Emerging Trends in Global Lung Cancer Burden

Abstract

Lung cancer remains the leading cause of cancer-related deaths worldwide, with its burden shaped by evolving risk factors, demographic changes, and healthcare disparities. Over the past decades, while age-standardized incidence and mortality rates have declined, the absolute number of cases has risen due to population growth and aging. Tobacco smoking remains the most common risk factor, accounting for approximately 60% of cases globally, though its contribution has declined in high-income regions due to effective tobacco control. Conversely, countries with lower socioeconomic development, particularly in East and South Asia, face rising incidence and mortality driven by increasing smoking prevalence, air pollution, and limited access to healthcare. Emerging risk factors, such as ambient air pollution and genetic predisposition, are increasingly significant, particularly in regions with lower Human Development Index scores. Sex disparities are evident, with lung cancer rates declining among men in many high-income countries but rising among women globally. Early-onset lung cancer is also an emerging concern, especially in middle socio-demographic index regions, driven by smoking, environmental exposures, and genetic factors. By 2035, it is predicted that lung cancer deaths could reach 3 million annually. To address the impact of the growing lung cancer burden, a multifaceted approach is needed, including strengthened tobacco control, improved air quality, promotion of clean cooking fuels, and expanded low-dose computed tomography screening, particularly in resource-constrained regions.

 

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Keywords

lung cancer - epidemiology - smoking - air pollution - early-onset lung cancer - global cancer trends

Lung cancer remains one of the most pressing public health challenges worldwide, accounting for the highest number of cancer-related deaths globally.[1] According to GLOBOCAN 2022, an estimated 2.5 million new cases and 1.8 million deaths were attributed to lung cancer ([Fig. 1]).[1] [2] [3] While age-standardized incidence and mortality rates (ASIR and ASMR) have declined in some high-income countries, the absolute number of cases continues to rise due to population growth, aging, and epidemiological transitions—from infectious to noncommunicable diseases.[4] Notably, ASIR and ASMR are approximately twice as high in men as in women.[2] A review based on data analysis from the Cancer Mortality Database gave a prediction that, by 2035, the annual global number of lung cancer deaths will reach 3 million.[5] This predicted increase includes a doubling of deaths in both men (from 1.1 million in 2012 to 2.1 million in 2035) and women (from 0.5 million to 0.9 million), with the twofold sex disparity expected to persist. The most rapid increases are anticipated in the African region and the East Mediterranean region.[5]

Fig. 1 Trends in incidence and mortality across regions according to HDI (excluding China and India) from 2022 to 2050 using the GLOBOCAN database. Trends in incidence and mortality numbers of lung cancer and crude incidence and mortality rates (per 100,000 population) across different regions from 2022 to 2050 are shown, respectively. Separate trend lines are provided for the total population and the EOLC group.

The burden of lung cancer varies significantly across different regions and is driven by a complex interplay of demographic, environmental, and socioeconomic factors.[6] Tobacco smoking remains the most important risk factor, accounting for 80 to 90% of lung cancer diagnoses in the United States, despite only approximately 15% of smokers developing lung cancer.[7] However, other factors such as exposure to environmental pollutants, occupational carcinogens, and genetic predispositions are emerging as significant contributors, particularly in low- and middle-income countries (LMICs) and in young patients.[8] [9] [10] [11] This review examines the evolving trends in lung cancer incidence and mortality, with a focus on geographic and sex disparities. It also explores the shifting significance of risk factors and their implications for global public health strategies.

