborators.
Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019.
All rates are reported per 100 000 population in a given year, and point estimates are presented with 95{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} uncertainty intervals (UIs). 95{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} UIs were estimated by generating 1000 draws in each computational step, and taking the 25th and 975th ordered values of the draws. Moreover, the SDI, an index that incorporates total fertility rate in women younger than 25 years, lag-distributed income per capita, and average years of education, and ranges from 0 to 100,
Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019.
was used to categorise the 204 GBD countries and territories into quintiles. GBD locations are also aggregated into 21 regions and seven super-regions.
Role of the funding source
The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.
Results
Burden of tracheal, bronchus, and lung cancer
Table 1Trends in the number of incident cases and age-standardised incidence rates from 2010 to 2019 globally and by SDI quintiles, by sex and for both sexes combined, for tracheal, bronchus, and lung cancer and larynx cancer
Data in parentheses are 95{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} uncertainty intervals. SDI=Socio-demographic Index.
Figure 1Trends in age-standardised rates of tracheal, bronchus, and lung cancer, 1990–2019
Deaths for males, females, and both sexes combined; disability-adjusted life-years (DALYs) for males, females, and both sexes combined; and incidence for males, females, and both sexes combined are shown. SDI=Socio-demographic Index.
Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
There were 2·04 million (95{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} UI 1·88 to 2·19) deaths attributable to tracheal, bronchus, and lung cancer in 2019: 1·39 million (1·26 to 1·51) deaths in males and 657 000 (590 000 to 719 000) deaths in females (table 2). The age-standardised death rate due to tracheal, bronchus, and lung cancer was 25·2 (23·2 to 27·0) per 100 000 in both sexes combined in 2019, 37·4 (34·1 to 40·7) per 100 000 in males and 15·0 (13·5 to 16·4) per 100 000 in females. The age-standardised death rate of tracheal, bronchus, and lung cancer declined by 5·7{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} (−12·6 to 1·5) globally from 2010 to 2019.
Table 2DALYs and deaths in 2019 (counts and age-standardised rates) and trends from 2010 to 2019, globally and by SDI quintiles, by sex and for both sexes combined, for tracheal, bronchus, and lung cancer and larynx cancer
Data in parentheses are 95{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} uncertainty intervals. DALY=disability-adjusted life-year. SDI=Socio-demographic Index.
Burden of larynx cancer
Mortality from tracheal, bronchus, and lung cancer and larynx cancer attributable to leading risk factors
Figure 2Proportion of deaths attributable to leading specific risk factors, by sex and SDI quintile, 2019, for tracheal, bronchus, and lung cancer (A) and larynx cancer (B)
Leading four specific risks for attributable deaths are shown for females and males. SDI=Socio-demographic Index. The error bars indicate 95{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} uncertainty intervals.
Figure 3Annualised rate of change in the age-standardised death rate of tracheal, bronchus, and lung cancer attributable to smoking, 2010–19
Overall, between 2010 and 2019, the greatest decline in age-standardised death rates attributable to smoking was seen in the high SDI quintile, with a decrease of 12·9{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} (95{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} UI 11·0–14·9) in both sexes combined. Smoking-attributable age-standardised deaths from tracheal, bronchus, and lung cancer decreased among males in all GBD regions, except for central sub-Saharan Africa, between 2010 and 2019. However, during the same period, an increase in smoking-attributable age-standardised deaths from tracheal, bronchus, and lung cancer was observed among females in 11 of 21 GBD regions, most prominently in eastern Europe, central sub-Saharan Africa, south Asia, north Africa and the Middle East, and eastern sub-Saharan Africa.
Figure 4Ranked contribution of risk factors to the age-standardised death rate of tracheal, bronchus, and lung cancer by region, 2019, for both sexes combined, females, and males
Risk factors are ranked from 1 (leading risk factor for age-standardised death; dark red) to 16 (lowest risk factor for age-standardised death; dark blue).
Figure 4Ranked contribution of risk factors to the age-standardised death rate of tracheal, bronchus, and lung cancer by region, 2019, for both sexes combined, females, and males
Risk factors are ranked from 1 (leading risk factor for age-standardised death; dark red) to 16 (lowest risk factor for age-standardised death; dark blue).
Discussion
Overview
Globally, the total number of incident cases of, and deaths and DALYs due to, tracheal, bronchus, and lung cancer and larynx cancer for both sexes combined increased over the past decade, while age-standardised rates steadily decreased. Despite considerable progress on decreasing these rates at the global level, concerning trends were observed in certain populations and geographical regions. While age-standardised incidence and death rates for tracheal, bronchus, and lung cancer decreased globally in males from 2010 to 2019, they increased among females globally over the same period, albeit more slowly than over the previous two decades. Moreover, increases in tracheal, bronchus, and lung cancer incidence and death rates were observed in the low SDI and low-middle SDI quintiles for both sexes combined, with even larger increases among females in these SDI quintiles.
- Henschke CI
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however, less information is available about their potential use or challenges associated with their implementation in lower SDI settings.
Reducing burden of tracheal, bronchus, and lung cancer and larynx cancer through risk factor mitigation
- Levy DT
- Chaloupka F
- Gitchell J
,
- Bertollini R
- Ribeiro S
- Mauer-Stender K
- Galea G
The MPOWER policy package by the Tobacco Free Initiative has succeeded in expanding evidence-based tobacco control measures to almost two-thirds of the global population as of July, 2019.
WHO report on the global tobacco epidemic, 2019. Offer help to quit tobacco use. July 25, 2019.
The MPOWER tobacco control package includes monitoring tobacco use and preventive measures, warning about tobacco use, enforcing bans on advertising tobacco, and raising taxes on tobacco.
