Lung cancer remains a significant public health challenge globally, constituting a primary cause of both cancer incidence and mortality [2, 26]. However, the disease burden varies greatly across countries and within each country. In this study, we presented epidemiological trends and quality of care for tracheal, bronchus and lung cancer in Fujian Province, China, and globally from 1990 to 2019. Overall, the burden of tracheal, bronchus and lung cancer in China was higher than the global level. In China, the burden of tracheal, bronchus and lung cancer in Fujian Province was slightly lower than the national average but still higher than the global level.
According to this study findings, the ASRs of death and DALY were higher in earlier years and began to decline after 2010. Similarly, a study conducted in Fujian Province showed that the five-year survival rate for lung cancer in Fujian Province increased from 13.8–23.7% between 2011 and 2020 [5]. This may be largely attributed to advancements in healthcare and primary prevention. In recent years, targeted therapies and immunotherapies for lung cancer have continually progressed, leading to significant advancements. From the predictive results of this study, it was observed that by the 2050, the ASR in Fujian Province were projected to decrease. Currently, next-generation sequencing technologies have enabled comprehensive identification of the genetic features of lung cancer, allowing for personalized treatment targeting mutation hotspots. As early as two decades ago, inhibitors targeting EGFR, KRAS, ROS1, among others, have been employed in clinical therapy [27]. However, the persistent challenge of acquired resistance during treatment remains unresolved, with only approximately 25% of patients benefiting from targeted therapies [28]. This contributes to lung cancer’s continued high mortality rates. Consequently, the development of combined precision immunotherapy and targeted treatment research has begun, aiming to improve long-term clinical outcomes and increase overall survival [28–30].
However, despite these improvements, we found that the ASR of incidence had continued to increase after 2014 in Fujian Province. In China, a large-scale lung cancer screening project was initiated in 2010 [31, 32]. This trend may be attributed to screening efforts. Some scholars have contended that lung cancer screening might result in overdiagnosis, given that a considerable number of patients identified through low-dose computed tomography (LDCT) scans do not exhibit malignant progression during subsequent follow-ups, yet still opt for surgery, especially among low-risk populations [33]. Nonetheless, screening for high-risk populations remains crucial, with LDCT proven effective in reducing lung cancer burden by aiding in early detection, improving prognosis, and reduced lung cancer mortality by 31% [34]. Therefore, to reduce over-screening and enhance cost-effectiveness, the China National Lung Cancer Screening Guideline with LDCT (2023 Version) specify defining high-risk populations for lung cancer as adults aged 50 and above with any of the following risk factors: smoking history, exposure to environmental or occupational carcinogens, presence of chronic obstructive pulmonary disease or diffuse pulmonary fibrosis or a history of tuberculosis, a history of malignant tumors, or a family history of lung cancer [32]. Additionally, other factors such as passive smoking and air pollution should also be considered in the assessment [32, 35]. This study also supports the observable increase in the burden of lung cancer among individuals aged 50 and older, emphasizing the significance of risk factors such as smoking, ambient particulate matter pollution, and secondhand smoke.
This study analyzed the burden of tracheal, bronchus and lung cancer across different age groups and found that the burden increased with age, especially among individuals aged 70 and above. Elderly individuals are susceptible to many diseases, particularly cancer. The aging process induces alterations in the microenvironment within the body, including epigenetic changes, alterations in cellular communication, protein homeostasis changes, mitochondrial dysfunction, and cellular senescence [36]. These processes manifest as the production of inflammatory mediators and weakening of the immune system, thereby driving the occurrence and progression of tumors in elderly individuals [37]. Meanwhile, the problem of aging in China is becoming increasingly serious [38, 39], which may concentrate the incidence and mortality rates among the elderly. A study on age-related lung cancer burden in China also suggested that population aging is a primary driving factor for increases in disease burden [40].
When analyzed by gender, it was observed that the burden of lung cancer in males higher than that in females. On the one hand, genetic factors contributed to this gender disparity. Research had identified gender-specific susceptibility genes on the X chromosome, with 24 SNPs found to be associated with male lung cancer cases but not with females [41]. On the other hand, from a risk factor perspective, the burden of lung cancer attributable to smoking was notably high among males. In China, the burden of lung cancer due to smoking was 1.26 times the global average level. Chinese males account for approximately 40% of global cigarette consumption [42]. Although the smoking rate in Fujian was slightly lower than the national level, the male smoking rate reached 48.9% [5]. However, between 2015 and 2019, there had been a declining trend in the burden of lung cancer in males. This could be attributed to tobacco control measures implemented by the Chinese government [43], but further strengthening of anti-smoking policies remained necessary in the future [42, 44]. Additionally, it is worth noting that the burden of lung cancer in females had been increased in recent years, with projections suggesting a continued upward trend until 2050. Females had needed to be vigilant about the effects of secondhand smoke and household air pollution. A prospective study had found a significant association between secondhand smoke exposure and the occurrence of EGFR mutations [45]. What’s more, young and middle-aged females are more likely to be frequently exposed to high-temperature cooking fumes in the kitchen. Cooking fumes contain harmful particulate matters and volatile organic compounds, including fine (ultrafine) particles, aldehydes, and polycyclic aromatic hydrocarbons [46]. Results from a Chinese cohort study showed that long-term exposure to cooking fumes increased the risk of lung cancer in non-smoking females by 1.4 to 3.8-folds [47]. Moreover, due to genetic factors and estrogen, females had been more susceptible to developing lung adenocarcinoma [48, 49].