Global Trends in Lung Cancer Incidence and Mortality

Incidence and Mortality Trends

Lung cancer remains a significant global health challenge, with incidence and mortality increasing substantially over the past decades. From the GLOBOCAN 2022 database, lung cancer was the most frequently diagnosed cancer in 2022, representing 12.4% of all cancers worldwide.[1] Lung cancer also remained the leading cause of cancer deaths, accounting for 18.7% of cancer deaths in the same year.[1] Despite these alarming figures, the 5-year survival rate for lung cancer remains below 20% in most countries.[12] These figures highlight the persistent burden of lung cancer due to population growth, aging, and increased exposure to risk factors such as smoking and air pollution.[13]

Data from the Global Burden of Disease 2021 highlighted the evolving burden of lung cancer.[14] From 1992 to 2021, the number of incident cases, deaths, and disability-adjusted life-years (DALYs) due to lung cancer increased by 75.60, 60.15, and 49.88%, respectively. However, during the same period, ASIR, ASMR, and age-standardized DALY rates (ASDR) decreased by 14.35, 22.07, and 25.68%, respectively.[8] These trends reflected annual declines in ASRs for incidence (−1.14%), mortality (−1.47%), and DALYs (−1.46%).[8]

 

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Regional and Sex Variations

The burden of lung cancer varies considerably across regions due to differences in socioeconomic development, healthcare infrastructure, and exposure to risk factors.[15] The current and future burden of lung cancer in a region largely depends on the trajectory of the smoking epidemic within its populations, as well as distinct sex differences in smoking patterns across transitioning and transitioned countries.[15]

To address these disparities, measures such as the Human Development Index (HDI) and socio-demographic index (SDI) are used to verify whether a country's burden of disease varies according to the degree of human development and socioeconomic development. HDI assesses human development based on health, education, and income,[16] [17] and SDI is a summary measure that quantifies the level of sociodemographic development and is constructed from measures of income per capita, average years of schooling, and total fertility rate.[18] According to the Global Burden of Disease 2021 data, high-middle SDI regions reported the highest number of incident cases, deaths, and DALYs in 2021. In contrast, low-middle SDI regions have shown increasing trends in age-standardized rates (ASRs) from 1992 to 2021, reflecting limited healthcare access and rising exposure to risk factors.[8]

Regional Variations

Annual declines in ASRs were most pronounced in high SDI regions. Mortality reductions were steepest in high SDI regions, with an annual decline of −3.57%[8] due to effective smoking cessation programs, better healthcare infrastructure, and early detection initiatives. In low- and low-middle-SDI regions (e.g., sub-Saharan Africa and South Asia), lung cancer trends have either increased or remained stable due to challenges such as limited healthcare infrastructure, late-stage diagnoses, and higher exposure to household air pollution and occupational carcinogens.[8] In the middle SDI regions, trends were mixed. While some countries reported declining male incidence rates due to reduced smoking prevalence, incidence rates for females, especially nonsmokers, with lung cancer were increasing.[8] [13]

According to estimates from the International Agency for Research on Cancer for 2020, low-HDI countries, such as those in sub-Saharan Africa, exhibited low mortality levels but were expected to experience a steady rise in lung cancer deaths for both sexes through 2040, driven by population growth and aging. In contrast, very high-HDI countries (e.g., Europe, North America, and Australia/New Zealand) showed declining trends in male lung cancer mortality, while incidence rates for female lung cancer were plateauing or increasing slightly.[15]

Globally, the highest ASIR, ASMR, and ASDR were reported in middle SDI regions, while countries like Monaco, Greenland, and Montenegro recorded the highest values.[8] Conversely, regions with high HDI exhibited higher incidence and mortality rates compared with low-HDI regions, with ASIRs and ASMRs in high-HDI countries being approximately 8.5 times and 6.5 times higher than those in low-HDI countries,[13] but they faced increasing trends due to demographic changes and rising exposure to risk factors.[19] At the country level, China ranked first in lung cancer incidence, followed by the United States and Japan in 2021. China, the United States, and India accounted for the highest number of deaths and DALYs.[8] [13]

 