WHO report on the global tobacco epidemic, 2019. Offer help to quit tobacco use. July 25, 2019.
- Mamtani R
- Cheema S
- Sheikh J
- Al Mulla A
- Lowenfels A
- Maisonneuve P
More research might be necessary to assess the barriers to effective smoking control programmes in locations where death rates for tracheal, bronchus, and lung cancer due to smoking are on the rise.
- Lopez AD
- Collishaw NE
- Piha T
,
- Thun M
- Peto R
- Boreham J
- Lopez AD
Based on this model, an increase in the prevalence of female smoking tends to occur decades later than male smoking, so there is a considerable lag time before the cumulative effects of smoking on health outcomes are observed in females.
- Thun M
- Peto R
- Boreham J
- Lopez AD
Secondhand smoke also contributed to an increasing attributable age-standardised death rate of tracheal, bronchus, and lung in females in countries lower on the SDI range. Genetic and hormonal factors are also thought to potentially play a role in residual deaths from lung cancer in females, but research on this subject is still very scarce.
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IARC monographs on the evaluation of carcinogenic risks to humans, volume 105: Diesel and gasoline engine exhausts and some nitroarenes.
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IARC monographs on the evaluation of carcinogenic risks to humans, volume 109. Outdoor air pollution.
Researchers found that each 10 μg/m3 increase in criteria air pollutants (ie, carbon monoxide, ground-level ozone, lead, nitrogen dioxide, particulate matter, and sulphur dioxide) increased lung cancer mortality by up to 27{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} in the USA (for PM2·5 concentrations over a 26-year period)
- Turner MC
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- Pope 3rd, CA
- Chen Y
- Gapstur SM
- Thun MJ
and by up to 30{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} in the Netherlands (for PM10 concentrations over a 7-year period).
- Fischer PH
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- et al.
As of 2016, approximately 92{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} of the world’s population was living in areas not meeting WHO air quality criteria,
Ambient air pollution: a global assessment of exposure and burden of disease.
again demonstrating the considerable potential to reduce the global burden of tracheal, bronchus, and lung cancer through risk factor mitigation, in this case through improved air quality.
- Isen A
- Rossin-Slater M
- Walker WR
As a likely consequence of this risk reduction, the age-standardised death rate of tracheal, bronchus, and lung cancer attributable to ambient particulate matter pollution declined by 68·0{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} (95{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} UI 22·8–85·3) in the USA from 1990 to 2019, one of the largest reductions in the world.
Our findings demonstrate that, despite considerable progress in reducing the age-standardised death rate of tracheal, bronchus, and lung cancer attributable to ambient particulate matter pollution in high SDI countries over the past decade, age-standardised rates remained unchanged globally. This was due to a rise of more than 35{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} in the age-standardised death rate of tracheal, bronchus, and lung cancer attributable to ambient particulate matter pollution in low SDI and low-middle SDI quintiles between 2010 and 2019. In these settings, reducing exposure to ambient particulate matter pollutants will be crucial to reducing the risk of tracheal, bronchus, and lung cancer in the future.
IARC monographs on the evaluation of carcinogenic risks to humans, volume 95. Household use of solid fuels and high-temperature frying.
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In many low SDI countries, the adoption and sustainable use of clean fuels (ie, gas and electricity) have been limited due to high costs.
- Batchelor S
- Brown E
- Scott N
- Leary J
Solid fuels with incomplete combustion produce more air pollutants and can cause both indoor and outdoor air pollution when used for cooking purposes.
How air pollution is destroying our health.
The Clean Cooking Alliance is one example of an initiative to expand access to clean, affordable, and modern energy for cooking.
- Batchelor S
- Brown E
- Scott N
- Leary J
Expanding access to cleaner energy and other efforts to reduce air pollution require investments in the energy sector and are of particular importance in regions such as sub-Saharan Africa, where about half of the population does not have access to electricity.
- Batchelor S
- Brown E
- Scott N
- Leary J
- Soeberg M
- Vallance DA
- Keena V
- Takahashi K
- Leigh J
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- Wu HY-J
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A study of a cohort of textile workers showed that up to 24{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} of deaths were preventable by following US Occupational Safety and Health Administration standards.
- Cole SR
- Richardson DB
- Chu H
- Naimi AI
In the high SDI quintile, the age-standardised death rate of tracheal, bronchus, and lung cancer attributable to asbestos was nearly 15 times higher than in the low SDI quintile, reflective of industrialisation and cumulative occupational exposures that occurred decades ago. It is essential that countries in low SDI regions also ban the use of products that contain asbestos and other occupational carcinogens as these countries continue to industrialise, to minimise the burden of tracheal, bronchus, and lung cancer due to these risk factors in the future.
- Singh R
- Vivek JM
- Rao B
- Asolekar SR
Reducing burden of tracheal, bronchus, and lung cancer through health-system strengthening and advances in treatment options
Global action plan for the prevention and control of NCDs 2013–2020.
Over the past decade, many higher SDI countries succeeded in reducing the age-standardised death rate of tracheal, bronchus, and lung cancer by more than 10{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641}, primarily through effective preventive measures (risk exposure reduction) and, to a lesser extent, advances in treatment options. In high SDI European countries, China, and the USA, advances in treatment, including molecular agents and immunotherapies recently approved by the US Food and Drug Administration, as well as potential new cytotoxic agents, emerging molecularly targeted agents, and novel immunotherapeutic strategies for treating tracheal, bronchus, and lung cancer have opened up an avenue to improve survival outcomes of patients with larynx cancer and tracheal, bronchus, and lung cancer in the near future.
