Tracheal, bronchus, and lung (TBL) cancer is the leading cause of cancer-related mortality, accounting for approximately 1.8 million deaths worldwide in 2022 (1). Despite advances in prevention and treatment, the 5-year survival rate for patients with TBL cancer is still relatively poor, ranging between 10% and 20% in most countries (2). Although COVID-19 infection itself is not established as a direct risk factor for lung cancer, the COVID-19 pandemic had substantial indirect effects on cancer epidemiology through widespread disruptions to screening, diagnostic pathways, and timely access to treatment (3, 4). These system-level delays and interruptions have been shown to influence the detection and outcomes of multiple cancers, including those of the respiratory system.

Previous studies have explored global trends in the TBL disease burden, as well as examining specific countries or regions and investigating modifiable risk factors such as smoking, ambient pollution, and high fasting plasma glucose etc. (5–7). These findings highlighted regional and sex-based heterogeneity, likely influenced by variations in risk factor distribution. However, although previous studies have described disparities in TBL cancer burden, few have examined demographic factors—such as population size, age structure, and disease severity—specifically contribute to the observed variations. Furthermore, various literature indicates that TBL cancer is prohibitively costly regarding direct medical expenses and indirect costs (8, 9). Evaluation of the economic burden of TBL cancer is essential for building investment cases for universal cancer control and informing public health decision-making. The United Nations Sustainable Development Goals (SDGs) emphasize the need to address health disparities, promote gender equality, and reduce inequalities within and among countries (10). However, there is still limited research analyzing TBL cancer burden through the lens of these global goals.

To address existing knowledge gaps, this study characterizes the observed changes in the TBL cancer burden using a decomposition analysis and quantified cross-country inequalities in disease outcomes. We further estimate the temporal and spatial patterns of the economic burden of TBL cancer through 2050 using a value of statistical life (VSL) framework. Building on these objectives, this research provides an integrative quantitative assessment of how population aging indicators, health status, and regional variation collectively shape the global TBL cancer burden. By simultaneously examining the economic consequences across diverse geographic and demographic contexts, the study offers insights that have been largely overlooked in prior work. Through identifying and quantifying the substantial financial losses attributable to TBL cancer, our findings underscore the need for region-specific and data-driven prevention and control strategies informed by the most current evidence.

In this study, we provided the first comprehensive quantification of global and regional trends in the disease and economic burden of TBL cancer, including an analysis of the change factors behind the growth in disease burden and the changing patterns of economic burden. Importantly, the decomposition results showed that the component representing adult population growth constituted the largest share of the observed changes in the global TBL cancer burden, exceeding the share attributed to population aging. Meanwhile, reductions in fatality and severity appeared as larger negative components in higher-SDI regions and among males. We also observed a measurable decline in health burden inequality over the past decade. Additionally, we anticipated a shift in the areas with the highest economic liabilities from high to high-middle SDI regions. Over time, the economic burdens of TBL cancer for males and females are expected to converge. Overall, by combining trend evaluation, decomposition analyses, inequality assessments, and economic projections, our study delivers a holistic and structurally informed assessment of how the global TBL cancer burden is changing. These innovative insights not only deepen our understanding of the dynamics surrounding TBL cancer but also offer essential guidance for prioritizing regions, populations, and strategies for effective prevention and treatment.

Females exhibited a substantial increase in the disease and economic burden associated with TBL cancer in almost all areas compared to males. The burden of smoking-associated TBL cancer has shown a downward trend, thus reflecting a global decline in smoking prevalence. Conversely, the burden of TBL cancer in never-smokers is on the rise (23), it is more frequently diagnosed in women and is preferentially prevalent among individuals of Asian descent. In East Asia, the higher burden among women has been consistently linked to a distinct molecular and etiological profile, characterized by a high prevalence of oncogenic driver mutations such as EGFR mutations and ALK rearrangements (23, 24), which occur more frequently in East Asia female than in other populations. These molecular features contribute to both disease susceptibility and clinical presentation and partly explain the elevated burden observed in East Asian women. Recent researches have increasingly highlighted the role of sex hormones, particularly estrogens, in the pathogenesis of lung cancer. Estrogen receptors are expressed in lung tissues, and their activation can influence crucial cellular processes, including proliferation, apoptosis, and angiogenesis, thereby contributing to tumor development (25). Moreover, females might be more exposed to certain environmental and occupational risk factors for TBL cancer, including indoor radon (26), secondhand smoke, and carcinogens related to cooking and heating practices than males, especially in low- and middle-income countries (27). Finally, our first analysis of TBL cancer showed that fatality and severity impact females less than males, suggesting that early detection and survival efforts may have somewhat overlooked women.

