Trends and incidence of stomach cancer in middle-aged and elderly populations: a global burden of disease analysis

Introduction

Stomach cancer remains one of the most significant challenges in global oncology, ranking as the fifth most common cancer and the third leading cause of cancer-related deaths worldwide (1). Despite advancements in early detection, treatment, and understanding of its pathophysiology, the global burden of stomach cancer continues to be disproportionately high, particularly among middle-aged and elderly populations (2).

Research into the multifactorial nature of stomach cancer has highlighted key risk factors, including Helicobacter pylori infection, unhealthy dietary habits, smoking, and genetic susceptibility. In particular, dietary patterns such as high intake of salted vegetables and fish have been shown to significantly contribute to gastric cancer incidence in East Asian populations, with an estimated 18.6% of cases in Korea in 2018 attributable to diet-related factors (3-5). Recent molecular studies have furthered our understanding by identifying genetic and epigenetic alterations that drive tumorigenesis, offering new opportunities for targeted therapies (2,6). The growing application of genomic technologies has also revealed distinct subtypes of stomach cancer, paving the way for more personalized treatment approaches (7,8).

The aging global population complicates the burden of stomach cancer, especially in low- and middle-income countries/regions where healthcare access and early detection are often limited (9,10). Older adults are particularly vulnerable due to cumulative exposure to risk factors and age-related changes in gastric physiology (11). As life expectancy increases, the number of middle-aged and elderly individuals at risk for developing stomach cancer is expected to rise, making it essential to track the evolving trends of the disease in these age groups (12).

While stomach cancer rates have declined in high-income countries/regions due to improvements in H. pylori eradication and healthier lifestyles, the incidence remains alarmingly high in several regions, and rates have even increased in some low- and middle-income countries/regions. These trends underscore the need for comprehensive studies to understand the evolving epidemiology of stomach cancer and inform public health strategies that address the needs of aging populations globally. We present this article in accordance with the STROBE reporting checklist (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-151/rc).

Methods

Data collection and sources

This study utilizes data from the Global Burden of Disease (GBD) Study 2021, which provides comprehensive and authoritative epidemiological information on the health status of countries/regions worldwide (13). The GBD Study aggregates data from multiple sources, including national health surveys, vital registration systems, health system reports, and peer-reviewed literature, aiming to provide consistent and comparable health burden estimates for 204 countries/regions (14).

The study focuses on middle-aged and elderly populations aged 50–74 years, with a particular emphasis on analyzing the trends in stomach cancer incidence within this age group. We specifically collected data disaggregated by age (50–54, 55–59, 60–64, 65–69, 70–74 years), sex (male, female), and region to explore the temporal trends and variations in incidence rates of stomach cancer. The dataset spans from 1990 to 2021, providing a rich longitudinal perspective for analyzing global trends in stomach cancer (14). The GBD Study employs advanced statistical modeling techniques, particularly the Bayesian meta-regression framework, to estimate disease burden in regions with sparse data, ensuring robust and reliable results even in countries/regions with limited data availability (15). In addition, the study explores regional and country-specific differences to reveal the diverse epidemiological patterns of stomach cancer worldwide.

Disease definition

Stomach cancer, or gastric cancer, is a malignancy that originates in the stomach lining. It is classified under the International Classification of Diseases (ICD) as follows: ICD-10: C16, C16.0, C16.1, C16.2, C16.3, C16.4, C16.5, C16.6, C16.8, C16.9; ICD-9: 151, 151.0, 151.1, 151.2, 151.3, 151.4, 151.5, 151.6, 151.8, 151.9, 209.23, V10.04 (13-15). Diagnosis of stomach cancer is typically confirmed through endoscopy, where tissue biopsies are obtained for histopathological examination (16). Additional diagnostic methods may include imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and endoscopic ultrasound, which aid in assessing tumor location, size, and spread to surrounding tissues or lymph nodes (17). Molecular and genetic analyses may also be employed in some cases to identify specific markers (16,17).

Statistical analysis

Temporal trends in the incidence of stomach cancer were evaluated using the Estimated Annual Percentage Change (EAPC), which quantifies the average annual change in incidence rates over time (18). The EAPC was calculated using a linear regression model applied to the natural logarithm of the incidence rates. The model assumes the relationship between time and the logarithm of the incidence rates is linear, where β represents the slope of the regression, and the EAPC is computed as EAPC =100×(exp(β)−1). A positive EAPC indicates an increasing trend in incidence rates, while a negative EAPC indicates a decreasing trend.