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Sex Disparities

Sex differences in lung cancer trends are striking, reflecting distinct smoking behaviors and risk exposures. According to the Global Burden of Disease Study 2021, between 1992 and 2021, males experienced significant reductions in ASIR (23.27%), ASMR (29.69%), and ASDR (32.58%), largely due to declining smoking rates and improved healthcare access.[8] In contrast, females experienced a 9.19% increase in incidence, with smaller reductions in mortality (−1.70%) and DALYs (−5.91%).[8] This trend underscored the growing burden of lung cancer in females, particularly in middle and low-SDI regions where smoking rates among women were increasing. In high-SDI regions, there were substantial reductions in ASMR, with an overall decline of −36.92% and an even larger reduction in males (−48.10%), largely attributed to effective tobacco control measures, improved healthcare access, and advancements in early detection and treatment. In contrast, low-middle SDI regions experienced a rising burden among females, with the ASIR increasing by 32.32% and the ASMR by 30.13%, primarily driven by increasing smoking prevalence and exposure to air pollution. Middle-SDI regions displayed mixed trends, with declining rates in males offset by rising rates in females.[8] [13] At the country level, in China, the overall ASIR increased by 0.74%, driven by a notable rise in female cases, reflecting growing tobacco use and environmental exposures. The sex disparity was particularly pronounced, with male ASIR and ASMR being approximately 1.7 and 2.7 times greater, respectively, than those of females in 2022.[13]

 

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Risk Factors and Their Evolving Impacts

Amid shifting tobacco policies, escalating air pollution levels, and evolving occupational and demographic factors, lung cancer risk factors have changed significantly over time ([Table 1]). According to the 2019 Global Burden of Disease study, while tobacco and air pollution-associated lung cancer ASMRs have decreased globally, tobacco-associated ASMRs have increased in China and Indonesia, while air pollution-associated ASMRs have risen in China, India, Pakistan, and Nigeria.[20] The occupational exposure to asbestos-associated lung cancer death has decreased.[8]

Table 1 A list of risk factors contributing to the recent trends of lung cancer in order of potential significance

Overall, potential risk factors for lung cancer	References	Potential risk factors for early onset lung cancer (EOLC)	References
Tobacco smoking	[8] [15] [20] [25] [28] [38]	Tobacco smoking	[9] [11] [50] [51]
Air pollution	[8] [20] [29] [30] [33]	Air pollution	[9] [11] [36]
Occupational exposures	[8] [20] [35] [36] [37]	–	–
Others: genetic or environmental	[11] [55] [56] [57]

Tobacco Smoking

The causal relationship between cigarette smoking and lung cancer was first demonstrated in the 1950s through large-scale epidemiological studies. This was subsequently confirmed by organizations such as the Royal College of Physicians in London, the United States Surgeon General, and the World Health Organization.[21] Historically, tobacco smoking has been the predominant risk factor for lung cancer, accounting for approximately 90% of cases.[22] The geographic and temporal patterns in both lung cancer incidence and mortality largely reflected the stage of the tobacco epidemic in different countries.[15] These patterns were influenced by historical smoking behaviors, including the intensity and duration of smoking, cigarette type, and degree of inhalation. In high-income countries where smoking prevalence peaked and then declined (e.g., the United Kingdom and United States), lung cancer rates among men followed a similar trajectory, albeit with a 20 to 25-year lag.[23] [24] Global efforts to control tobacco use have led to a decline in smoking rates in many regions, especially in developed countries, contributing to reduced tobacco-associated lung cancer mortality,[19] [20] while in developing countries, smoking rates continued to rise.[5] According to the Global Burden of Disease Study 2021, the population-attributable fraction of lung cancer deaths linked to smoking has declined from approximately 67.5% globally in 1992 to 59% in 2021. In detail, tobacco use accounted for 60% of lung cancer deaths in high SDI regions, 63.5% in high-middle SDI regions, 57.5% in middle SDI regions, 51.5% in low-middle SDI regions, and 33.5% in low SDI regions.[8] Tobacco-associated lung cancer mortality remained high in countries like China and Indonesia, and tobacco-associated ASMR has increased.[8] [20] Tobacco exposure remained the largest modifiable risk factor worldwide with a stronger historical impact on males, underscoring the urgent need for equity-focused tobacco control measures.[15] Among women, the tobacco epidemic was less advanced compared with men, with smoking trends varying significantly by region.[1] [25] In most transitioned countries, lung cancer rates in women continued to rise, with only a few, such as the United States, showing stabilization or decline.[26] As a result, in several countries, lung cancer incidence in women was nearing or surpassing that in men, particularly among younger and middle-aged populations, indicating a growing lung cancer burden among women in the coming decades.[27] In countries where the tobacco epidemic is in an earlier stage, smoking prevalence among men has either recently peaked or continues to increase, suggesting that lung cancer rates will likely rise over the next few decades without effective mitigation strategies to promote cessation or to prevent initiation.[1] The potential for a rapid rise in global lung cancer mortality is of pressing concern for countries with the highest daily smoking prevalence among men, such as Indonesia (54.4%) and China (41.5%).[1] [28] Smoking also influenced histological lung cancer subtypes, with adenocarcinoma in nonsmokers becoming more prevalent compared with squamous cell carcinoma usually associated with smoking. This change is particularly noticeable among women and nonsmokers, with the ratio of these two subtypes in males shifting from 1:18 in 1950 to 1:1.2 to 1.4 in 1993.[21]

