2022 incidence and mortality of gastric cancer globally and in China
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摘要:
目的 分析2022年不同人类发展指数（HDI）国家和地区胃癌的发病和死亡状况，了解全球及中国的胃癌负担。 方法 收集GLOBOCAN 2022数据库中胃癌的发病和死亡数据及《2022人类发展报告》中2022年全球各国HDI数据，采用Spearman秩相关分析胃癌年龄标化发病率（ASIR）、年龄标化死亡率（ASMR）、死亡发病比（M/I）与HDI之间的关联，使用Wilcoxon秩和检验分析男性和女性胃癌ASIR、ASMR的差异。 结果 2022年全球胃癌发病和死亡人数位均列全球各癌种第5位，中国胃癌发病和死亡人数分别位列中国各癌种第5和第3位。在不同HDI国家和地区，胃癌ASIR、ASMR从高到低依次为高、极高、中等、低HDI国家和地区。胃癌ASIR与HDI呈正相关（rs＝0.256，P＝0.001），ASMR与HDI无明显相关性（rs＝－0.008，P＝0.918），M/I与HDI呈负相关（rs＝－0.831，P＜0.001）。全球、中国及各HDI分类国家和地区男性的胃癌ASIR和ASMR均高于女性（均P＜0.05）。全球胃癌ASIR和ASMR均在45岁之前无明显波动，在45岁之后呈快速上升趋势。中国胃癌ASIR和ASMR在各个年龄段均高于全球平均水平。 结论 极高和高HDI国家和地区胃癌发病和死亡负担高于中等和低HDI国家和地区。中国胃癌发病和死亡负担高于全球平均水平，需采取有针对性的防控措施。 Abstract:Objective To analyze the incidence and mortality of gastric cancer in countries and territories with different human development index (HDI) levels in 2022, and to understand the burden of gastric cancer globally and in China. Methods Data on gastric cancer incidence and mortality were collected from GLOBOCAN 2022 and HDI data for all countries were obtained from the Human development report 2022. Spearman correlation was applied to examine the associations between the age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR), mortality-to-incidence ratio (M/I), and HDI for gastric cancer. The Wilcoxon rank-sum test was used to assess the differences in ASIR and ASMR between males and females. Results In 2022, gastric cancer ranked the 5th in both incidence and mortality among all cancer types globally. In China, gastric cancer ranked the 5th in incidence and the 3rd in mortality among all cancer types. The ASIR and ASMR of gastric cancer showed a descending trend from high, very high, medium to low HDI countries and territories. The ASIR of gastric cancer was positively correlated with HDI (rs＝0.256, P＝0.001), while ASMR showed no significant correlation with HDI (rs＝－0.008, P＝0.918). The M/I was negatively correlated with HDI (rs＝－0.831, P < 0.001). The ASIR and ASMR of gastric cancer in males were significantly higher than those in females globally, in China, and across all HDI groups (all P < 0.05). Globally, both ASIR and ASMR of gastric cancer remained relatively stable before the age of 45, but showed a consistently rising trend after the age of 45. In China, the ASIR and ASMR of gastric cancer exceeded global average level across all age groups. Conclusion The burden of gastric cancer incidence and mortality is higher in very high and high HDI countries and territories compared to medium and low HDI countries and territories. In China, the burden of gastric cancer incidence and mortality is above the global average, highlighting the need for targeted prevention and control measures. -
Keywords:
- stomach neoplasms /
- incidence /
- mortality /
- human development index