Additionally, the relationship between incidence rates and the Socio-Demographic Index (SDI) was assessed both globally and across countries/regions (19). The Pearson correlation coefficient (ρ) was used to evaluate the strength and direction of this association, with statistical significance set at P<0.05. All statistical analyses and visualizations were conducted using R software, employing appropriate packages for regression and correlation analysis.

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of The Affiliated Wuxi People’s Hospital of Nanjing Medical University (No. WP20241109). As this study involved secondary analysis of publicly available data, the ethics committee waived the requirement for informed consent. No personal or identifiable information was used.

Results

Global trends in middle-aged and elderly populations

From 1990 to 2021, the global number of stomach cancer cases in middle-aged and elderly populations (50–74 years) increased from 618,492 [95% uncertainty interval (UI): 553,829 to 679,670] to 725,622 (95% UI: 618,179 to 844,948), representing a 17.32% increase (Figure 1A and Table 1). However, the incidence rate declined significantly, from 80.67 (95% UI: 72.24 to 88.65) per 100,000 in 1990 to 44.18 (95% UI: 37.64 to 51.45) per 100,000 in 2021, with an EAPC of −2.15 [95% confidence interval (CI): −2.23 to −2.06] (Figure 1B and Table 1).

Figure 1 Global stomach cancer burden among middle-aged and elderly populations. (A) Number of stomach cancer cases among middle-aged and elderly populations by sex from 1990 to 2021. (B) Incidence rates of stomach cancer among middle-aged and elderly populations by sex from 1990 to 2021. (C) Number of stomach cancer cases among middle-aged and elderly populations across different age groups from 1990 to 2021. (D) Incidence rates of stomach cancer among middle-aged and elderly populations across different age groups from 1990 to 2021.

Sex-specific trends revealed that stomach cancer incidence rates were consistently higher in males than in females across the study period. In 1990, the incidence rate for males was 112.67 (95% UI: 96.03 to 127.37) per 100,000, decreasing to 65.03 (95% UI: 53.11 to 79.46) in 2021 (EAPC: −1.93; 95% CI: −2.01 to −1.85) (Figure 1B and Table 1). For females, the incidence rate declined from 50.19 (95% UI: 45.78 to 55.3) in 1990 to 24.36 (95% UI: 21.47 to 27.72) in 2021 (EAPC: −2.66; 95% CI: −2.79 to −2.54) (Figure 1B and Table 1). Despite the overall decline, the reduction in incidence rate was more pronounced in females than in males.

Differences by age group

Across all age groups (50–74 years), the incidence of stomach cancer demonstrated a declining trend, though the magnitude of decline varied by age. The incidence rate in the 50–54 age group decreased from 40.58 (95% UI: 35.01 to 44.89) per 100,000 in 1990 to 19.21 (95% UI: 16.31 to 23.11) in 2021 (EAPC: −2.55; 95% CI: −2.73 to −2.38) (Table 1). Similarly, the incidence rate in the 55–59 and 60–64 age groups also showed declines, with EAPCs of −2.47 (95% CI: −2.58 to −2.37) and −2.15 (95% CI: −2.22 to −2.09), respectively (Table 1).

For the 65–69 age group, the incidence rate decreased from 116.77 (95% UI: 106.68 to 128.31) in 1990 to 67.12 (95% UI: 57.07 to 77.92) in 2021 (EAPC: −1.95; 95% CI: −2.03 to −1.87), while the number of cases increased from 144,340 (95% UI: 131,866 to 158,602) in 1990 to 185,153 (95% UI: 157,412 to 214,943) in 2021 (Figure 1C,1D and Table 1). Similarly, for the 70–74 age group, the incidence rate declined from 151.37 (95% UI: 138.46 to 168.22) in 1990 to 93.28 (95% UI: 79 to 107.51) in 2021, with an EAPC of −1.68 (95% CI: −1.82 to −1.55), while the number of cases rose from 128,152 (95% UI: 117,220 to 142,419) in 1990 to 192,015 (95% UI: 162,607 to 221,305) in 2021 (Figure 1C,1D and Table 1). These results indicate that, while the incidence rates of stomach cancer have declined across all age groups, the decline is less pronounced in older age groups, particularly those aged 65–74 years. The increasing absolute number of cases in these age groups suggests a growing burden of the disease in older populations, reflecting demographic changes and sustained risk factors.