- Shum E
- Wang F
- Kim S
- Perez-Soler R
- Cheng H
Such advances in the treatment of tracheal, bronchus, and lung cancer and larynx cancer could reduce the disease burden of these cancers in upcoming years as these treatments become more widely available, at least in locations that have the financial capacity to consider their implementation. To reduce the burden of tracheal, bronchus, and lung cancer through better treatment options beyond high SDI countries, however, effective therapies will need to be made accessible at much lower costs. Many lower SDI countries will not have the resources to support new, elaborate, and intensive cancer treatments, as many do not have the health-system capacity to provide widespread access to current treatment options such as surgery, chemotherapy, genetic analysis, and targeted medications. Although risk reduction remains the best option for reducing the burden of tracheal, bronchus, and lung cancer and larynx cancer in most populations, lower SDI countries should also be considering opportunities for more broad health-system strengthening, which could further help to reduce the burden of these and other non-communicable diseases.
Reducing tracheal, bronchus, and lung cancer burden through screening and subsequent early treatment
- Henschke CI
- Yankelevitz DF
- Libby DM
- Pasmantier MW
- Smith JP
- Miettinen OS
,
- Greenwood-Lee J
- Jewett L
- Woodhouse L
- Marshall DA
,
- Lyratzopoulos G
- Vedsted P
- Singh H
There is currently no screening protocol for larynx cancer, but lung cancer screening (specifically, low-dose CT) was recently shown to be a cost-effective approach for high-risk populations in the USA
- Black WC
- Gareen IF
- Soneji SS
- et al.
and is under assessment in Europe.
- Oudkerk M
- Devaraj A
- Vliegenthart R
- et al.
,
- Pedersen JH
- Rzyman W
- Veronesi G
- et al.
Lung cancer screening could improve the survival of patients with lung cancer by identifying patients at early stages.
- Henschke CI
- Yankelevitz DF
- Libby DM
- Pasmantier MW
- Smith JP
- Miettinen OS
The National Lung Screening Trial (NLST) in the USA found that the implementation of annual low-dose CT resulted in a 20{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} reduction in lung cancer mortality in people at high risk of developing lung cancer.
- Henschke CI
- Yankelevitz DF
- Libby DM
- Pasmantier MW
- Smith JP
- Miettinen OS
,
- Black WC
- Gareen IF
- Soneji SS
- et al.
,
- Aberle DR
- Adams AM
- Berg CD
- et al.
Based on the available evidence, the US Preventive Services Task Force now recommends annual lung cancer screening with low-dose CT for people in the USA aged 55–80 years who have at least a 30-pack-year history of smoking, currently smoke, or have quit smoking within the past 15 years.
In addition to low-dose CT, a signature of non-coding mRNAs, DNA methylation, and somatic mutations that can be detected from peripheral blood are under investigation to detect tracheal, bronchus, and lung cancers at early stages.
- Kovalchik SA
- Tammemagi M
- Berg CD
- et al.
,
- Sozzi G
- Boeri M
- Rossi M
- et al.
- Kovalchik SA
- Tammemagi M
- Berg CD
- et al.
This is particularly true for populations at the highest risk of death from tracheal, bronchus, and lung cancer, since lung cancer screening is most cost-effective when the risk of premature death is highest.
- Kovalchik SA
- Tammemagi M
- Berg CD
- et al.
Despite progress on tracheal, bronchus, and lung cancer screening research, however, screening should only be seen as an effective method for reducing the burden of tracheal, bronchus, and lung cancer in certain populations and locations with the capacity to diagnose and manage imaging findings, and only in combination with programmes aimed at reducing exposure to risk factors. Many countries are not in a position to adopt lung cancer screening protocols due to a combination of factors, including expenses and inadequate health-system capacity required for screening and subsequent treatment, and the need to consider additional unique challenges associated with implementation in low-resource settings. Moreover, with 80·3{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} (95{14f62f8d01b0e9e4416e7be29f093eee2960b1e4c60488fca25d8fca5b82c641} UI 77·5–83·2) of all deaths from tracheal, bronchus, and lung cancer in 2019 attributable to risk factor exposure, preventive measures are still the most important steps to control incidence, and thereby mortality, worldwide. If the necessary resources become more widely available in the future, the cost-effectiveness of screening protocols for tracheal, bronchus, and lung cancer could be assessed and then considered for wider implementation in high-risk populations around the world. For policy makers evaluating whether and how to expand screening in the future, it is important first to consider local risk-factor contexts, challenges with misdiagnosis, and, as previously discussed, the ability of the health-care system to treat patients who are diagnosed. Screening programmes alone will not improve health outcomes without subsequent access to effective diagnosis and treatment options. Any strategy to reduce the burden of tracheal, bronchus, and lung cancer should take all of these local factors into consideration and prioritise risk reduction and health-system strengthening before implementing screening protocols, particularly in lower SDI settings.
Goal 3: ensure health lives and promote well-being for all at all ages.
,
Global action plan for the prevention and control of NCDs 2013–2020.
In low SDI countries, prioritisation of resources to reduce the risk of larynx cancer and tracheal, bronchus, and lung cancer by implementing smoking control programmes, stronger air quality regulations and enforcement, better access to clean fuel sources, and occupational risk factor legislation, can be cost-effective approaches to reduce deaths from larynx cancer and tracheal, bronchus, and lung cancer.
- Veglia A
- Pahwa M
- Demers PA
Furthermore, previous research suggests that joint exposure to ambient particulate matter pollution and smoking might have greater than additive effects on death rates for tracheal, bronchus, and lung cancer,
- Turner MC
- Krewski D
- Pope 3rd, CA
- Chen Y
- Gapstur SM
- Thun MJ
so such interventions might produce larger benefits than suggested in our analysis.