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胃癌是全球常见的恶性肿瘤之一，2020年全球胃癌死亡人数达到76.9万，死亡率位列各癌种第四，仅次于肺癌、结直肠癌和肝癌[1]。近75%的胃癌发病可归因于幽门螺杆菌（Helicobacter pylori，Hp）感染，其他危险因素包括饮酒、吸烟和摄入高盐食品等[2]。目前胃癌主要通过根治Hp感染和胃癌筛查等技术进行防控[3]。胃癌由于早期缺乏特异性临床体征，一经发现常常已经进入中晚期，治疗效果有限[4]。胃癌筛查有助于早期诊断，然而非侵入性筛查手段的灵敏度和特异度低，侵入性筛查手段的费用高且依从性低，限制了胃癌筛查的推广[5]。胃癌预后相对较差，世界上大部分地区胃癌患者的5年生存率约为20%，中国胃癌患者的5年生存率不足50%，但在日本和韩国5年生存率已超过70%[6-7]。中国胃癌发病和死亡人数在全球各国均位列第一，虽然我国自20世纪60年代末启动了系统性癌症防控工作，但仍是胃癌高发国家之一[8]。我国自2005年开展上消化道癌早诊、早治项目，提高了早期胃癌检出率，改善了胃癌患者生存率，但胃癌仍是癌症防治的重点癌种[9]。
有研究发现癌症发病率、死亡率和经济、文化、医疗水平等有关[10]。人类发展指数（human development index，HDI）是衡量健康和长寿、知识水平及生活水平三大基本维度的综合指数[11]。分析HDI与胃癌发病和死亡的关系有助于了解HDI对胃癌的影响及为胃癌防控提供新的视角。中国近30年内经历了从低HDI（1990－1996年）向中等HDI（1997－2010年）最终成为高HDI（2011－2020年）国家的过渡[12]。在经济发展和社会转型的过程中，需要借鉴不同HDI国家胃癌的防控经验。本研究旨在利用GLOBOCAN 2022胃癌数据，分析全球、不同HDI国家和地区及中国2022年胃癌的发病和死亡情况，探索胃癌流行和HDI状况的关联，为制定更有针对性和有效的胃癌防控策略提供科学依据。
1 资料和方法
1.1 资料来源
胃癌数据来源于国际癌症研究机构发布的GLOBOCAN 2022数据库（https://gco.iarc.fr/today/en），涵盖了185个国家和地区的癌症发病率和死亡率数据。通过《疾病和有关健康问题的国际统计分类（第十次修订本）》（ICD-10）代码C16识别GLOBOCAN 2022数据库中的胃癌。根据联合国开发计划署公布的《2022人类发展报告》（https://hdr.undp.org/data-center/human-development-index#/indicies/HDI）获得2022年世界各国HDI数据及分类。HDI水平分为4类，即极高HDI（0.800~1）、高HDI（0.700~0.799）、中等HDI（0.550~0.699）、低HDI（0~0.549）[13]。
1.2 统计学处理
下载并整理2022年胃癌发病人数、粗发病率、年龄标化发病率（age-standardized incidence rate，ASIR）、死亡人数、粗死亡率、年龄标化死亡率（age-standardized mortality rate，ASMR）数据。在分析2022年胃癌数据和HDI的关联时，剔除缺失数据的国家，最终共176个国家纳入分析。将人群按每5岁一组，从0~4岁组至≥85岁组共分为18个组。年龄标化率的计算使用Segi’s世界标准人口年龄构成进行标化[14]。死亡发病比（mortality-to-incidence ratio，M/I）为死亡人数/同期发病人数。胃癌ASIR、ASMR和M/I与HDI的相关性分析采用Spearman秩相关。男性和女性之间胃癌ASIR、ASMR的差异分析采用Wilcoxon秩和检验。应用SPSS 25.0和GraphPad Prism 9.5.0软件进行统计学分析及绘图。检验水准（α）为0.05（双侧）。
2 结果
2.1 2022年全球及中国胃癌发病情况
2022年全球胃癌发病人数位列各癌种第5位，男性胃癌发病人数位列男性各癌种第4位，女性胃癌发病人数位列女性各癌种第7位。中国胃癌发病人数位列各癌种第5位，男性胃癌发病人数位列中国男性各癌种第4位，女性胃癌发病人数位列中国女性各癌种第6位。中国胃癌发病人数占全球胃癌发病人数的37.02%，中国男性胃癌发病人数占全球男性胃癌发病人数的39.29%，中国女性胃癌发病人数占全球女性胃癌发病人数的32.85%。见表 1。
表 1 2022年全球及中国总人口、男性、女性发病人数排前8位的癌症Table 1 Incidence of top 8 cancers among total population, males, and females in China and globally in 2022Global China Precedence Number of incident cases/(×104) Proportion/% Crude incidence rate/(×10－5) ASIR/(×10－5) Precedence Number of incident cases/(×104) Proportion in China/% Proportion in the world/% Crude incidence rate/(×10－5) ASIR/(×10－5) Total Total All cancers 1 997.65 100.00 253.4 196.9 All cancers 482.47 100.00 24.15 341.8 201.6 Lung 248.07 12.42 31.5 23.6 Lung 106.06 21.98 42.75 75.1 40.8 Breast 229.68 11.50 58.7 46.8 Colorectum 51.71 10.72 26.84 36.6 20.1 Colorectum 192.64 9.64 24.4 18.4 Thyroid 46.61 9.66 56.76 33.0 24.6 Prostate 146.79 7.35 37.0 29.4 Liver 36.77 7.62 42.45 26.0 15.0 Stomach 96.88 4.85 12.3 9.2 Stomach 35.87 7.43 37.02 25.4 13.7 Liver 86.61 4.34 11.0 8.6 Breast 35.72 7.40 15.55 51.7 33.0 Thyroid 82.12 4.11 10.4 9.1 Oesophagus 22.40 4.64 