Regional differences

Stomach cancer incidence rates have shown significant regional variation, with high-SDI regions experiencing the most substantial declines in recent decades (20). In these regions, the incidence rate decreased from 74.51 per 100,000 in 1990 to 32.34 in 2021 (EAPC: −2.92, 95% CI: −3.00 to −2.84), with the number of cases falling from 140,726 to 106,445 (Figure 2A,2B and Table 1). Similarly, high-middle SDI regions saw a notable reduction in incidence rates, from 110.54 per 100,000 in 1990 to 63.34 in 2021 (EAPC: −2.06, 95% CI: −2.18 to −1.95), while the number of cases increased from 215,212 to 237,515 (Figure 2A,2B and Table 1). These declines reflect improvements in healthcare, lifestyle changes, and the impact of H. pylori eradication programs. In contrast, regions with low and low-middle SDI showed smaller reductions in incidence rates, with the incidence rate in low-middle SDI regions decreasing from 32.96 per 100,000 in 1990 to 24.45 in 2021 (EAPC: −0.97, 95% CI: −1.02 to −0.93), while cases increased from 40,959 to 70,010. Similarly, in low SDI regions, the incidence rate fell from 37.85 per 100,000 in 1990 to 24.84 in 2021 (EAPC: −1.46, 95% CI: −1.53 to −1.40), while the number of cases rose from 17,693 to 25,639 (Figure 2A,2B and Table 1).

Figure 2 Regional trends in stomach cancer incidence among middle-aged and elderly populations. (A) New cases of stomach cancer in different SDI regions from 1990 to 2021. (B) Incidence rates of stomach cancer in different SDI regions from 1990 to 2021. (C) Sex-specific stomach cancer incidence rates in 2021 at global, SDI regional, and geographical regional levels. SDI, Socio-Demographic Index.

When examining specific locations, considerable regional differences are evident in both incidence rates and trends (20). For example, East Asia had one of the highest incidence rates in 1990 (157.38 per 100,000) but showed a significant decrease to 88.55 per 100,000 by 2021 (EAPC: −2.02, 95% CI: −2.15 to −1.88) (Table 1). Despite this decrease, East Asia remains one of the regions with the highest burden of stomach cancer, particularly for males, as reflected in the gender-specific incidence rates (Figure 2C). Similarly, Western Europe showed a decrease from 50.35 per 100,000 in 1990 to 23.60 per 100,000 in 2021 (EAPC: −2.52, 95% CI: −2.58 to −2.46) (Table 1). In contrast, regions with lower SDI, such as Southern Sub-Saharan Africa and Eastern Sub-Saharan Africa, demonstrated smaller declines. Southern Sub-Saharan Africa saw a minimal change in incidence rates, moving from 22.65 per 100,000 in 1990 to 21.39 per 100,000 in 2021 (EAPC: −0.25, 95% CI: −0.61 to 0.11), while Eastern Sub-Saharan Africa had a more significant reduction but still remained relatively high, from 35.23 per 100,000 in 1990 to 20.29 per 100,000 in 2021 (EAPC: −2.02, 95% CI: −2.11 to −1.93) (Figure 2A,2B and Table 1). Fortunately, although the number of cases may have increased or decreased in some regions, the incidence rates have generally declined across nearly all regions, highlighting a global trend toward a reduced stomach cancer burden despite regional differences.

Differences across countries/regions

For the country-level analysis, the data reveals substantial variability in the incidence and trends of stomach cancer among older adults across different countries/regions (21). Notably, some countries/regions exhibit large changes in both the number of cases and incidence rates. For example, the United Arab Emirates experienced a sharp increase in the number of cases but a pronounced decline in the incidence rate (36.69 to 10.25 per 100,000; EAPC: −3.66, 95% CI: −4.05 to −3.28), suggesting that the rise in cases mainly reflects demographic expansion rather than a true increase in risk (Figure 3A). This sharp rise may be linked to changing lifestyle factors and healthcare improvements in the respective countries/regions. In contrast, Andorra showed a more modest increase in cases, with incidence rates declining from 42.88 per 100,000 in 1990 to 20.99 per 100,000 in 2021, but with a 31.08% increase in the number of cases (EAPC: −2.22, 95% CI: −2.47 to −1.97) (Figure 3A,3B and Table S1).

