Trends in incidence and mortality for gynaecological cancers in Southeastern China during 2011–2020: a retrospective analysis of registry data

Abstract

Objectives

This study aimed to investigate the changes in the incidence and mortality trends of ovarian cancer (OC), cervical cancer (CC) and uterine cancer (UC) in the Fujian Province, southeastern China.

Design

Provincial, population-based, retrospective observational study.

Setting

Fujian province, southeastern China between 2011-2020.

Participants

From 2011 to 2020, 6178 new cases and 2037 deaths caused by 3 gynaecological cancers were eligible for analysis.

Primary and secondary outcome measures

The primary outcome measures were the incidence and mortality rates, including the age-standardised incidence rate (ASIR) and age-standardised mortality rate (ASMR), of three gynaecological cancers. The secondary outcome measure was the prevalence (average annual per cent changes (AAPC)).

Results

The incidence of all three gynaecological cancers increased from 2011 to 2020. CC had the slowest upward trend, with an AAPC of 2.54% over the period. However, it had the highest ASIR among the 3 cancers in 2020 (10.41/100 000). UC showed a rapid increase, with an AAPC of 15.15% from 2016 to 2020. While the mortality rate of UC remained stable, both CC and OC also exhibited rising trends, with the CC having the highest ASMR (3.05/100 000) in 2020. The ASMR for CC increased rapidly, with the highest AAPC of 5.51%. Conversely, changes in the ASMR for UC were not statistically significant (p=0.601). Moreover, high incidence rates were more common among perimenopausal women and older participants in the respective cancer groups where the increased mortality was observed.

Conclusions

Gynaecological cancer burden remains a public health issue in Fujian Province, with an increasing incidence. Improving the healthcare system and promoting a healthy lifestyle should be highlighted to reduce the cancer burden.

Correspondence to Dr Yang Sun; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• This study examined the burden of gynaecological malignancy in Fujian Province using the latest and most reliable data from the Fujian Cancer Prevention and Control Centre.

• The study covered 5 million people from coastal and inland areas, both developed and developing regions, and rural and urban settings.

• Jointpoint regression was used to analyse epidemiological changes.

• We could not perform an age-period-cohort analysis because of the limitation of 10-year observation.

Background

Gynaecological cancers significantly impact women’s life and health and their families.^{1 2} Among these malignancies, cancers of the cervix, uterus and ovaries contribute the most to the global cancer burden in women.³ Ovarian cancer (OC) is particularly lethal, with approximately 75% of cases recurring in advanced stage.^{4 5} Furthermore, cervical cancer (CC) is the fourth most common female malignancy worldwide, with an estimated 604 127 new cases and 341 831 deaths in 2022.³ Additionally, uterine cancer (UC) has become the most prevalent gynaecological cancer in high-income countries and is increasing in incidence worldwide, with an estimated 65 950 new UC cases.^{6 7} Noticeably, the global costs of gynaecological cancers are tremendously high. The costs of cancer care are estimated at US$519 billion for OC, US$682 billion for CC and US$193 billion for UC worldwide between 2020 and 2050.⁸ Hence, understanding the epidemiological situations and trends in CC, OC and UC is crucial for advancing aetiological research, preventing occurrence and reducing economic burdens.¹

China is the world’s most populous nation, with a high proportion of gynaecological cancers. According to a recent study, approximately 17.51% of deaths from malignant tumours of the female reproductive system occur in China.⁹ The incidence and mortality rates of gynaecological cancers continue to rise.^9–11 However, their epidemiological characteristics usually vary based on regions with specific economic and cultural backgrounds.^{1 10 12} Fujian is a key province in the eastern coastal region of China. It represents a typical example of coastal Asia and southeastern China. Fujian Province is notable for its coastal geography (an area of 124 000 km²),¹³ a large population (41.87 million as of 2021)¹⁴ and its prosperous economy. Currently, cancer represents a significant health challenge among females in Fujian Province, with an age-standardised 5-year relative survival of 38.90%.¹⁵ Moreover, the 2021 annual report of the Fujian Oncology Registry revealed that the crude incidences of overall cancers in women rose to 262.66 per 100 000, and the crude mortality rate reached 112.66 per 100 000.