43.83 15.9 8.3 Cervix uteri 66.23 3.31 16.9 14.1 Cervix uteri 15.07 3.12 22.75 21.8 13.8 Male Male All cancers 1 031.16 100.00 259.6 212.6 All cancers 253.39 100.00 24.57 351.4 209.6 Lung 157.20 15.25 39.6 32.1 Lung 65.87 26.00 41.90 91.4 52.0 Prostate 146.79 14.23 37.0 29.4 Colorectum 30.77 12.14 28.77 42.7 24.7 Colorectum 106.94 10.37 26.9 21.9 Liver 26.79 10.57 44.60 37.2 22.7 Stomach 62.75 6.08 15.8 12.8 Stomach 24.66 9.73 39.29 34.2 19.5 Liver 60.07 5.83 15.1 12.7 Oesophagus 16.75 6.61 45.85 23.2 13.1 Bladder 47.13 4.57 11.9 9.3 Prostate 13.42 5.29 9.14 18.6 9.7 Oesophagus 36.52 3.54 9.2 7.6 Thyroid 12.49 4.93 60.49 17.3 13.3 NHL 31.14 3.02 7.8 6.6 Bladder 7.32 2.89 15.53 10.2 5.7 Female Female All cancers 966.49 100.00 247.0 186.3 All cancers 229.08 100.00 23.70 331.6 197.0 Breast 229.68 23.76 58.7 46.8 Lung 40.19 17.54 44.23 58.2 30.3 Lung 90.86 9.40 23.2 16.2 Breast 35.72 15.59 15.55 51.7 33.0 Colorectum 85.70 8.87 21.9 15.2 Thyroid 34.12 14.89 55.51 49.4 36.5 Cervix uteri 66.23 6.85 16.9 14.1 Colorectum 20.94 9.14 24.44 30.3 15.7 Thyroid 61.47 6.36 15.7 13.6 Cervix uteri 15.07 6.58 22.75 21.8 13.8 Corpus uteri 42.04 4.35 10.7 8.4 Stomach 11.21 4.89 32.85 16.2 8.3 Stomach 34.13 3.53 8.7 6.0 Liver 9.98 4.35 37.60 14.4 7.4 Ovary 32.46 3.36 8.3 6.7 Corpus uteri 7.77 3.39 18.48 11.3 6.8 Proportion: The proportion of cases of the cancer among all cancer cases globally; Proportion in China: The proportion of cases of the cancer among all cancer cases in China; Proportion in the world: The proportion of cases of the cancer in China relative to all cases of the same cancer globally. ASIR: Age-standardized incidence rate; NHL: Non-Hodgkin lymphoma. 2.2 2022年全球及中国胃癌死亡情况
2022年全球胃癌死亡人数位列全球各癌种第5位，男性胃癌死亡人数位列全球男性各癌种第4位，女性胃癌死亡人数位列全球女性各癌种第6位。中国胃癌死亡人数位列中国各癌种第3位，男性胃癌死亡人数位列中国男性各癌种第3位，女性胃癌死亡人数位列中国女性各癌种第4位。中国胃癌死亡人数占全球胃癌死亡人数的39.44%，中国男性胃癌死亡人数占全球男性胃癌死亡人数的42.46%，中国女性胃癌死亡人数占全球女性胃癌死亡人数的33.88%。见表 2。
表 2 2022年全球及中国总人口、男性、女性死亡人数排前8位的癌症Table 2 Mortality of top 8 cancers among total population, males, and females in China and globally in 2022Global China Precedence Number of deaths/(×104) Proportion/% Crude mortality rate/(×10－5) ASMR/(×10－5) Precedence Number of deaths/(×104) Proportion in China/% Proportion in the world/% Crude mortality rate/(×10－5) ASMR/(×10－5) Total Total All cancers 974.38 100.00 123.6 91.7 All cancers 257.42 100.00 26.42 182.3 96.5 Lung 181.75 18.65 23.1 16.8 Lung 73.33 28.49 40.35 51.9 26.7 Colorectum 90.40 9.28 11.5 8.1 Liver 31.65 12.30 41.72 22.4 12.6 Liver 75.87 7.79 9.6 7.4 Stomach 26.04 10.11 39.44 18.4 9.4 Breast 66.61 6.84 17.0 12.7 Colorectum 24.00 9.32 26.55 17.0 8.6 Stomach 66.02 6.78 8.4 6.1 Oesophagus 18.75 7.28 42.09 13.3 6.7 Pancreas 46.74 4.80 5.9 4.2 Pancreas 10.63 4.13 22.74 7.5 3.9 Oesophagus 44.54 4.57 5.7 4.3 Breast 7.50 2.91 11.26 10.9 6.1 Prostate 39.74 4.08 10.0 7.3 Brain and