Figure 3 Global distribution of stomach cancer incidence among middle-aged and elderly populations in 204 countries/regions. (A) Percentage change in the number of stomach cancer cases between 1990 and 2021. (B) Stomach cancer incidence rates among middle-aged and elderly populations across countries/regions in 2021.

Other countries/regions, such as Germany, saw a notable reduction in incidence rates from 50.68 per 100,000 in 1990 to 28.9 per 100,000 in 2021 (EAPC: −1.95, 95% CI: −2.07 to −1.84), accompanied by a significant decline in the number of cases, from 10,867 in 1990 to 8,228 in 2021 (Figure 3B). This decline could be attributed to advances in early detection, improved treatment options, and lifestyle changes. Similarly, Italy and Spain experienced considerable reductions in incidence rates, reflecting similar healthcare and lifestyle changes, with cases dropping from 10,021.59 to 6,147.41 in Italy (EAPC: −2.65, 95% CI: −2.8 to −2.49) and from 5,639.44 to 4,007.99 in Spain (EAPC: −2.5, 95% CI: −2.58 to −2.43) (Figure 3B and Table S1).

However, some countries/regions with lower SDI regions showed slower reductions or even increases in cases. For instance, Nigeria and Mozambique experienced smaller declines in incidence rates (Nigeria: EAPC: −1.73, 95% CI: −1.85 to −1.62, Mozambique: 0.28, 95% CI: 0.09 to 0.47). Moreover, Zimbabwe demonstrated a slight increase in incidence rates, from 34.6 to 39.73 per 100,000, despite a rise in the number of cases from 287.46 to 569.02, with a positive EAPC of 0.99 (95% CI: 0.51 to 1.47) (Table S1). These findings reflect both the increasing burden in some nations, especially those in the lower SDI categories, and the success in reducing incidence rates in high-SDI countries/regions, although challenges remain globally in controlling the rise of stomach cancer among aging populations.

Correlation analysis

Stomach cancer in middle-aged and elderly populations shows significant regional and temporal variation. The incidence trends indicate that countries/regions with higher incidence rates in 1990 generally experienced more substantial declines in recent decades (ρ=−0.34, P<0.001) (Figure 4A). Furthermore, a stronger negative correlation exists between the EAPC and the SDI in 2021 (ρ=−0.491, P<0.001), suggesting that higher SDI countries/regions saw more marked reductions in incidence rates (Figure 4B). Although the relationship between SDI and current incidence rates is weak (ρ=−0.123, P=0.09), lower SDI regions still show higher incidence rates, reflecting the persistent burden of stomach cancer in these areas (Figure 4C). These findings underscore the influence of both historical factors and current socio-economic development on the epidemiology of stomach cancer.

Figure 4 Correlation between stomach cancer incidence, EAPC, and SDI among middle-aged and elderly populations. (A) Correlation between stomach cancer incidence and EAPC in middle-aged and elderly populations in 1990. Each dot represents a country/region, and the dot size indicates the number of stomach cancer cases in 1990. Case count categories are defined as follows: <1,000; 1,000–<10,000; and 10,000–100,000, with lower bounds inclusive and upper bounds exclusive. (B) Correlation between the SDI and EAPC of stomach cancer incidence in 2021. Each dot represents a country/region, and the dot size indicates the number of stomach cancer cases in 2021. Case count categories are defined as follows: <1,000; 1,000–<10,000; and 10,000–100,000, with lower bounds inclusive and upper bounds exclusive. (C) Relationship between stomach cancer incidence and SDI across countries/regions. EAPC, Estimated Annual Percentage Change; SDI, Socio-Demographic Index.

Discussion

Stomach cancer remains a significant global health challenge, especially for middle-aged and elderly populations (22). The findings of this study highlight a complex global landscape, with notable declines in incidence rates in high-SDI regions but continuing challenges in low- and middle-SDI countries/regions. This aligns with existing literature that underscores the role of improved healthcare infrastructure, healthier lifestyles, and public health interventions in reducing the burden of stomach cancer, particularly in higher-income countries/regions. However, despite these achievements, the absolute number of cases continues to rise globally, largely driven by demographic aging and the sustained exposure to risk factors over time. In particular, our study reveals that individuals aged 65–74 years experienced a slower decline in incidence rates, and the number of cases in this age group continued to grow, reflecting the shifting age structure of the global population. These findings underscore the urgency of developing age-specific prevention and early detection strategies, especially as populations continue to age. Additionally, the persistent disparities between high- and low-SDI regions highlight the pressing need to address socioeconomic inequalities in cancer care and prevention efforts worldwide (21).