Limitations and strengths
- Smits AJJ
- Kummer JA
- Hinrichs JWJ
- et al.
,
- Shi Y
- Au JS-K
- Thongprasert S
- et al.
As another example, the *2 allele of mitochondrial aldehyde dehydrogenase (ALDH2*2), which is associated with decreased metabolism of alcohol, higher alcohol toxicity, and possible carcinogenicity, is more prevalent in east Asian populations than in other populations.
- Chang JS
- Hsiao J-R
- Chen CH
Additionally, the magnitude of the contribution of each risk factor to lung cancer varies for different histological subtypes of lung cancer,
and we could not differentiate these different histological subtypes. Similarly, we were unable to separate statistical records related to tracheal cancers from lung and bronchial cancers because of the registration overlap in data sources for this study.
- Bray F
- Ferlay J
- Soerjomataram I
- Siegel RL
- Torre LA
- Jemal A
estimates (2·19 million vs 2·09 million incident cases in 2018, and 1·98 million vs 1·76 million deaths in 2018), which can be partially attributed to GBD 2019 covering 19 more countries than GLOBOCAN and to each set of estimates having different data sources and methods. GBD 2019 includes many aggregated cancer registry databases, including Cancer Incidence in Five Continents (CI5), EUREG, US SEER Database, and NORDCAN.
- Bray F
- Ferlay J
- Soerjomataram I
- Siegel RL
- Torre LA
- Jemal A
,
- Steliarova-Foucher E
- O’Callaghan M
- Ferlay J
- et al.
,
- Altekruse SF
- Rosenfeld GE
- Carrick DM
- et al.
Conclusion
Although tracheal, bronchus, and lung cancer was still the leading cause of cancer death globally in 2019, age-standardised incidence and death rates for respiratory tract cancer (ie, tracheal, bronchus, and lung cancer and larynx cancer) appeared to decline between 2010 and 2019 at the global level. However, our study highlights the increasing rates of tracheal, bronchus, and lung cancer incidence in the low SDI quintile, particularly among females. Smoking remained the leading risk factor for deaths from tracheal, bronchus, and lung cancer at the global level for both males and females in 2019, but for females in six GBD regions and in the low SDI quintile the leading risk factor was either ambient particulate matter pollution or household air pollution from solid fuels. These findings should provide the impetus for policy makers to expand culturally responsive smoking control programmes, enact and enforce stricter air quality regulations, and expand access to clean energy in homes. Policies such as smoking cessation programmes and smoking regulations, air quality acts with enforceable regulations, low-emission zones in towns and cities, widespread access to clean energy in locations without it, and occupational risk standards that minimise asbestos exposure all have the potential to help reduce the incidence of and mortality attributable to tracheal, bronchus, and lung cancer, if done using locally appropriate, evidence-based strategies. Screening protocols such as low-dose CT for tracheal, bronchus, and lung cancer and the introduction of effective treatments such as mutation-targeted cancer treatment could be additional steps to reduce mortality from and the burden of larynx cancer and tracheal, bronchus, and lung cancer in high SDI countries with adequate health-care infrastructure. In lower SDI settings, improving access to health care, streamlining referral pathways for cancer, and strengthening health systems for cancer diagnosis and treatment could be important strategies to reduce tracheal, bronchus, and lung cancer mortality, in addition to risk reduction programmes.
GBD 2019 Respiratory Tract Cancers Collaborators
Hedyeh Ebrahimi*, Zahra Aryan*, Sahar Saeedi Moghaddam, Catherine Bisignano, Shahabeddin Rezaei, Farhad Pishgar, Lisa M Force, Hassan Abolhassani, Eman Abu-Gharbieh, Shailesh M Advani, Sohail Ahmad, Fares Alahdab, Vahid Alipour, Syed Mohamed Aljunid, Saeed Amini, Robert Ancuceanu, Catalina Liliana Andrei, Tudorel Andrei, Jalal Arabloo, Morteza Arab-Zozani, Malke Asaad, Marcel Ausloos, Atalel Fentahun Awedew, Atif Amin Baig, Ali Bijani, Antonio Biondi, Tone Bjørge, Dejana Braithwaite, Michael Brauer, Hermann Brenner, Maria Teresa Bustamante-Teixeira, Zahid A Butt, Giulia Carreras, Carlos A Castañeda-Orjuela, Odgerel Chimed-Ochir, Dinh-Toi Chu, Michael T Chung, Aaron J Cohen, Kelly Compton, Baye Dagnew, Xiaochen Dai, Lalit Dandona, Rakhi Dandona, Frances E Dean, Meseret Derbew Molla, Abebaw Alemayehu Desta, Tim Robert Driscoll, Emerito Jose A Faraon, Pawan Sirwan Faris, Irina Filip, Florian Fischer, Weijia Fu, Silvano Gallus, Birhan Gebresillassie Gebregiorgis, Ahmad Ghashghaee, Mahaveer Golechha, Kebebe Bekele Gonfa, Giuseppe Gorini, Bárbara Niegia Garcia Goulart, Maximiliano Ribeiro Guerra, Nima Hafezi-Nejad, Samer Hamidi, Simon I Hay, Claudiu Herteliu, Chi Linh Hoang, Nobuyuki Horita, Mihaela Hostiuc, Mowafa Househ, Ivo Iavicoli, Irena M Ilic, Milena D Ilic, Seyed Sina Naghibi Irvani, Farhad Islami, Ashwin Kamath, Supreet Kaur, Rovshan Khalilov, Ejaz Ahmad Khan, Jonathan M Kocarnik, Burcu Kucuk Bicer, G Anil Kumar, Carlo La Vecchia, Qing Lan, Iván Landires, Savita Lasrado, Paolo Lauriola, Elvynna Leong, Bingyu