CNS 5.66 2.20 22.78 4.0 2.5 Male Male All cancers 543.03 100.00 136.7 109.8 All cancers 162.93 100.00 30.00 226.0 127.5 Lung 123.32 22.71 31.0 24.8 Lung 51.59 31.66 41.83 71.6 39.5 Liver 52.18 9.61 13.1 10.9 Liver 22.98 14.10 44.03 31.9 19.1 Colorectum 49.98 9.20 12.6 9.9 Stomach 18.16 11.14 42.46 25.2 13.8 Stomach 42.76 7.87 10.8 8.6 Colorectum 14.26 8.75 28.53 19.8 10.9 Prostate 39.74 7.32 10.0 7.3 Oesophagus 14.04 8.62 44.09 19.5 10.7 Oesophagus 31.84 5.86 8.0 6.5 Pancreas 6.11 3.75 24.67 8.5 4.7 Pancreas 24.76 4.56 6.2 5.0 Prostate 4.75 2.92 11.96 6.6 3.3 Leukaemia 17.33 3.19 4.4 3.7 Bladder 3.25 1.99 13.09 4.5 2.3 Female Female All cancers 431.35 100.00 110.3 76.9 All cancers 94.49 100.00 21.91 136.8 67.8 Breast 66.61 15.44 17.0 12.7 Lung 21.74 23.01 37.21 31.5 14.7 Lung 58.42 13.54 14.9 9.8 Colorectum 9.74 10.31 24.10 14.1 6.5 Colorectum 40.42 9.37 10.3 6.5 Liver 8.68 9.18 36.63 12.6 6.2 Cervix uteri 34.89 8.09 8.9 7.1 Stomach 7.88 8.34 33.88 11.4 5.3 Liver 23.69 5.49 6.1 4.1 Breast 7.50 7.94 11.26 10.9 6.1 Stomach 23.26 5.39 6.0 3.9 Cervix uteri 5.57 5.89 15.96 8.1 4.5 Pancreas 21.98 5.10 5.6 3.5 Oesophagus 4.71 4.98 37.08 6.8 2.9 Ovary 20.70 4.80 5.3 4.0 Pancreas 4.52 4.78 20.56 6.6 3.1 Proportion: The proportion of deaths from the cancer among all cancer deaths globally; Proportion in China: The proportion of deaths from the cancer among all cancer deaths in China; Proportion in the world: The proportion of deaths from the cancer in China relative to all deaths from the same cancer globally. ASMR: Age-standardized mortality rate; CNS: Central nervous system. 2.3 胃癌发病、死亡情况与HDI的相关性分析
将全球176个国家和地区的胃癌ASIR、ASMR、M/I与HDI进行相关性分析，结果显示，胃癌ASIR与HDI呈正相关（rs＝0.256，P＝0.001），胃癌ASMR与HDI无明显相关性（rs＝－0.008，P＝0.918），胃癌M/I与HDI呈负相关（rs＝－0.831，P＜0.001）；男性、女性胃癌M/I都与HDI呈负相关（rs＝－0.787，P＜0.001；rs＝－0.803，P＜0.001）。将HDI进行分组分析，在极高HDI国家和地区中，男性和女性胃癌ASIR（rs＝－0.391，P＝0.002；rs＝－0.309，P＝0.015）、ASMR（rs＝－0.533，P＜0.001；rs＝－0.524，P＜0.001）、M/I（rs＝－0.621，P＜0.001；rs＝－0.538，P＜0.001）均与HDI呈负相关；在高、低HDI国家和地区，男性及女性胃癌M/I均与HDI呈负相关（高HDI国家和地区：男性rs＝－0.346，P＝0.023；女性rs＝－0.592，P＜0.001；低HDI国家和地区：男性rs＝－0.426，P＝0.014；女性rs＝－0.408，P＝0.019）。见表 3。
表 3 胃癌发病和死亡情况与HDI的Spearman秩相关分析Table 3 Spearman rank correlation analyses of gastric cancer incidence and mortality with HDIClassfication Group ASIR ASMR M/I rs P value rs P value rs P value Global Total 0.256 0.001 －0.008 0.918 －0.831 ＜0.001 Male 0.303 ＜0.001 0.092 0.226 －0.787 ＜0.001 Female 0.132 0.081 －0.131 0.082 －0.803 ＜0.001 Very high HDI Total －0.345 0.006 －0.565 ＜0.001 －0.655 ＜0.001 Male －0.391 0.002 －0.533 ＜0.001 －0.621 ＜0.001 Female －0.309 0.015 －0.524 ＜0.001 －0.538 ＜0.001 High HDI Total 0.292 0.057 0.228 0.142 －0.486 0.001 Male 0.267 0.084 0.252 0.103 －0.346 0.023 Female 0.324 0.034 0.232 0.134 －0.592 ＜0.001 Medium HDI Total 0.285 0.083 0.261 0.114 －0.019 0.910 Male 0.313 0.056 0.295 0.072 0.002 0.989 