High-SDI regions, such as Japan and South Korea, have seen substantial decreases in stomach cancer incidence rates, reflecting the successful implementation of H. pylori eradication programs, better early detection, and improved treatment options. Similarly, in rural areas of China’s Henan Province, population-based endoscopic screening programs were associated with significant declines in both incidence and mortality from 2010 to 2018 (23-25). These trends are consistent with prior studies that have emphasized the positive impact of national screening programs and public health initiatives in reducing stomach cancer prevalence (26). In contrast, many low-SDI regions, including parts of Sub-Saharan Africa and South Asia, have experienced slower declines in incidence rates, and in some cases, a rise in the number of cases (27). This discrepancy is largely due to limited access to healthcare, inadequate screening programs, and persistent risk factors, such as H. pylori infection and unhealthy dietary habits, which remain prevalent in these regions (28).

The findings also reveal a critical issue: while the overall incidence rates have declined in high-income countries/regions, the burden of stomach cancer remains disproportionately high among older populations. This is particularly evident in the 65–74 years age group, where the decline in incidence rates has been less pronounced, and the number of cases has continued to rise. The increasing burden of stomach cancer among elderly populations has been noted in other studies, which highlight the cumulative effect of long-term exposure to risk factors, such as smoking, poor diet, and H. pylori infection (29,30). As life expectancy increases, the number of older individuals at risk for stomach cancer is expected to continue growing, necessitating targeted screening and preventive measures for this age group.

Moreover, the correlation between incidence rates and the SDI emphasizes the ongoing disparity between high- and low-SDI regions. High-SDI countries/regions tend to have lower incidence rates and more significant reductions over time, reflecting the advantages of better healthcare systems, public health campaigns, and lifestyle modifications. This trend is supported by a previous study that has found similar patterns in the relationship between socio-economic development and cancer outcomes (26). On the other hand, lower SDI regions still face significant challenges in controlling stomach cancer due to factors such as limited healthcare resources, lower awareness of the disease, and persistent cultural and dietary habits that promote the risk factors for stomach cancer (31).

The increase in stomach cancer cases in some low-SDI countries/regions, like Nigeria and Mozambique, highlights the need for urgent public health interventions. As noted in other research, improving access to healthcare, enhancing public awareness, and implementing H. pylori eradication programs are crucial steps in mitigating the impact of stomach cancer in these regions (32). Additionally, lifestyle modifications, including reducing salt intake and promoting healthier diets, should be prioritized as part of comprehensive public health strategies. Furthermore, culturally tailored prevention programs and strengthened surveillance systems are essential for effectively addressing regional disparities, especially in underserved and aging populations.

Conclusions

Overall, this study reveals significant regional differences in stomach cancer incidence trends, particularly among middle-aged and elderly populations. High-SDI regions have seen notable declines in both incidence rates and cases, while low and middle-SDI regions show slower reductions. Despite an increase in the absolute number of cases, the decline in incidence rates is smaller in older age groups, especially those aged 65–74 years. Our analysis highlights a strong correlation between higher SDI and reduced incidence rates, underscoring the importance of socio-economic development. These findings stress the need for targeted public health strategies, especially in low-SDI regions, and approaches tailored to the aging global population. These findings stress the need for equitable resource allocation, enhanced surveillance in vulnerable groups, and culturally appropriate strategies to strengthen early detection and prevention, particularly in low-SDI regions and among aging populations.

Acknowledgments

We would like to acknowledge the long-standing efforts of the Global Burden of Disease collaboration team in providing the valuable data and resources that made this study possible.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-151/rc

Peer Review File: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-151/prf

Funding: This work was supported by Wuxi Municipal Bureau on Science and Technology (No. WX18IVJN017).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-151/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of The Affiliated Wuxi People’s Hospital of Nanjing Medical University (No. WP20241109). As this study involved secondary analysis of publicly available data, the ethics committee waived the requirement for informed consent. No personal or identifiable information was used.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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