Li, Stephen S Lim, Alan D Lopez, Azeem Majeed, Reza Malekzadeh, Navid Manafi, Ritesh G Menezes, Tomasz Miazgowski, Sanjeev Misra, Abdollah Mohammadian-Hafshejani, Shafiu Mohammed, Ali H Mokdad, Alex Molassiotis, Lorenzo Monasta, Rahmatollah Moradzadeh, Lidia Morawska, Joana Morgado-da-Costa, Shane Douglas Morrison, Mukhammad David Naimzada, Javad Nazari, Cuong Tat Nguyen, Huong Lan Thi Nguyen, Rajan Nikbakhsh, Virginia Nuñez-Samudio, Andrew T Olagunju, Nikita Otstavnov, Stanislav S Otstavnov, Mahesh P A, Adrian Pana, Eun-Kee Park, Faheem Hyder Pottoo, Akram Pourshams, Mohammad Rabiee, Navid Rabiee, Amir Radfar, Alireza Rafiei, Muhammad Aziz Rahman, Pradhum Ram, Priya Rathi, David Laith Rawaf, Salman Rawaf, Nima Rezaei, Nicholas L S Roberts, Thomas J Roberts, Luca Ronfani, Gholamreza Roshandel, Abdallah M Samy, Milena M Santric-Milicevic, Brijesh Sathian, Ione Jayce Ceola Schneider, Mario Sekerija, Sadaf G Sepanlou, Feng Sha, Masood Ali Shaikh, Rajesh Sharma, Aziz Sheikh, Sara Sheikhbahaei, Sudeep K Siddappa Malleshappa, Jasvinder A Singh, Freddy Sitas, Emma Elizabeth Spurlock, Paschalis Steiropoulos, Rafael Tabarés-Seisdedos, Eyayou Girma Tadesse, Ken Takahashi, Eugenio Traini, Bach Xuan Tran, Khanh Bao Tran, Ravensara S Travillian, Marco Vacante, Paul J Villeneuve, Francesco S Violante, Zabihollah Yousefi, Deniz Yuce, Vesna Zadnik, Maryam Zamanian, Kazem Zendehdel, Jianrong Zhang, Zhi-Jiang Zhang, Farshad Farzadfar, Christopher J L Murray, and Mohsen Naghavi.
* Joint first authors (contributed equally as co-first authors).
Affiliations
Non-communicable Diseases Research Center (H Ebrahimi MD, Z Aryan MD, S Saeedi Moghaddam MSc, S Rezaei MS, F Pishgar MD, Prof F Farzadfar DSc), Research Center for Immunodeficiencies (H Abolhassani PhD, Prof N Rezaei PhD), School of Medicine (N Hafezi-Nejad MD), Digestive Diseases Research Institute (Prof R Malekzadeh MD, Prof A Pourshams MD, S G Sepanlou MD), Cancer Research Center (K Zendehdel PhD), Tehran University of Medical Sciences, Tehran, Iran; Brigham and Women’s Hospital (Z Aryan MD), Division of General Internal Medicine (Prof A Sheikh MD), Harvard University, Boston, MA, USA; Institute for Health Metrics and Evaluation (C Bisignano MPH, L M Force MD, Prof M Brauer DSc, A J Cohen DSc, K Compton BS, X Dai PhD, Prof L Dandona MD, Prof R Dandona PhD, F E Dean BA, W Fu MSc, Prof S I Hay FMedSci, J M Kocarnik PhD, Prof S S Lim PhD, Prof A D Lopez PhD, Prof A H Mokdad PhD, E E Spurlock BA, R S Travillian PhD, Prof C J L Murray DPhil, Prof M Naghavi MD), Department of Health Metrics Sciences, School of Medicine (Prof R Dandona PhD, Prof S I Hay FMedSci, Prof S S Lim PhD, Prof A D Lopez PhD, Prof A H Mokdad PhD, Prof C J L Murray DPhil, Prof M Naghavi MD), University of Washington, Seattle, WA, USA; Department of Human Sciences (S Rezaei MS), Ohio State University, Columbus, OH, USA; Department of Global Pediatric Medicine (L M Force MD), St. Jude Children’s Research Hospital, Memphis, TN, USA; Department of Laboratory Medicine (H Abolhassani PhD), Karolinska University Hospital, Huddinge, Sweden; Department of Clinical Sciences (E Abu-Gharbieh PhD), University of Sharjah, Sharjah, United Arab Emirates; Social Behavioral Research Branch (S M Advani PhD), National Institute of Health, Bethesda, MD, USA; Department of Oncology (S M Advani PhD), Georgetown University, Washington, DC, USA; Faculty of Pharmacy (S Ahmad MSc), MAHSA University, Kuala Langat, Malaysia; Mayo Evidence-based Practice Center (F Alahdab MSc), Mayo Clinic Foundation for Medical Education and Research, Rochester, MN, USA; Health Management and Economics Research Center (V Alipour PhD, J Arabloo PhD, A Ghashghaee BSc), Department of Health Economics (V Alipour PhD), Student Research Committee (A Ghashghaee BSc), School of Medicine (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; International Centre for Casemix and Clinical Coding (Prof S M Aljunid PhD), National University of Malaysia, Bandar Tun Razak, Malaysia; Department of Health Services Management (S Amini PhD), Department of Epidemiology (R Moradzadeh PhD, M Zamanian PhD), Department of Pediatrics (J Nazari MD), Arak University of Medical Sciences, Arak, Iran; Pharmacy Department (Prof R Ancuceanu PhD), Cardiology Department (C Andrei PhD), Internal Medicine Department (M Hostiuc PhD), Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Statistics and Econometrics (Prof T Andrei PhD, Prof M Ausloos PhD, Prof C Herteliu PhD, A Pana MD), Bucharest University of Economic Studies, Bucharest, Romania; Social Determinants of Health Research Center (M Arab-Zozani PhD), Birjand University of Medical Sciences, Birjand, Iran; Department of Plastic Surgery (M Asaad MD), University of Texas, Houston, TX, USA; School of Business (Prof M Ausloos PhD), University of Leicester, Leicester, UK; Department of Surgery (A F Awedew MD), Addis Ababa University, Addis Ababa, Ethiopia; Unit of Biochemistry (A A Baig PhD), Universiti Sultan Zainal Abidin (Sultan Zainal Abidin University), Kuala Terengganu, Malaysia; Social Determinants of Health Research Center (A Bijani PhD), Babol University of Medical Sciences, Babol, Iran; Department of General Surgery and