Female 0.150 0.369 0.127 0.448 －0.212 0.201 Low HDI Total －0.036 0.842 －0.049 0.789 －0.489 0.004 Male －0.041 0.821 －0.059 0.746 －0.426 0.014 Female －0.074 0.681 －0.107 0.555 －0.408 0.019 Very high, high, medium, and low HDI mean the HDI being 0.800-1, 0.700-0.799, 0.550-0.699, and 0-0.549, respectively. HDI: Human development index; ASIR: Age-standardized incidence rate; ASMR: Age-standardized mortality rate; M/I: Mortality-to-incidence ratio. 2.4 2022年不同HDI国家和地区胃癌发病和死亡情况
在不同HDI国家和地区，男性胃癌ASIR、ASMR从高到低均为高、极高、中等、低HDI国家和地区。高HDI国家和地区胃癌ASIR分别是极高、中等、低HDI国家和地区的1.2、2.2、2.9倍，ASMR是极高、中等、低HDI国家和地区的1.7、1.7、2.3倍。中国胃癌ASIR、ASMR均高于全球水平，均是全球的1.5倍，中国男性和女性胃癌ASIR、ASMR分别高于全球男性和女性胃癌ASIR、ASMR。全球、中国及各HDI分类国家和地区男性的胃癌ASIR、ASMR均高于女性（均P＜0.05）。高HDI国家和地区男性胃癌ASIR、ASMR和女性差异最大，男性ASIR、ASMR分别是女性的2.3、2.4倍。胃癌M/I随着HDI的升高呈下降趋势，且在男性和女性中的趋势一致。见表 4。
表 4 全球、不同HDI国家和地区、中国胃癌的发病和死亡情况Table 4 Incidence and mortality of gastric cancer globally, in different HDI countries and territories, and in ChinaClassfication Group Crude incidence rate/(×10－5) ASIR/(×10－5) Crude mortality rate/(×10－5) ASMR/(×10－5) M/I Very high HDI Total 21.4 9.7 11.2 4.7 0.52 Male 27.2 13.6 13.8 6.5 0.51 Female 15.6 6.4** 8.6 3.2** 0.55 High HDI Total 17.4 11.4 12.9 8.1 0.74 Male 23.1 16.1 17.3 11.8 0.75 Female 11.6 7.1** 8.4 4.9** 0.73 Medium HDI Total 5.0 5.3 4.4 4.7 0.88 Male 6.2 7.0 5.4 6.2 0.88 Female 3.7 3.8** 3.2 3.3** 0.87 Low HDI Total 2.1 3.9 1.9 3.5 0.88 Male 2.3 4.5 2.1 4.0 0.88 Female 1.9 3.3** 1.7 3.0* 0.88 Global Total 12.3 9.2 8.4 6.1 0.68 Male 15.8 12.8 10.8 8.6 0.68 Female 8.7 6.0** 6.0 3.9** 0.68 China Total 25.4 13.7 18.4 9.4 0.73 Male 34.2 19.5 25.2 13.8 0.74 Female 16.2 8.3** 11.4 5.3** 0.70 Very high, high, medium, and low HDI mean the HDI being 0.800-1, 0.700-0.799, 0.550-0.699, and 0-0.549, respectively. *P＜0.05, **P＜0.01 vs male group in the same classification. HDI: Human development index; ASIR: Age-standardized incidence rate; ASMR: Age-standardized mortality rate. 2.5 全球、不同HDI国家和地区、中国胃癌年龄别ASIR胃癌年龄别ASIR
在不同性别中的分布与总人口分布类似。全球胃癌ASIR在45岁之前无明显波动，在45岁之后均呈快速上升趋势。高HDI国家和地区胃癌ASIR在84岁前均高于其他HDI水平的国家和地区，中等及低HDI国家和地区的胃癌ASIR在各个年龄段均处于相对较低的水平。中国胃癌ASIR在84岁前随年龄增长而增高，在各个年龄段均高于全球水平。见图 1。
图 1 全球、不同HDI国家和地区、中国胃癌年龄别ASIRFig. 1 ASIR of gastric cancer globally, in different HDI countries and territories, and in ChinaVery high, high, medium, and low HDI mean the HDI being 0.800-1, 0.700-0.799, 0.550-0.699, and 0-0.549, respectively. HDI: Human development index; ASIR: Age-standardized incidence rate.
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2.6 全球、不同HDI国家和地区、中国胃癌年龄别ASMR胃癌年龄别ASMR
在不同性别中的分布趋势与总人口的分布类似。全球胃癌ASMR在45岁之前无明显波动，在45岁之后呈快速上升趋势。高HDI国家和地区胃癌ASMR在不同年龄段均高于其他HDI水平国家和地区，中等及低HDI国家和地区的胃癌ASMR在各年龄段均处于相对较低水平。中国胃癌ASMR在各年龄段变化同全球趋势，且在各个年龄段均高于全球水平。见图 2。