 

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Air Pollution

Air pollution—both ambient and indoor—has become a significant contributor to lung cancer mortality, with ambient air pollution accounting for 15% and indoor air pollution from burning solid fuels accounting for 0.035% globally in 2021, according to the Global Burden of Disease data.[8] [14] [20] [29] [30] Ambient air pollution has emerged as a significant risk factor, particularly in middle- and high-middle-SDI regions, like China, India, Pakistan, and Nigeria.[20] Particulate matter (PM) has been shown to have a relative risk (RR) of 1.16 for every 10 μg/m³ increase in PM_2.5 and 1.23 for PM₁₀ in relation to lung cancer incidence. The risk was even higher for lung cancer mortality.[29] In East Asia, where smoking prevalence among women was low, a significant proportion of lung cancer cases were linked to outdoor air pollution and indoor solid fuel use for heating and cooking.[31] [32] China reported the highest PM-associated lung cancer mortality in 2019 (8.8/100,000), which was twice the global average.[20] The burden of lung cancer attributable to indoor or household air pollution has decreased due to cleaner cooking technologies.[8] Nevertheless, household air pollution from solid fuels contributed significantly to lung cancer burden, accounting for approximately 33% of lung cancer death in low SDI regions and 17.5% of lung cancer death in low-middle SDI regions in 2021.[8] [9] [33] [34] The pooled effect estimate for biomass smoke as a lung carcinogen has odds ratio (OR) of 1.50 (95% confidence interval [CI]: 1.17–1.94) with the risk of lung cancer from solid fuel use greater in females (OR: 1.81; 95% CI: 1.54–2.12) compared with males (OR: 1.16; 95% CI: 0.79–1.69).[33]

 

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Occupational Exposures and Population Aging

Occupational carcinogens, such as asbestos, silica, and radon,[4] have long been recognized as significant lung cancer risk factors. According to the Global Burden of Disease Study 2021, the population-attributable fraction of lung cancer deaths linked to asbestos exposure has declined from approximately 12.5% globally in 1992 to 9.5% in 2021,[8] and asbestos-associated lung cancer ASMR has declined globally, from 8.91/100,000 to 6.0/100,000.[20] However, the impact of asbestos exposure associated lung cancer death remained a significant contributor to lung cancer burden and accounted for 18% of lung cancer death in high SDI regions with ASMR in the United States remained twice as high as the global average for the period 1990 to 2019.[8] [20] Radon exposure, a group 1 carcinogen, particularly in indoor settings, accounted for 3 to 6% of lung cancer globally. The RR of lung cancer increased by 16% per 100 Bq/m³ of radon exposure, highlighting the importance of addressing this risk in indoor environments.[4] [35] [36] Radon exposure has gained attention in high-middle SDI regions, particularly as a risk factor for nonsmokers.[8] [20] [36] [37]