In addition to the aforementioned risk factors, Fujian Province also need to address the burden of lung cancer caused by ambient particulate matter pollution. In 2019, ambient particulate matter pollution ranked as the second-largest factor contributing to lung cancer ASR of DALY in China, following only smoking. This held true for Fujian Province as well. Many strong evidence indicated that air pollution played a driving role in the occurrence and development of lung cancer [50–52]. With the rapid development of the economy and the acceleration of urbanization, considerable environmental challenges have also been brought to China. China was one of the countries with the worst air quality in the world. In 2017, with 81.1% of the population still lived in areas exceeding the least stringent WHO air quality interim target of 35 µg/m3 [53]. Fujian has better air quality than other high-pollution areas in China and is recognized as relatively good air quality in the country. In 2021, the PM2.5 level in Fujian Province was 18µg/m3 [54], while the national average PM2.5 concentration was 30µg/m3 [55]. This may also be one of the reasons why the burden of lung cancer in Fujian Province was slightly lower than the national average.
Because of the development of the Chinese economy, the proportion of lung cancer ASR of DALY caused by household air pollution from solid fuels had been decreasing year by year. The number of households using solid fuels had decreased significantly [53]. In recent years, the government has taken a series of measures to improve air quality, and further efforts will be needed to advance environmental protection policies in the future. Moreover, in 2019, occupational exposure to asbestos was identified as the third risk factor for global burden of tracheal, bronchus, and lung cancers, especially among males. Asbestos was commonly used in the processing of building materials. However, asbestos produces large clouds of dust during mining, processing and application. Asbestos was classified as a Class I carcinogen by the International Agency for Research on Cancer. Previous studies had indicated that the burden of non-communicable diseases caused by asbestos was higher in high sociodemographic index (SDI) regions, while the burden in medium and low SDI regions was continued to increase [56]. In addition, the asbestos-induced lung cancer accounted for 55%-85% of occupational cancers [56]. Based on the survey finding [57], it was revealed that due to the development strategy of the Western Development and strengthened environmental controls in eastern cities in China, asbestos production enterprises were mainly located in western and central regions. The cases of asbestosis were predominantly reported in Tianjin, Beijing, Shandong, and Xinjiang, with fewer cases in Fujian Province, where the number of asbestosis cases was less than 30. It is imperative to continuously improve measures for the prevention and control of occupational asbestos exposure and related diseases. Governments worldwide are strongly encouraged to decrease the use of asbestos.
Age and gender equality in the quality of care are key elements of the health system standards [9]. In this study, we did not observe significant gender differences in the quality of care, but differences based on age were evident. The QCI improved with increasing age, possibly due to several reasons. On the one hand, Elderly patients often received more attention and specialized care due to their complex healthcare needs [58, 59]. On the other hand, healthcare providers might prioritize elderly patients or allocate more resources to them. A cohort study indicated higher satisfaction with care among elderly cancer patients, who also spent more time with physicians [60]. Conversely, the quality of care for younger individuals might be lower due to limited access to healthcare services, lack of awareness about preventive measures, and delays in diagnosis or treatment. Younger individuals might also have different healthcare priorities or face higher financial burden in care [60], resulting in lower quality care compared to the elderly. Furthermore, this study also observed decreased trends in QCI over the past 30 years. Considering the advancements in medical technology and improvements in healthcare policies, the decline in the quality of lung cancer care seems contrary to expectations. However, several reasons could contribute to this decrease. For instance, societal factors such as changes in environmental pollution, race, and disparities in access to healthcare could impact the incidence and management of lung cancer [61–64], thus affecting its overall quality of care. Additionally, precision oncology treatments are costly and do not benefit all cancer patients [65]. Healthcare policies or resource allocation strategies need to be weighed against cost-effectiveness, leading to potential gaps or inefficiencies in service delivery [66]. In Fujian Province, a more pronounced decline in QCI was observed. It could be attributed to disparities in the allocation and efficiency of utilization of resources. High-level public hospitals exhibited relatively higher bed occupancy rates, while other hospitals showed lower rates [67]. The workload of hospital physicians may be substantial, potentially impacting the efficiency and quality of medical services. Additionally, investments in health care in Fujian Province might be lower compared to other more economically developed regions in China, indicating a need to further strengthen the construction of the health service system [68]. Other specific reasons would require higher-level evidence from research to explore and substantiate.
This study has several strengths. Firstly, it comprehensively analyzed tracheal, bronchial, and lung cancer epidemiological trends in Fujian, informing future healthcare strategies. Secondly, changes in risk factors were identified, guiding updates to comprehensive prevention policies. Lastly, this study used QCI to evaluate healthcare equity for lung cancer populations. However, there are limitations. Firstly, it relied on GBD 2019 data, which has inherent limitations in accuracy. However, GBD collaborators continuously update and improve statistical methods to minimize errors [13, 69]. Secondly, GBD 2019 lacks data on lung cancer’s pathological subtypes, limiting detailed insights into subtype-specific burdens.