Medical-Surgical Specialties (Prof A Biondi PhD, M Vacante PhD), University of Catania, Catania, Italy; 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 Epidemiology (D Braithwaite PhD), University of Florida, Gainesville, FL, USA; Cancer Population Sciences Program (D Braithwaite PhD), University of Florida Health Cancer Center, Gainesville, FL, USA; School of Population and Public Health (Prof M Brauer DSc), University of British Columbia, Vancouver, BC, Canada; Division of Clinical Epidemiology and Aging Research (Prof H Brenner MD), German Cancer Research Center, Heidelberg, Germany; Department of Public Health (Prof M T Bustamante-Teixeira PhD, Prof M R Guerra PhD), Federal University of Juiz de Fora, Juiz de Fora, Brazil; School of Public Health and Health Systems (Z A Butt PhD), University of Waterloo, Waterloo, ON, Canada; Al Shifa School of Public Health (Z A Butt PhD), Al Shifa Trust Eye Hospital, Rawalpindi, Pakistan; Oncological Network, Prevention and Research Institute (G Gorini MD), Institute for Cancer Research, Prevention and Clinical Network, Florence, Italy (G Carreras PhD); 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; Institute of Industrial Ecological Science (O Chimed-Ochir PhD), University of Occupational and Environmental Health, Kitakyushu, Japan; Center for Biomedicine and Community Health (D-T Chu PhD), VNU-International School, Hanoi, Vietnam; Department of Otolaryngology (M T Chung MD), Wayne State University, Detroit, MI, USA; Health Effects Institute, Boston, MA, USA (A J Cohen DSc); Department of Human Physiology (B Dagnew MSc), Department of Biochemistry (M Derbew Molla MSc), Department of Surgical Nursing (A A Desta MSc), University of Gondar, Gondar, Ethiopia; Public Health Foundation of India, Gurugram, India (Prof L Dandona MD, Prof R Dandona PhD, G Kumar PhD); Indian Council of Medical Research, New Delhi, India (Prof L Dandona MD); Sydney School of Public Health (Prof T R Driscoll PhD), Menzies Centre for Health Policy (F Sitas PhD), University of Sydney, Sydney, NSW, Australia; Department of Health Policy and Administration (E J A Faraon MD), University of the Philippines Manila, Manila, Philippines; Department of Biology and Biotechnology “Lazzaro Spallanzani” (P S Faris PhD), University of Pavia, Pavia, Italy; Department of Biology (P S Faris PhD), Cihan University-Erbil, Erbil, Iraq; Psychiatry Department (I Filip MD), Kaiser Permanente, Fontana, CA, USA; School of Health Sciences (I Filip MD), A.T. Still University, Mesa, AZ, USA; Institute of Gerontological Health Services and Nursing Research (F Fischer PhD), Ravensburg-Weingarten University of Applied Sciences, Weingarten, Germany; Department of Environmental Health Sciences (S Gallus DSc), Mario Negri Institute for Pharmacological Research, Milan, Italy; Department of Nursing (B G Gebregiorgis MSc), Debre Berhan University, Debre Berhan, Ethiopia; Health Systems and Policy Research (M Golechha PhD), Indian Institute of Public Health Gandhinagar, Gandhinagar, India; Department of Surgery (K B Gonfa MD), Madda Walabu University, Bale Robe, Ethiopia; Postgraduate Program in Epidemiology (Prof B N G Goulart DSc), Federal University of Rio Grande do Sul, Porto Alegre, Brazil; Department of Radiology and Radiological Science (N Hafezi-Nejad MD, S Sheikhbahaei MD), Johns Hopkins University, Baltimore, MD, USA; School of Health and Environmental Studies (Prof S Hamidi DrPH), Hamdan Bin Mohammed Smart University, Dubai, United Arab Emirates; School of Business (Prof C Herteliu PhD), London South Bank University, London, UK; Center of Excellence in Behavioral Medicine (C L Hoang BMedSci), Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam; Department of Pulmonology (N Horita PhD), Yokohama City University, Yokohama, Japan; National Human Genome Research Institute (NHGRI) (N Horita PhD), National Institutes of Health, Bethesda, MD, USA; College of Science and Engineering (Prof M Househ PhD), Hamad Bin Khalifa University, Doha, Qatar; Department of Public Health (Prof I Iavicoli PhD), University of Naples Federico II, Naples, Italy; Faculty of Medicine (I M Ilic PhD, Prof M M Santric-Milicevic PhD), School of Public Health and Health Management (Prof M M Santric-Milicevic PhD), University of Belgrade, Belgrade, Serbia; Department of Epidemiology (Prof M D Ilic PhD), University of Kragujevac, Kragujevac, Serbia; Research Institute for Endocrine Sciences (S S N Irvani MD), Obesity Research Center (R Nikbakhsh MD), Shahid Beheshti University of Medical Sciences, Tehran, Iran; Surveillance and Health Services Research (F Islami PhD), American Cancer Society, Atlanta, GA, USA; Kasturba Medical College, Mangalore (A Kamath MD, P Rathi MD), Manipal Academy of Higher Education, Manipal, India (A Kamath MD); University of Texas Health Science Center, San Antonio, TX, USA (S Kaur MD); Department of Biophysics and Biochemistry (Prof R Khalilov PhD), Baku State University, Baku, Azerbaijan; Russian Institute for Advanced Study (Prof R Khalilov PhD), Moscow State Pedagogical University, Moscow, Russia; Department of Epidemiology and Biostatistics (E A Khan MPH), Health Services Academy, Islamabad, Pakistan; Public Health Sciences