The aging population also contributed significantly to the rising lung cancer burden. Individuals over the age of 50 accounted for the largest proportion of lung cancer cases, with an upward trend in cases, mortality, and DALYs in this age group over the past 30 years.[8] This was largely due to population aging and increased exposure to cumulative risk factors over time.[38]

 

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Emerging Risk Factors

Emerging risk factors, including metabolic and behavioral factors, are anticipated to contribute more significantly to the global lung cancer burden. High fasting plasma glucose has been identified as a potential contributor to increased lung cancer risk, warranting targeted public health interventions to address this metabolic risk.[20] Advancements in artificial intelligence could play a transformative role in understanding the complex interplay of genetic, environmental, and behavioral factors contributing to lung cancer.[39]

 

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Sex Disparities in Lung Cancer Burden

Lung cancer incidence and mortality rates were consistently higher in males than in females. However, while age-standardized rates for males have declined over time, rates for females have remained relatively stable, with some regions experiencing an upward trend.[8] [40] Globally, lung cancer incidence among females has risen, particularly in high-middle and low-middle SDI regions, where smoking prevalence among women has increased.[8] Between 2010 and 2019, the ASIR for females rose by 0.9%, while the ASIR for males declined by 7.4%. This rise in female lung cancer cases can be attributed to several factors, including increasing smoking prevalence among women in previous decades, exposure to second-hand smoke, and environmental risks such as outdoor air pollution and indoor air pollution from cooking fuels.[41]

Similarly, the global male-to-female ratio for lung cancer incidence and mortality has narrowed over time, which reflects both the rising burden among women and the declining rates in men in some regions. In 2021, males had 2.23 times higher incidence rates and 2.36 times higher mortality rates than females, a significant reduction from historical gaps.[8] In 2022, lung cancer ranked first among men and second among women for both incidence and mortality, with male-to-female lung cancer incidence and mortality ratios of around 2:1. However, regional variations were striking. In North America and North Europe, the ratios were close to unity, while in North Africa and East Europe, they ranged from 4:1 to 5:1.1.[1]

Among men, lung cancer remained the most diagnosed cancer in 33 countries and the leading cause of cancer death in 89 countries. The highest incidence rates in men were observed in East Asia, followed by Micronesia/Polynesia and East Europe, with Türkiye reporting the highest national rate globally. In women, lung cancer was the leading cause of cancer death in 23 countries, including China and the United States.[1]

The risk factors for lung cancer vary significantly by sex. Tobacco smoking and occupational exposures were primary contributors among males, while females were more likely to be affected by second-hand smoke and household air pollution, particularly in LMICs where biomass fuels were commonly used for cooking and heating.[8] [9]

 

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Early-Onset Lung Cancer

Rising Burden in Young Adults

Early-onset lung cancer (EOLC), defined as lung cancer diagnosed in individuals aged 20 to 49, presents unique trends and risk profiles compared with lung cancer in older populations, necessitating tailored approaches to treatment and prevention.[11] Using the Global Burden of Disease 2019 data, EOLC was estimated to have caused 135,704 cases worldwide in 2019, corresponding to an ASIR of 4.0 (95% CI: 3.6–4.3) per 100,000 population. There are significant geographic and sociodemographic disparities in the epidemiological burden of EOLC. EOLC is the second leading cause of cancer death among young adults. The burden was higher in males and individuals from middle- and high-middle SDI regions.[9] The global incidence of EOLC has decreased overall; this decline was more pronounced in males and followed a gradient across SDI levels, with greater reductions observed in high and high-middle SDI regions.[9] The global increase in EOLC cases in low- and low-middle SDI regions has been primarily driven by population growth, whereas epidemiological changes have accounted for substantial reductions in EOLC cases across most other regions.[9]