Although there has been research assessing the overall survival of patients with cancer in Fujian, the gynaecological cancer epidemiological data in this region are still unavailable.¹⁵ Investigating temporal epidemiological trends of the three leading gyanecological cancers could provide scientific evidence for cancer prevention and control in Fujian Province and other similar regions in Asia. In this study, from 2011 to 2020, the incidence and mortality trends of OC, CC and UC were analysed from seven cancer registrations, mainly covering Fujian Province in southeastern China. Age, period and birth cohort effects were also demonstrated.

Methods

Patients and public involvement

We used a non-open-access database available from the Fujian Cancer Prevention and Control Office. All data were anonymised for the analysis. The patients and the public were not involved in the design, conduct, reporting or dissemination plans of our research plans.

Data source

The Fujian Cancer Prevention and Control Office is responsible for population-based cancer surveillance and statistics in the province and has been conducting population-based cancer registries since 2009. The registry collects information on new cancer cases from hospitals in its jurisdiction and uses a combination of passive and active follow-up methods to obtain patient survival status. The registry regularly obtains population-based cause-of-death surveillance data and matches them with cancer incidence data, which are supplemented by the time and underlying cause of death; this approach is known as passive follow-up. Active follow-up involves collecting the survival status of cases where the cause of death did not match the incidence data, through telephone calls and in-person visits. The registries inspected the data based on the guidelines for cancer registries in China and the data review rules established by the International Agency for Research on Cancer/International Association for Cancer Registries.

All registries regularly upload data through the ‘Fujian Cancer Registration Information System’ developed by the Fujian Cancer Prevention and Control Office, which was used to collate and export the data. Unqualified cases (lacking the required information) were rechecked by the local registries for authenticity. The demographic information for each registry was obtained from the Public Security Household Registration Department.

Data on new cases and deaths data due to OC, CC and UC from 2011 to 2020 were collected from the seven cancer registries, including from Changle, Hanjiang, Huian, Xiamen, Tongan, Xiangan and Yongding counties in Fujian Province. The seven registries covered 5 192 271 people accounting for 12.4% of the population of Fujian Province. They also have the longest and the most improved quality cancer epidemiological data of Fujian Province, involving coastal and inland populations, developed and developing areas, and rural and urban people.

Study population

Cancers are encoded following the International Classification of Diseases for Oncology, third edition, and the International Classification of Diseases 10th Revision. Based on these classifications, the study included cancers of the cervix (C53), uterus (C54-55) and ovaries (C56). Patients with non-Fujian household registration or incomplete information on sex and age at diagnosis were excluded from the study.

Statistical analyses

Statistical analyses were performed using SAS (V.9.0), the joinpoint regression program (V.4.4) and Excel. The crude and age-standardised rates (ASR) were computed using SAS V.9.0. Age-standardised incidence rates (ASIRs) and age-standardised mortality rates (ASMRs) were calculated employing Segi’s standard population and were expressed per 100 000 people. Next, a joinpoint regression analysis was performed to estimate the annual per cent change (APC) for each segment and the average annual per cent change (AAPC) over the entire period to quantify the trends of the ASIRs and ASMRs. Finally, to investigate the effects of the different factors, we described the incidence and mortality rates in the ages, periods and birth cohorts. Among them, age (20–85 years) and birth cohort (1921–1991) were subdivided into 5-year intervals. The birth cohort was obtained by subtracting the age from the period. The significance level was defined as two-sided alpha=0.05.

Owing to the retrospective nature of this study and the anonymity of personal information, the requirement for ethics committee approval was waived.

Results

Prevalence of three gynaecological cancers

Descriptions of the baseline characteristics of the study are summarised in table 1. A total of 6178 new cases and 2037 deaths from the 3 main gynaecological cancers were recorded, including 1249 cases and 589 deaths of OC, 3030 new cases and 926 deaths of CC, 1899 cases and 522 deaths of UC.