图 2 全球、不同HDI国家和地区、中国胃癌年龄别ASMRFig. 2 ASMR of gastric cancer globally, in different HDI countries and territories, and in ChinaVery high, high, medium, and low HDI mean the HDI being 0.800-1, 0.700-0.799, 0.550-0.699, and 0-0.549, respectively. HDI: Human development index; ASMR: Age-standardized mortality rate.下载:
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3 讨论
2022年全球胃癌发病率和死亡率相较于2020年[1]有所下降。胃癌的发病率和死亡率近年来呈下降趋势，有研究指出这与Hp根除治疗和胃癌筛查策略有关[15]。胃癌的发病风险主要与Hp感染有关，从1990年到2022年全球Hp感染患病率由58.2%下降到43.1%[16]。胃癌的死亡风险降低主要与胃癌筛查策略的实施有关，在日本、韩国等极高HDI国家和地区，随着胃癌高危人群筛查策略的实施，胃癌预后持续改善[17]。中国胃癌ASIR从2020年的20.74/10万下降到2022年的13.7/10万，ASMR由15.99/10万下降到9.4/10万，自我国启动系统癌症防治工作以来，胃癌发病率和死亡率持续下降[18]，但我国胃癌防治仍面临极大的负担和挑战。
高HDI国家和地区胃癌ASIR高于极高HDI国家和地区，造成这种差异的原因可能与高HDI国家和地区Hp感染率高于极高HDI国家和地区有关。最新研究表明，在极高、高、中等、低HDI国家和地区，Hp感染率分别为44.4%（95% CI 42.5%~46.3%）、53.9%（95% CI52.5%~55.2%）、52.4%（95% CI 48.6%~56.2%）、55.6%（95% CI 52.1%~59.1%）[19]。尽管中等、低HDI国家和地区Hp感染率很高，但是其胃癌的发病率却远低于极高、高HDI国家和地区，这可能与中等、低HDI国家和地区感染的Hp菌株致癌风险较低有关。同时由于中等、低HDI国家和地区常见的肠道寄生虫感染可诱导辅助性T细胞产生抗炎免疫反应，这可能抑制了Hp感染引发的炎症，进一步降低了胃癌风险[20]。此外，由于内镜检查数据不足、医疗保健机会有限及预期寿命相对较短等原因，中等、低HDI国家和地区胃癌的发病率可能被低估[21]。除了Hp感染外，吸烟和饮酒等胃癌危险因素在不同HDI国家和地区的分布也存在差异。极高、高HDI国家和地区平均吸烟率和酒精使用障碍的患病率均比中等、低HDI国家和地区更高[22-23]。与从不吸烟者相比，吸烟者患胃癌的风险增加1.53倍，且吸烟时间越长胃癌发病风险越高[24]。同样，重度饮酒者患胃癌的风险比不饮酒者高1.2~2.1倍[25]。
在不同HDI国家和地区，男性胃癌发病率和死亡率均高于女性，这可能也与Hp感染率在男性中高于女性有关[26]。男性和女性在吸烟率方面存在差异，WHO统计数据显示，2021年全球男性吸烟率为29%，女性吸烟率为5%[22]。男性和女性在饮酒率方面也存在差异，全球约6.7%的男性为重度饮酒者，而女性仅占0.6%[23]。此外，雌激素在与Hp感染有关的胃癌发病中发挥着保护作用[27]。这些因素可能与胃癌在不同性别中负担差异有关。
胃癌M/I随着HDI的升高呈下降趋势，且在男性和女性中的趋势一致。由于HDI是反映教育系统、医疗服务和人均收入等的综合性指标，随着HDI的升高胃癌患者在早期发现、医疗保健、预后护理等方面有所改善[13]。研究表明，高收入国家胃癌患者的存活率显著高于低收入国家[28]。因此，提高胃癌诊断治疗水平、改善医疗保健质量及提高居民生活水平对降低胃癌死亡率具有重要意义。全球胃癌ASIR和ASMR总体趋势不是随着HDI的升高而降低，而仅在极高HDI国家和地区随着HDI的升高呈下降趋势，这提示高、中等、低HDI国家和地区可能存在胃癌负担改善与经济发展不对称的情况。胃癌ASIR和ASMR总体变化趋势是随年龄增长而上升，在45岁以后呈快速增长趋势。我国最新的胃癌筛查指南推荐胃癌筛查起始年龄为45岁[29]，本研究结果亦支持这一建议。
2022年中国胃癌发病人数和死亡人数分别占全球胃癌的37.02%和39.44%，均显著高于中国人口在全球人口中的占比。21世纪以来，随着社会经济快速发展及胃癌筛查与早诊、早治等防控措施的不断推广，我国胃癌负担持续下降[30]。然而，在人口快速老龄化、Hp感染率高、吸烟与饮酒流行率高及高盐饮食习惯等多重危险因素的综合作用下，我国胃癌的防控仍面临严峻挑战。目前我国尚未将Hp感染筛查和根除治疗纳入胃癌防治策略中。有研究指出，在高危人群中开展Hp感染筛查和根除策略具有成本-效果优势[31]。因此，在既往胃癌早筛、早治项目成功经验的基础上，我国可进一步将胃癌防控重点转向Hp感染早期筛查，在高危人群中推广胃癌筛查和早期干预策略，强化健康教育，提升公众对胃癌危险因素的认知水平，扩大胃癌筛查的覆盖面和可及性，从而降低胃癌负担。
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图 1 全球、不同HDI国家和地区、中国胃癌年龄别ASIR
Fig. 1 ASIR of gastric cancer globally, in different HDI countries and territories, and in China
Very high, high, medium, and low HDI mean the HDI being 0.800-1, 0.700-0.799, 0.550-0.699, and 0-0.549, respectively. HDI: Human development index; ASIR: Age-standardized incidence rate.
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图 2 全球、不同HDI国家和地区、中国胃癌年龄别ASMR
Fig. 2 ASMR of gastric cancer globally, in different HDI countries and territories, and in China
Very high, high, medium, and low HDI mean the HDI being 0.800-1, 0.700-0.799, 0.550-0.699, and 0-0.549, respectively. HDI: Human development index; ASMR: Age-standardized mortality rate.