Division (J M Kocarnik PhD), Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Faculty of Medicine (B Kucuk Bicer PhD), Gazi University, Ankara, Turkey; Department of Clinical Sciences and Community Health (Prof C La Vecchia MD), University of Milan, Milan, Italy; Division of Cancer Epidemiology and Genetics (Q Lan PhD), National Cancer Institute, Rockville, MD, USA; Unit of Genetics and Public Health (Prof I Landires MD), Unit of Microbiology and Public Health (V Nuñez-Samudio PhD), Institute of Medical Sciences, Las Tablas, Panama; Department of Public Health (V Nuñez-Samudio PhD), Ministry of Health, Herrera, Panama (Prof I Landires MD); Department of Otorhinolaryngology (S Lasrado MS), Father Muller Medical College, Mangalore, India; Institute of Clinical Physiology (P Lauriola MD), National Research Council, Pisa, Italy; Faculty of Science (E Leong PhD), Universiti Brunei Darussalam, Bandar Seri Begawan, Brunei; Department of Sociology (B Li PhD), Shenzhen University, Shenzhen, China; Melbourne School of Population and Global Health (Prof A D Lopez PhD), Department of General Practice (J Zhang MD), University of Melbourne, Melbourne, VIC, Australia; 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, UK; Non-communicable Disease Research Center (Prof R Malekzadeh MD, S G Sepanlou MD), Shiraz University of Medical Sciences, Shiraz, Iran; School of Medicine (N Manafi MD), University of Manitoba, Winnipeg, MB, Canada; Forensic Medicine Division (Prof R G Menezes MD), Department of Pharmacology (F H Pottoo PhD), Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; Department of Propedeutics of Internal Diseases & Arterial Hypertension (Prof T Miazgowski MD), Pomeranian Medical University, Szczecin, Poland; Department of Surgical Oncology (Prof S Misra MCh), All India Institute of Medical Sciences, Jodhpur, India; 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; Heidelberg Institute of Global Health (HIGH) (S Mohammed PhD), Heidelberg University, Heidelberg, Germany; School of Nursing (Prof A Molassiotis PhD), Hong Kong Polytechnic University, Hong Kong, China; Clinical Epidemiology and Public Health Research Unit (L Monasta DSc, L Ronfani PhD), Burlo Garofolo Institute for Maternal and Child Health, Trieste, Italy; International Laboratory for Air Quality and Health (Prof L Morawska PhD), Queensland University of Technology, Brisbane, QLD, Australia; University Hospital Center of Porto (J Morgado-da-Costa MSc), University of Porto, Porto, Portugal; Section of Plastic Surgery (S D Morrison MD), University of Michigan School of Medicine, Ann Arbor, MI, USA; Laboratory of Public Health Indicators Analysis and Health Digitalization (M Naimzada MD, N Otstavnov BA, S S Otstavnov PhD), Moscow Institute of Physics and Technology, Dolgoprudny, Russia; Experimental Surgery and Oncology Laboratory (M Naimzada MD), Kursk State Medical University, Kursk, Russia; Institute for Global Health Innovations (C T Nguyen MPH, H L T Nguyen MPH), Duy Tan University, Hanoi, Vietnam; 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 Project Management (S S Otstavnov PhD), National Research University Higher School of Economics, Moscow, Russia; Department of Respiratory Medicine (Prof M P A DNB), Jagadguru Sri Shivarathreeswara Academy of Health Education and Research, Mysore, India; Department of Health Metrics (A Pana MD), Center for Health Outcomes & Evaluation, Bucharest, Romania; Department of Medical Humanities and Social Medicine (Prof E-K Park PhD), Kosin University, Busan, South Korea; Biomedical Engineering Department (Prof M Rabiee PhD), Amirkabir University of Technology, Tehran, Iran; Department of Chemistry (N Rabiee MSc), Sharif University of Technology, Tehran, Iran; College of Medicine (A Radfar MD), University of Central Florida, Orlando, FL, USA; Department of Immunology (Prof A Rafiei PhD), Molecular and Cell Biology Research Center (Prof A Rafiei PhD), Department of Environmental Health (Prof Z Yousefi PhD), Mazandaran University of Medical Sciences, Sari, Iran; School of Nursing and Healthcare Professions (M Rahman PhD), Federation University Australia, Berwick, VIC, Australia; School of Nursing and Midwifery (M Rahman PhD), La Trobe University, Melbourne, VIC, Australia; Department of Cardiology (P Ram MD), Emory University, Atlanta, GA, USA; University College London Hospitals, London, UK (D L Rawaf MD); Academic Public Health England (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 Medicine (N L S Roberts MPH), Weill Cornell Medical College, New York, NY, USA; Department of Medicine (T J Roberts MD), Massachusetts General Hospital, Boston, MA, USA; Golestan Research Center of Gastroenterology and Hepatology (GRCGH) (G Roshandel PhD), Golestan University of Medical Sciences, Gorgan, Iran; Department of Entomology (A M Samy PhD), Ain Shams University, Cairo, Egypt; Department of Geriatrics and Long Term Care (B Sathian PhD), Hamad Medical Corporation, Doha, Qatar; Faculty of Health & Social Sciences (B Sathian PhD), Bournemouth University, Bournemouth, UK; Department of Health Sciences (I J C Schneider PhD), Federal University of Santa Catarina, Araranguá, Brazil; Department of Medical