Table 1

Incidence and mortality of 3 gynaecological cancers in Fujian province 2011–2020 (per 100 000)

Data types	Year	OC			CC			UC
		Absolute population	Crude rate	ASR	Absolute population	Crude rate	ASRs	Absolute population	Crude rate	ASR
Incidence	2011	73	3.51	2.97	190	9.13	7.43	141	6.78	5.65
	2012	92	4.35	3.44	278	13.13	10.10	157	7.42	5.86
	2013	104	4.77	3.46	262	12.01	9.04	147	6.74	5.24
	2014	123	5.55	4.42	266	12.01	9.48	148	6.68	5.20
	2015	126	5.54	4.22	274	12.05	9.00	169	7.43	5.64
	2016	134	5.79	4.40	345	14.91	10.89	144	6.22	4.60
	2017	101	4.28	3.26	329	13.95	10.27	172	7.29	5.47
	2018	133	5.40	3.90	323	13.12	9.46	247	10.03	7.28
	2019	149	5.94	4.49	389	15.52	11.03	274	10.93	7.80
	2020	214	8.24	6.17	374	14.40	10.41	300	11.55	8.25
Mortality	2011	28	1.35	1.22	42	2.02	1.62	28	1.35	1.10
	2012	43	2.03	1.72	66	3.12	2.42	48	2.27	1.70
	2013	47	2.15	1.51	64	2.93	2.22	50	2.29	1.73
	2014	59	2.66	2.09	105	4.74	3.74	63	2.85	2.06
	2015	53	2.33	1.71	88	3.87	2.90	62	2.73	1.99
	2016	78	3.37	2.39	90	3.89	2.76	48	2.07	1.49
	2017	66	2.80	2.10	118	5.00	3.70	51	2.16	1.58
	2018	72	2.92	2.13	124	5.04	3.55	60	2.44	1.68
	2019	68	2.71	1.86	117	4.67	3.28	47	1.87	1.29
	2020	75	2.89	2.09	112	4.31	3.05	65	2.50	1.58

ASRs, age-standardised rates ; CC, cervical cancer; OC, ovarian cancer; UC, uterine cancer.

The trends in ASIR and ASMR are shown in figure 1. The ASIR values for all three cancers ascended. The incidence of OC was the lowest but rose most rapidly, with an increase in the ASIR from 2.97/100 000 in 2011 to 6.17/100 000 in 2020. Meanwhile, CC ranked first in incidence, with the ASIR rising from 7.43/100 000 in 2011 to 10.41/100 000 in 2020. Simultaneously, the incidence rate of UC remained stable at approximately 5/100 000 during the first 5 years and then increased significantly from 4.6/100 000 in 2016 to 8.25/100 000 in 2020. However, the ASMR trend varied. The tendency of OC slightly increased but levelled off during the last 5 years (approximately 2/100 000). CC had the highest mortality rate growing from 1.62/100 000 in 2011 to 3.05/100 000 in 2020. However, UC showed no apparent changes in ASMR (p=0.601).

Figure 1. Trends of the age-standardised incidence and mortality rates of 3 gynaecological cancers from 2011 to 2020 (per 100 000). (A) Incidence rates. (B) Mortality rates. CC, cervical cancer; OC, ovarian cancer; UC, uterine cancer.

The joinpoint regression

The joinpoint regression results for the ASRs in the incidence and mortality are presented in table 2. Both the ASIR and ASMR increased in the OC and CC groups. The AAPC of ASIR and ASMR for OC was 5.08% (p=0.021) and 4.63% (p=0.028), respectively. Meanwhile, CC also showed a significantly increased change over the entire period, with AAPC of 2.65% (p=0.031) and 6.3% (p=0.023), respectively. For UC, the ASIR continued to increase (AAPC=4.7%, p=0.014), while ASMR remained unchanged (AAPC=2.2%, p=0.601).