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表 1 2022年全球及中国总人口、男性、女性发病人数排前8位的癌症
Table 1 Incidence of top 8 cancers among total population, males, and females in China and globally in 2022
Global China Precedence Number of incident cases/(×104) Proportion/% Crude incidence rate/(×10－5) ASIR/(×10－5) Precedence Number of incident cases/(×104) Proportion in China/% Proportion in the world/% Crude incidence rate/(×10－5) ASIR/(×10－5) Total Total All cancers 1 997.65 100.00 253.4 196.9 All cancers 482.47 100.00 24.15 341.8 201.6 Lung 248.07 12.42 31.5 23.6 Lung 106.06 21.98 42.75 75.1 40.8 Breast 229.68 11.50 58.7 46.8 Colorectum 51.71 10.72 26.84 36.6 20.1 Colorectum 192.64 9.64 24.4 18.4 Thyroid 46.61 9.66 56.76 33.0 24.6 Prostate 146.79 7.35 37.0 29.4 Liver 36.77 7.62 42.45 26.0 15.0 Stomach 96.88 4.85 12.3 9.2 Stomach 35.87 7.43 37.02 25.4 13.7 Liver 86.61 4.34 11.0 8.6 Breast 35.72 7.40 15.55 51.7 33.0 Thyroid 82.12 4.11 10.4 9.1 Oesophagus 22.40 4.64 43.83 15.9 8.3 Cervix uteri 66.23 3.31 16.9 14.1 Cervix uteri 15.07 3.12 22.75 21.8 13.8 Male Male All cancers 1 031.16 100.00 259.6 212.6 All cancers 253.39 100.00 24.57 351.4 209.6 Lung 157.20 15.25 39.6 32.1 Lung 65.87 26.00 41.90 91.4 52.0 Prostate 146.79 14.23 37.0 29.4 Colorectum 30.77 12.14 28.77 42.7 24.7 Colorectum 106.94 10.37 26.9 21.9 Liver 26.79 10.57 44.60 37.2 22.7 Stomach 62.75 6.08 15.8 12.8 Stomach 24.66 9.73 39.29 34.2 19.5 Liver 60.07 5.83 15.1 12.7 Oesophagus 16.75 6.61 45.85 23.2 13.1 Bladder 47.13 4.57 11.9 9.3 Prostate 13.42 5.29 9.14 18.6 9.7 Oesophagus 36.52 3.54 9.2 7.6 Thyroid 12.49 4.93 60.49 17.3 13.3 NHL 31.14 3.02 7.8 6.6 Bladder 7.32 2.89 15.53 10.2 5.7 Female Female All cancers 966.49 100.00 247.0 186.3 All cancers 229.08 100.00 23.70 331.6 197.0 Breast 229.68 23.76 58.7 46.8 Lung 40.19 17.54 44.23 58.2 30.3 Lung 90.86 9.40 23.2 16.2 Breast 35.72 15.59 15.55 51.7 33.0 Colorectum 85.70 8.87 21.9 15.2 Thyroid 34.12 14.89 55.51 49.4 36.5 Cervix uteri 66.23 6.85 16.9 14.1 Colorectum 20.94 9.14 24.44 30.3 15.7 Thyroid 61.47 6.36 15.7 13.6 Cervix uteri 15.07 6.58 22.75 21.8 13.8 Corpus uteri 42.04 4.35 10.7 8.4 Stomach 11.21 4.89 32.85 16.2 8.3 Stomach 34.13 3.53 8.7 6.0 Liver 9.98 4.35 37.60 14.4 7.4 Ovary 32.46 3.36 8.3 6.7 Corpus uteri 7.77 3.39 18.48 11.3 6.8 Proportion: The proportion of cases of the cancer among all cancer cases globally; Proportion in China: The proportion of cases of the cancer among all cancer cases in China; Proportion in the world: The proportion of cases of the cancer in China relative to all cases of the same cancer globally. ASIR: Age-standardized incidence rate; NHL: Non-Hodgkin lymphoma. 表 2 2022年全球及中国总人口、男性、女性死亡人数排前8位的癌症
Table 2 Mortality of top 8 cancers among total population, males, and females in China and globally in 2022
Global China Precedence Number of deaths/(×104) Proportion/% Crude mortality rate/(×10－5) ASMR/(×10－5) Precedence Number of deaths/(×104) Proportion in China/% Proportion in the world/% Crude mortality rate/(×10－5) ASMR/(×10－5) Total Total All cancers 974.38 100.00 123.6 91.7 All cancers 257.42 100.00 26.42 182.3 96.5 Lung 181.75 18.65 23.1 16.8 Lung 73.33 28.49 40.35 51.9 26.7 Colorectum 90.40 9.28 11.5 8.1 Liver 31.65 12.30 41.72 22.4 12.6 Liver 75.87 7.79 9.6 7.4 Stomach 26.04 10.11 39.44 18.4 9.4 Breast 66.61 6.84 17.0 12.7 Colorectum 24.00 9.32 26.55 17.0 8.6 Stomach 66.02 6.78 8.4 6.1 Oesophagus 18.75 7.28 42.09 13.3 6.7 Pancreas 46.74 4.80 5.9 4.2 Pancreas 10.63 4.13 22.74 7.5 3.9 Oesophagus 44.54 4.57 5.7 4.3 Breast 7.50 2.91 11.26 10.9 6.1 Prostate 39.74 4.08 10.0 7.3 Brain and CNS 5.66 2.20 22.78 4.0 2.5 Male Male All cancers 543.03 100.00 136.7 109.8 All cancers 162.93 100.00 30.00 226.0 127.5 Lung 123.32 22.71 31.0 24.8 Lung 51.59 31.66 41.83 71.6 39.5 