Statistics, Epidemiology and Medical Informatics (M Sekerija PhD), University of Zagreb, Zagreb, Croatia; Department of Epidemiology and Prevention of Chronic Noncommunicable Diseases (M Sekerija PhD), Croatian Institute of Public Health, Zagreb, Croatia; Center for Biomedical Information Technology (F Sha PhD), Shenzhen Institutes of Advanced Technology, Shenzhen, China; Independent Consultant, Karachi, Pakistan (M A Shaikh MD); University School of Management and Entrepreneurship (R Sharma PhD), Delhi Technological University, Delhi, India; Centre for Medical Informatics (Prof A Sheikh MD), University of Edinburgh, Edinburgh, UK; Department of Hematology-Oncology (S K Siddappa Malleshappa MD), Baystate Medical Center, Springfield, MA, USA; School of Medicine (Prof J A Singh MD), University of Alabama at Birmingham, Birmingham, AL, USA; Medicine Service (Prof J A Singh MD), US Department of Veterans Affairs (VA), Birmingham, AL, USA; Centre for Primary Health Care and Equity (CPHCE) (F Sitas PhD), University of New South Wales, Sydney, NSW, Australia; Department of Medicine (P Steiropoulos MD), Democritus University of Thrace, Alexandroupolis, Greece; 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 Biomedical Sciences (E G Tadesse MSc), Arba Minch University, Arba Minch, Ethiopia; Asbestos Diseases Research Institute, Sydney, NSW, Australia (Prof K Takahashi PhD); Institute for Risk Assessment Sciences (IRAS) (E Traini MSc), Utrecht University, Utrecht, Netherlands; Department of Health Economics (B X Tran PhD), Hanoi Medical University, Hanoi, Vietnam; Department of Molecular Medicine and Pathology (K B Tran MD), University of Auckland, Auckland, New Zealand; Clinical Hematology and Toxicology (K B Tran MD), Maurice Wilkins Centre, Auckland, New Zealand; School of Mathematics and Statistics (Prof P J Villeneuve PhD), Carleton University, Ottawa, ON, Canada; Department of Medical and Surgical Sciences (Prof F S Violante MD), University of Bologna, Bologna, Italy; Occupational Health Unit (Prof F S Violante MD), Sant’Orsola Malpighi Hospital, Bologna, Italy; Cancer Institute (D Yuce MD), Hacettepe University, Ankara, Turkey; Epidemiology and Cancer Registry Sector (Prof V Zadnik PhD), Institute of Oncology Ljubljana, Ljubljana, Slovenia; Victorian Comprehensive Cancer Centre, Melbourne, VIC, Australia (J Zhang MD); School of Medicine (Z Zhang PhD), Wuhan University, Wuhan, China.
Contributors
Declaration of interests
R Ancuceanu reports consultancy or speakers’ fees from UCB, Sandoz, AbbVie, Zentiva, Teva, Laropharm, CEGEDIM, Angelini, Biessen Pharma, Hofigal, AstraZeneca, and Stada. J A Singh reports fees from Crealta and Horizon, Medisys, Fidia, Two labs Inc, Adept Field Solutions, Clinical Care options, ClearView Healthcare Partners, Putnam Associates, FocusForward, Navigant Consulting, Spherix, MedIQ, UBM LLC, Trio Health, Medscape, WebMD, and Practice Point communications; and the National Institutes of Health and the American College of Rheumatology; placement on the speaker’s bureau of Simply Speaking; ownership of stock options in TPT Global Tech, Vaxart pharmaceuticals and Charlotte’s Web Holdings. J A Singh previously owned stock options in Amarin, Viking, and Moderna pharmaceuticals; placement on the steering committee of OMERACT, an international organisation that develops measures for clinical trials and receives arm’s length funding from 12 pharmaceutical companies; and serves on the FDA Arthritis Advisory Committee. J A Singh is also a member of the Veterans Affairs Rheumatology Field Advisory Committee; and is the editor and the Director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis. All other authors declare no competing interests.
Acknowledgments
S M Aljunid acknowledges support from the Department of Health Policy and Management, Faculty of Public Health, Kuwait University and International Centre for Casemix and Clinical Coding, Faculty of Medicine, National University of Malaysia, for the approval to participate in this research project. M Ausloos and C Herteliu are partially supported by a grant from the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084. A J Cohen acknowledges support from the Health Effects Institute, Boston, MA USA. I Landires is a member of the Sistema Nacional de Investigación (SNI), which is supported by the Secretaría Nacional de Ciencia, Tecnología e Innovación (SENACYT), Panamá. A Pana acknowledges support by a grant from the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084. A Sheikh acknowledges support from Health Data Research UK. M M Santric-Milicevic acknowledges support from the Ministry of Education, Science and Technological Development of the Republic of Serbia (Contract No. 175087). F Sha acknowledges support from the Shenzhen Social Science Fund ( grant number SZ2020C015 ) and the Shenzhen Science and Technology Program ( grant number KQTD20190929172835662 ). A M Samy acknowledges support from the Egyptian Fulbright Mission Program.
Supplementary Materials
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Published: August 16, 2021
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© 2021 The Author(s). Published by Elsevier Ltd.