Table 2

Joinpoint regression analysis incidence and mortality trends in Fujian 2011–2020

Cancers	Rates	AAPC (%, 95% CI)	P value	Trend 1			Trend 2
				Period	APC (%, 95% CI)	P value	Period	APC (%, 95% CI)	P value
OC	ASIR	5.08 (1.0 to 9.3)	0.021*	2011–2020	5.08 (1.0 to 9.3)	0.021*
	ASMR	4.63 (0.6 to 8.8)	0.028*	2011–2020	4.63 (0.6 to 8.8)	0.028*
CC	ASIR	2.65 (0.3 to 5.0)	0.031*	2011–2020	2.65 (0.3 to 5.0)	0.031*
	ASMR	6.3 (1.1 to 11.8)	0.023*	2011–2020	6.3 (1.1 to 11.8)	0.023*
UC	ASIR	4.7 (0.9 to 8.6)	0.014*	2011–2016	−2.9 (8.3 to 2.8)	0.237	2016–2020	15.1 (6.2 to 24.8)	0.007
	ASMR	2.2 (−5.9 to 11.1)	0.601	2011–2013	29.6 (16.8 to 102.0)	0.193	2013–2020	−4.5 (−10 to 1.4)	0.105

*P<0.05 was considered statistically significant.

AAPC, average annual per cent change; APC, annual per cent change; ASIRs, age-standardised incidence rates; ASMRs, age-standardised mortality rates; CC, cervical cancer; OC, ovarian cancer; UC, uterine cancer.

Age, period and cohort effects

Age-specific incidence and mortality rates are shown in figure 2. In OC, the incidence rate initially increased in the 15–19 age group (8.98/100 000) and was as high as 100 per 100 000 in individuals aged 50–79 years, peaking in the 60–64 age group (133.78/100 000). Regarding CC, the incidence rate began to rise in the 20–24 age group (5.01/100 000) and peaked in the 45–59 age group, exceeding 300 per 100 000. The incidence rate of UC increased from 14.29/100 000 in the 30–34 age group to 270.31/100 000 (maximum) in the 55–59 age group. Patients aged 50–64 were the most susceptible to UC (＞200/100 000). Meanwhile, the mortality rates of OC and UC both began to rise starting in the 40–44 age group (15 per 100 000). Additionally, the highest mortality rates for both cancers occurred in the 75–79 age groups, reaching 120 per 100 000. In comparison, CC mortality was more prevalent among younger individuals. It increased in the 30–34 age group and was the highest (114.88/100 000) in the 50–54 age group. Moreover, the mortality rate of patients aged 45–84 years was over 80 per 100 000.

Figure 2. Age-specific incidence and mortality rates of three gynaecological cancers from 2011 to 2020 (per 100 000). (A, B) Incidence and mortality of ovarian cancer. (C, D) Incidence and mortality of cervical cancer. (E, F) Incidence and mortality of uterine cancer.

Temporal trends in the incidence and mortality rates with significant changes according to age group from 2011 to 2021 are shown in figure 3. The full version is provided as a supplement (online supplemental figure S1). The incidence rates of OC and UC in the 45–59 and 65–69 age groups ascended from 2011 to 2021 and descended in the 75–79 age group. Similarly, OC mortality showed an upward trend among those aged 45–64 and a downward trend among the 70–74 age group. In UC, the mortality rate increased in patients aged >75 years. Regarding CC, the incidence rate increased in the 50–54 and 60–79 age groups. Moreover, the 50–54 age group always had the highest rates during the study period. Simultaneously, the mortality increased in the 60–74 and 80–84 age groups.

Figure 3. Temporal trends in the incidence and mortality rates of three gynaecological cancers, with significant changes observed across different age groups from 2011 to 2020 (per 100 000). (A, B) Incidence and mortality of ovarian cancer. (C, D) Incidence and mortality of cervical cancer. (E, F) Incidence and mortality of uterine cancer.