A cross-sectional study based on the United States Cancer Statistics (USCS) and the Surveillance, Epidemiology, and End Results (SEER) program (2001–2019) found that during that period, the incidence of EOLC declined from 9.0 to 4.5 per 100,000 population, with decreases observed across all demographic groups except for young adults aged 20 to 29. The rate of decline was faster in men compared with women, and in Black individuals compared with White individuals. There was a higher incidence of EOLC among young men versus young women and among Black individuals versus White individuals.[42] In Europe and the United States, EOLC accounts for 7.7 to 10% of lung cancer cases, with distinct characteristics including a higher proportion of females, nonsmokers, and more advanced stages at diagnosis compared with older individuals.[43] [44] [45] Adenocarcinoma is the predominant histology in EOLC, comprising 47 to 95% of cases. EOLC patients were more likely to have targetable driver mutations compared with older patients. These mutations include EGFR (20–57%), ALK (4.2–25%), ROS1 (6%), and HER2 (OR: 5.71; 95% CI: 1.34–24.33),[45] [46] while KRAS mutation rates are lower in EOLC (7–9% in Caucasians vs. 2–9% in Asians).[47] [48]

Survival rates for EOLC have consistently improved across all demographic groups. Between 2001 and 2017 (SEER data), survival gains were more prominent in men compared with women and in Black individuals compared with White individuals. However, disparities in survival outcomes by sex and race persisted.[42] In addition, EOLC often has a profound impact on patients' lives, disrupting careers, social aspirations, fertility, and physical independence.[11]

 

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Risk Factors for Early-Onset Lung Cancer

The onset of lung cancer at a younger age may be attributed to a complex interplay between genetic susceptibility and environmental carcinogens([Table 1]).[11] Several factors, including sex, tobacco smoking, ambient air pollution, and socio-economic factors, including gross domestic product per capita, have been independently associated with EOLC incidence at the population level.[9] Women under 40 are disproportionately affected, representing 52% of EOLC compared with 48% in men, possibly due to differences in hormonal regulation and DNA repair mechanisms.[49] [50] Tobacco smoking, the leading cause of lung cancer worldwide, plays a definitive role in EOLC, not as consistently as the older populations. It was estimated that smoking accounted for 15 to 71% of EOLC in young adults versus 34 to 90% in older individuals.[11] This reduced impact may be attributed to the shorter or lesser cumulative exposure in younger individuals. However, smoking remains the leading contributor to EOLC burden globally, except in some regions such as Andean Latin America, North Africa, and low-SDI regions, where ambient air and indoor air pollution are the primary attributable risk factors.[50] [51] Childhood exposure to second-hand smoke significantly increased lung cancer risk, with an adjusted OR of 1.3.[52] Emerging evidence has linked e-cigarette and cannabis use to more aggressive lung cancer forms in younger patients, often associated with advanced-stage diagnoses and poorly differentiated lung carcinomas.[10] [53] This highlights the need for further investigation into the long-term effects of vaping. A retrospective study conducted in South–East London cancer centers (2011–2020) analyzed 248 EOLC patients diagnosed with nonsmall cell lung cancer. Among those with documented smoking history, 30% were never-smokers, underscoring the significant contribution of risk factors other than smoking in the development of EOLC.[54]

Family history is also believed to play a critical role in EOLC risk. First-degree relatives of young lung cancer patients have a 2.6-fold increased risk of developing the disease.[51] Furthermore, 4 to 15% of young lung cancer patients harbor pathogenic germline variants in DNA repair genes, such as TP53, BRCA, and EGFR, which are associated with early-onset disease.[55] [56] [57] These findings suggest that genetic predisposition may interact with environmental factors to create a unique risk profile for EOLC.