Liver 52.18 9.61 13.1 10.9 Liver 22.98 14.10 44.03 31.9 19.1 Colorectum 49.98 9.20 12.6 9.9 Stomach 18.16 11.14 42.46 25.2 13.8 Stomach 42.76 7.87 10.8 8.6 Colorectum 14.26 8.75 28.53 19.8 10.9 Prostate 39.74 7.32 10.0 7.3 Oesophagus 14.04 8.62 44.09 19.5 10.7 Oesophagus 31.84 5.86 8.0 6.5 Pancreas 6.11 3.75 24.67 8.5 4.7 Pancreas 24.76 4.56 6.2 5.0 Prostate 4.75 2.92 11.96 6.6 3.3 Leukaemia 17.33 3.19 4.4 3.7 Bladder 3.25 1.99 13.09 4.5 2.3 Female Female All cancers 431.35 100.00 110.3 76.9 All cancers 94.49 100.00 21.91 136.8 67.8 Breast 66.61 15.44 17.0 12.7 Lung 21.74 23.01 37.21 31.5 14.7 Lung 58.42 13.54 14.9 9.8 Colorectum 9.74 10.31 24.10 14.1 6.5 Colorectum 40.42 9.37 10.3 6.5 Liver 8.68 9.18 36.63 12.6 6.2 Cervix uteri 34.89 8.09 8.9 7.1 Stomach 7.88 8.34 33.88 11.4 5.3 Liver 23.69 5.49 6.1 4.1 Breast 7.50 7.94 11.26 10.9 6.1 Stomach 23.26 5.39 6.0 3.9 Cervix uteri 5.57 5.89 15.96 8.1 4.5 Pancreas 21.98 5.10 5.6 3.5 Oesophagus 4.71 4.98 37.08 6.8 2.9 Ovary 20.70 4.80 5.3 4.0 Pancreas 4.52 4.78 20.56 6.6 3.1 Proportion: The proportion of deaths from the cancer among all cancer deaths globally; Proportion in China: The proportion of deaths from the cancer among all cancer deaths in China; Proportion in the world: The proportion of deaths from the cancer in China relative to all deaths from the same cancer globally. ASMR: Age-standardized mortality rate; CNS: Central nervous system. 表 3 胃癌发病和死亡情况与HDI的Spearman秩相关分析
Table 3 Spearman rank correlation analyses of gastric cancer incidence and mortality with HDI
Classfication Group ASIR ASMR M/I rs P value rs P value rs P value Global Total 0.256 0.001 －0.008 0.918 －0.831 ＜0.001 Male 0.303 ＜0.001 0.092 0.226 －0.787 ＜0.001 Female 0.132 0.081 －0.131 0.082 －0.803 ＜0.001 Very high HDI Total －0.345 0.006 －0.565 ＜0.001 －0.655 ＜0.001 Male －0.391 0.002 －0.533 ＜0.001 －0.621 ＜0.001 Female －0.309 0.015 －0.524 ＜0.001 －0.538 ＜0.001 High HDI Total 0.292 0.057 0.228 0.142 －0.486 0.001 Male 0.267 0.084 0.252 0.103 －0.346 0.023 Female 0.324 0.034 0.232 0.134 －0.592 ＜0.001 Medium HDI Total 0.285 0.083 0.261 0.114 －0.019 0.910 Male 0.313 0.056 0.295 0.072 0.002 0.989 Female 0.150 0.369 0.127 0.448 －0.212 0.201 Low HDI Total －0.036 0.842 －0.049 0.789 －0.489 0.004 Male －0.041 0.821 －0.059 0.746 －0.426 0.014 Female －0.074 0.681 －0.107 0.555 －0.408 0.019 Very high, high, medium, and low HDI mean the HDI being 0.800-1, 0.700-0.799, 0.550-0.699, and 0-0.549, respectively. HDI: Human development index; ASIR: Age-standardized incidence rate; ASMR: Age-standardized mortality rate; M/I: Mortality-to-incidence ratio. 表 4 全球、不同HDI国家和地区、中国胃癌的发病和死亡情况
Table 4 Incidence and mortality of gastric cancer globally, in different HDI countries and territories, and in China
Classfication Group Crude incidence rate/(×10－5) ASIR/(×10－5) Crude mortality rate/(×10－5) ASMR/(×10－5) M/I Very high HDI Total 21.4 9.7 11.2 4.7 0.52 Male 27.2 13.6 13.8 6.5 0.51 Female 15.6 6.4** 8.6 3.2** 0.55 High HDI Total 17.4 11.4 12.9 8.1 0.74 Male 23.1 16.1 17.3 11.8 0.75 Female 11.6 7.1** 8.4 4.9** 0.73 Medium HDI Total 5.0 5.3 4.4 4.7 0.88 Male 6.2 7.0 5.4 6.2 0.88 Female 3.7 3.8** 3.2 3.3** 0.87 Low HDI Total 2.1 3.9 1.9 3.5 0.88 Male 2.3 4.5 2.1 4.0 0.88 Female 1.9 3.3** 1.7 3.0* 0.88 Global Total 12.3 9.2 8.4 6.1 0.68 Male 15.8 12.8 10.8 8.6 0.68 Female 8.7 6.0** 6.0 3.9** 0.68 China Total 25.4 13.7 18.4 9.4 0.73 Male 34.2 19.5 25.2 13.8 0.74 Female 16.2 8.3** 11.4 5.3** 0.70 Very high, high, medium, and low HDI mean the HDI being 0.800-1, 0.700-0.799, 0.550-0.699, and 0-0.549, respectively. *P＜0.05, **P＜0.01 vs male group in the same classification. HDI: Human development index; ASIR: Age-standardized incidence rate; ASMR: Age-standardized mortality rate. -
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