The cohort-specific incidence and mortality rates according to age group are shown in online supplemental figure S2. The three cancer types had similar incidence and mortality changes. The incidence rates increased steadily in birth cohorts aged 50–69 years for OC, 50–79 years for CC and 45–74 years for UC. The mortality rates of the three cancers also increased steadily (OC aged: 40–74 years old, CC aged: over 45 and UC aged: over 55). Particularly, an upward trend was observed in patients with CC aged 35–39 with a peaked mortality rate (over 10 per 100 000).

Discussion

This is the first study to provide an up-to-date overview of the temporal epidemiological trends of OC, CC and UC in Fujian Province, which is representative of southeastern China. Overall, the incidence of the three cancers showed increasing trends, with an approximately doubled ASR. Mortality rates also increased measurably for both CC and OC but stabilised for UC. Each cancer exhibited unique features in its mortality. Our results enhance understanding of cancer prevention, inform aetiological research and address gaps in the epidemiology of gynaecological cancers in southeast China.

Local medical and health service levels and socioeconomic development were highly associated with the incidence trends. The incidence of CC has decreased in many well-developed countries with effective healthcare systems, including those in North America and Western Europe. Human papillomavirus (HPV) infection is known as a major factor related to CC development. In these nations, the widespread application of HPV vaccination and cytological screening has effectively reduced the progression of CC.¹⁶ However, the HPV vaccination and cytological screening in underdeveloped countries are not as widespread as in these developed countries.¹⁷ For example, in China, HPV vaccines are unable to meet demand owing to the large population and high costs.^{18 19} According to Li, southeast China, including Fujian Province, had the second-highest HPV infection rate of 18.3% (95% CI 13.4% to 23.3%) and the highest CC incidence rate of 94.4% (95% CI 91.5% to 97.4%) compared with that of other Chinese regions.²⁰ In addition, more CC cases were detected through the Fujian Province Cervical Lesion Screening Cohorts, a leading programme that significantly expanded screening opportunities.²¹ Therefore, enhancing CC screening awareness and facilitating the healthcare system should be given equal importance in reducing the incidence of CC.

For UC and OC, the main affected population is 50–64 years, likely owing to metabolism, reproduction and other factors. The increasing trend of UC in our study was similar to that observed in China and globally.^{22 23} The growing obese population is one of the contributing factors to this trend.²⁴ However, the age groups with the highest incidence vary across different regions. For example, the peak of UC onset in Egypt was observed in the 60–69 age group,²⁵ while that in the UK was in the 75–79 age group.²⁶ This may be related to differences in life expectancy across countries, as well as differences in healthcare services, early screening and diagnostic methods. The Chinese family planning policy may be a contributing factor to the increased OC incidence. This policy, involving a reduced number of pregnancies and longer total ovulation cycles, is associated with OC risk factors. In our study, OC incidence was high among women approximately 50 years between 2011 and 2022. These women, who were approximately 20–30 years old in 1988, were the primary group affected by the implementation of China’s family planning policy, leading us to infer that this policy may have been a driver of the observed trend. Furthermore, in the neighbouring province of Guangdong, a similar phenomenon has been observed, with an increased incidence trend of OC among those affected by the family planning policy.¹² In recent years, increased rates of OC have been observed in several countries, such as Japan, which may be related to increased rates of obesity and the adoption of Western-style diets.²⁷ It was proved that overweight women had a 7% higher risk of OC, while obese women had a 28% higher risk.²⁸ Additionally, high red meat intake was also positively associated with OC.^{29 30} While the OC incidence in several countries with high Human Development Index (HDI) levels was believed to be associated with the use of oral contraceptive pills,³¹ this association has not been proven in Fujian or China.