Environmental carcinogens, including radon gas, air pollution, and second-hand smoke, have been implicated in the development of EOLC ([Table 1]).[9] [11] Radon gas contributes to 3 to 14% of lung cancer, with younger populations showing heightened sensitivity to its effects.[4] [36] [58] Air pollution, in particular PM_2.5 level, has been linked to increased lung cancer risk in younger populations, with a higher RR of 1.63 compared with the older cohort.[29] [30] Occupational exposures, such as asbestos and silica, may also play a role in EOLC, with latency periods as short as 5 years, further emphasizing the need for preventive measures in workplace environments.[59] [60]

Racial disparities in EOLC incidence are evident, with higher rates observed among non-White populations, particularly in African origins.[42] These disparities may reflect differences in access to healthcare, environmental exposures, and genetic susceptibility, warranting further investigation into the underlying causes.

 

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Future Projections and Challenges

Lung cancer mortality is anticipated to rise globally, presenting significant social and political challenges.[15] By 2050, lung cancer cases are projected to increase significantly ([Fig. 1]). Projections for China in 2050 is estimated to be approximately 1.12 million new cases and 960,000 deaths among men, including estimates of 680,000 new cases and 450,000 deaths among women. In the United States, the corresponding projections are 170,000 new cases and 110,000 deaths among men, and 160,000 new cases and 90,000 deaths among women.[13] A notable rise in the burden of EOLC is also expected, with global cases projected to increase by 31.1% in 2040, particularly among females and individuals in high-middle and middle-SDI regions.[9]

While lung cancer rates among men are expected to stabilize or decline in many regions due to improved smoking cessation programs and pollution controls, rates among women are projected to rise significantly. The rise in female lung cancer incidence will likely be most pronounced in low-middle SDI regions, where prevention efforts remain insufficient. This trend reflects historical smoking patterns among females, increasing exposure to second-hand smoke, and growing environmental pollution.[8]

 

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Policy Implications and Recommendations

The evolving epidemiological landscape of lung cancer and future projections underscore the urgent need for comprehensive prevention and early detection of lung cancer and relevant control strategies. Key priorities include reinforcing tobacco control measures, addressing environmental risk factors, and improving access to lung screening and early detection programs.[19] Tailored approaches are essential to address disparities by sex, age, and socioeconomic status, as well as the unique challenges faced by LMICs.

Strengthening Tobacco Control and Improving Air Quality

Tobacco is the leading cause of lung cancer, and effective tobacco control measures will significantly reduce the disease burden. Addressing tobacco use and air pollution remains critical, particularly in low- and middle-SDI regions where smoking rates are highest and pollution is the most severe in the region. Since the 1960s, global efforts have gradually implemented tobacco control policies.[19] The World Health Organization Framework Convention on Tobacco Control introduced the MPOWER package to assist in national implementation of effective interventions to reduce the demand for tobacco through six policy intervention strategies. One strategy is to increase tobacco taxes, which has been a proven successful strategy to reduce demand for tobacco, and this has been successfully implemented in some regions.[61] Expanding tobacco control policies, including taxation, advertising bans, and smoking cessation programs, is essential in LMICs to reduce global lung cancer rates.[19]

Smoking cessation initiatives tailored to women, combined with education campaigns, are vital to counter the rising female lung cancer incidence, particularly in middle-SDI regions. Stricter environmental regulations targeting industrial emissions, transitioning to clean energy, and promoting the use of clean cooking fuels in households are crucial to mitigating ambient and indoor air pollution. Policies aimed at reducing workplace exposures to carcinogens, such as asbestos and silica, are also critical.[8] [20] Complementing these efforts, public awareness campaigns and community-based interventions are necessary to address the social and cultural determinants of smoking and other lung cancer risk factors.