Changes in mortality were attributed to multiple factors including ageing and treatment. Ageing should be considered a key factor in rising mortality rates.¹ In our study, patients aged over 65 years old accounted for the majority of deaths across all 3 cancers, consistent with previous research findings.^{1 32} Notably, CC mortality was more prevalent among younger individuals, peaking in the 35–39 age group. A similar trend was also observed in other regions like Latin America and Japan.^{33 34} Sexual behaviours (eg, early sexual activity) and the resulting increased HPV infection were the potential reasons for this phenomenon.³³ Additionally, effective treatments were still not widely implemented, particularly against the background of rising incidence rates in OC and CC.³⁵ For OC, a recent study showed an approximate 100% increase in OC deaths in low HDI countries compared with 28% in high HDI countries in 2024, relative to 2020 estimates.³⁶ Platinum resistance and late-stage diagnosis are the primary concerns for relapse and death in OC, with no effective methods currently available to change this situation.³⁷ Similar to CC, treatments such as vascular endothelial growth factor inhibitors and immunotherapy for OC can impose significant economic burdens and their efficacy remains debated.⁶ Quality cancer care and effective treatment are essential for improving outcomes for patients with OC and CC. In contrast, our study found that UC mortality has remained stable, consistent with global trends.³⁸ In some countries, such as China, the trend in UC mortality has even decreased, likely owing to the early detection and diagnosis facilitated by the identification of abnormal vaginal bleeding.¹ The varying trends may account for the different education levels regarding UC. A recent study showed that the overall average rate of core knowledge of cancer prevention and control measures among adults in Fujian Province was below the 70% target set out by the Chinese Department of Health.¹⁴ Additionally, education level, pollution, exercise and even small molecules are also potential risk factors that could contribute to increased mortality in these three gynaecological cancers.^{12 14 39}

To the best of our knowledge, this is the first epidemiological survey to include the incidence and mortality of three major gynaecological cancers at the provincial level in southeastern China. It provided the most updated evaluation of temporal trends to convey scientific evidence for cancer prevention and ongoing surveillance. However, our study had certain limitations. First, research on approximately 12.4% of the population was limited to the regions of the 7 cancer registries. However, it covered 5 million people in Fujian Province, including coastal and inland populations, developed and developing areas, and rural and urban people. Overall, the samples are representative. Moreover, our study, with the longest duration and the largest sample size, focused on female reproductive malignancies using data from Fujian cancer registries to provide an overview of prevalence trends.⁴⁰ Thus, developing a more advanced system for collecting comprehensive epidemiological data remains necessary. Second, the study period of 10 years was inadequate to construct a favourable APC model for investigating other effects on changing trends, including age, period and birth cohort.⁴¹ A longer-term cohort is needed to investigate the relative impacts of epidemiological changes. Finally, more detailed information that might affect the epidemic trends, such as pathology and rural–urban differences, should be discussed.

Conclusion

Overall, the incidence of these three cancers steadily doubled in Fujian Province during the 10 years. The mortality rates of OC and CC also gradually increased. Notably, OC mortality was highest among the older individuals, whereas CC mortality was more prevalent in younger populations. The dynamically changing incidence and mortality rates suggest that raising awareness about cancer prevention is critical for alleviating the burden of gynaecological cancer. Expanding the coverage of HPV vaccination and advocating for a healthy lifestyle should be emphasised. Further in-depth studies are necessary to explore more epidemiological details, learn about the aetiology and treatment evaluation, and provide suggestions on medical or health resource distribution and cancer management.

The authors thank the participants and staff of the Department of Epidemiology at Fujian Cancer Hospital for their contributions.

Data availability statement

Data are available upon reasonable request. The data used or analysed in the current study are available from the corresponding author upon reasonable request.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

The Ethics Committee of Fujian Cancer Hospital determined that ethics approval and informed consent were not required for this research, because this is a retrospective study that used source data that were completely unidentifiable and all data were anonymous. The research was conducted in accordance with the Declaration of Helsinki, and the research data were kept confidential, exempted this study.

Footnote

Contributors YS is the guarantor of the present study. LL wrote the manuscript and analysed the data. YZ instructed and analysed the data. JL checked and revised the manuscript. SD, NX and HY contributed by analysing data.

Funding This work was sponsored by the Major Project for Young and Middle-aged Health Researchers of Fujian Province, China (grant number：2022ZQNZD008).

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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