 

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Promoting Early Detection

Since most lung cancers are diagnosed at advanced stages when curative treatment is no longer possible, early detection remains a cornerstone of prevention efforts. Low-dose computed tomography (LDCT) screening has been proven to reduce lung cancer mortality in high-risk populations, such as smokers and former smokers.[62] [63] However, the translation of these benefits to the general population has been challenging due to issues such as false positives, overdiagnosis, complication rates, prohibitive costs, and limited infrastructure.[64] Despite these challenges, LDCT screening remains a promising tool for improving outcomes in different ethnic populations. Japan, which has achieved the highest diagnosis rate of stage I lung cancer (38.6%), has also demonstrated a relatively high age-standardized 5-year net survival rate of 32.9%.[19]

The United States Preventive Services Task Force currently recommends annual LDCT screening for individuals aged 50 to 80 years with a 20-pack-year smoking history, including those who have quit smoking within the past 15 years.[65] Australia plans to introduce a national lung cancer screening program by July 2025 for high-risk smokers and former smokers.[66] The European Commission, aligning with Europe's Beating Cancer Plan, is also proposing a stepwise implementation of lung cancer screening programs across its 27 member states.[67] [68] Expanding LDCT screening programs to high-risk populations and in low-SDI regions is essential to reduce mortality and disability-adjusted life years (DALYs).

Current screening programs focus primarily on smoking history, excluding younger populations and nonsmokers. Incorporating family history, environmental exposures (e.g., air pollution and radon), and genetic predispositions could enhance early detection. Continued innovation in imaging technologies, incorporating artificial intelligence, and biomarker research can help minimize false positives and overdiagnosis, improving the cost-effectiveness and efficiency of screening programs.[69]

 

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Addressing Disparities and Emerging Challenges

The rising burden of lung cancer among younger populations, particularly EOLC, highlights the need for targeted interventions. Younger patients, especially women and those in middle-SDI regions, face unique challenges.[8] [9] Advances in molecular profiling and precision medicine can help tailor treatments to the unique clinical and molecular profiles of younger lung cancer patients. Addressing the specific needs of younger patients—such as fertility preservation, career disruption, and social support—requires a multidisciplinary approach. Projections of rising female lung cancer rates necessitate targeted awareness campaigns, smoking cessation programs tailored to women, and policies addressing environmental risks. Emerging technologies, such as artificial intelligence, offer transformative potential for lung cancer prevention and care. Artificial intelligence can enhance the understanding of genetic and environmental interactions, improve risk prediction models, and optimize early detection strategies. Expanding access to these advancements, particularly in low-SDI regions, is crucial for reducing global disparities in lung cancer outcomes. Despite progress, LMICs face significant challenges due to socioeconomic and healthcare constraints. Targeted interventions, including tobacco control, pollution mitigation, and improved access to early detection and treatment, are essential. Coordinated efforts are needed to ensure equitable healthcare and strengthen infrastructure.[8]

 

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Conclusion

Despite a global decline in the age-standardized rates of lung cancer over the past 30 years, lung cancer remains a significant public health challenge. Regional and sex-based disparities persist, reflecting the complex interplay of risk factors, demographic shifts, and regional variations. While high-SDI regions have achieved notable progress in reducing lung cancer incidence and mortality, the burden is increasingly shifting toward low- and middle-SDI regions, particularly among females. This shift is further compounded by rising air pollution, sex-specific trends, and EOLC. Addressing these challenges requires a comprehensive, multifaceted approach that integrates prevention, early detection, and equitable access to care. Strengthening tobacco control, mitigating pollution, promoting clean cooking fuels, reducing occupational hazards, targeted prevention and screening programs, and expanding access to LDCT screening are fundamental to reducing lung cancer incidence and mortality. Addressing disparities in sex, age, and socioeconomic status, alongside leveraging advances in precision medicine and technology, is critical to shaping a future where lung cancer is preventable, detectable at earlier stages, and more effectively treatable.

 

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Conflict of Interest

None declared.

Acknowledgment

The authors thank Prof. Chongzhi Di for his advice.

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Publication History

Article published online:
14 August 2025