Existing studies have shown that the global burden of TBL cancer, as reflected in ASDR and ASDAR, has declined over recent decades (5). This trend is primarily driven by the success of smoking reduction campaigns (28) and advances in early detection and targeted therapy (29), particularly the global decline in smoking rates and the widespread adoption of low-dose CT screening, which have facilitated earlier diagnosis and significantly reduced mortality (30, 31). Complementing these risk-factor based findings, our decomposition analysis illustrates how demographic and disease-severity components have jointly shaped the observed increases in absolute deaths and DALYs. The decomposition results showed that, after the component representing adult population growth, the aging component accounted for the next largest share of the observed increases in deaths and DALYs. This trend was particularly pronounced in high SDI regions. World Health Organization (WHO) has championed the concept of “healthy aging,” a pivotal initiative to enhance the quality of life for older individuals (32). The statistic is that only about 10% of individuals over 65 in high-SDI countries like the United States and Europe are achieving healthy aging (33). To address these challenges, strengthening interventions that promote healthy lifestyles, mitigate cancer risk factors, and enhance the wellbeing of older population is essential. These measures not only reduce the disease burden but also contribute significantly to the realization of SDGs, which emphasizes ensuring healthy lives and promoting wellbeing for all at all ages. Therefore, these regions necessitate targeted prevention and control strategies specifically for the older population. Implementing measures that promote healthy lifestyles, mitigate cancer risk factors, and enhance the overall wellbeing of the older adults is crucial to alleviating the burden of TBL cancer.

Another significant finding from our inequality analysis is that regional differences in TBL cancer burden have decreased. This reduction was partly due to opposing trends in disease burden between higher and lower SDI areas and partly caused by an increase in population size in middle and low SDI areas, as revealed by the decomposition analysis. The mitigating effect of reduced TBL cancer fatality and severity was weaker in regions with middle and low SDI levels, whereas it significantly affected TBL cancer-related deaths and DALY numbers in high and high-middle SDI regions. This phenomenon may be attributed to higher SDI areas that often have more comprehensive healthcare coverage and insurance schemes (34), ensuring that a significant portion of the population has access to healthcare services. However, middle and low SDI countries often have limited healthcare infrastructure, fewer financial resources, and a higher prevalence of other competing health priorities (34). The SDGs explicitly call for reducing inequalities within and among countries, as outlined in SDG 10. Achieving this goal requires addressing disparities in healthcare access, outcomes, and resources, particularly in resource-constrained settings. Our findings highlight the importance of strengthening healthcare systems in middle and low SDI regions by strategically allocating medical budgets to implement early screening programs, improving treatment quality, and expanding medical insurance coverage. These targeted interventions not only help to reduce TBL cancer mortality, disease severity, and economic burden but also play a critical role in bridging the gap between higher and lower SDI regions. By aligning with SDG 10′s mandate to promote equitable healthcare access and outcomes, these measures contribute to reducing global health disparities and ensuring more inclusive progress toward sustainable health systems. This approach underscores the need for international collaboration and resource-sharing to address persistent inequalities, ultimately supporting the global commitment to achieving health equity.

Moreover, we focus on changes in absolute numbers, rather than just rates, as these figures provide a clearer, more direct understanding of the magnitude of the disease burden. While changes in rates are important for epidemiological studies, the absolute numbers of deaths and DALYs offer more concrete evidence of the scale of the challenge faced by health systems, particularly in terms of resource allocation and prioritization (35). This is especially relevant for policymaking, where absolute numbers are often more critical in informing decisions regarding healthcare investments, interventions, and long-term strategies.

Economic evaluations further suggest that by 2050, the region facing the highest TBL cancer economic burden will shift from the high SDI region to the high-middle SDI region. While high SDI countries often have the financial flexibility and resources to allocate to comprehensive cancer prevention strategies, early detection, and advanced treatment options, the socioeconomic pressures arising from a growing disease burden are expected to increase (36). Additionally, as high-middle SDI countries experience economic growth, their healthcare expenditures and the value they place on life years (as reflected in the VSL) tend to increase (37). Moreover, high- and high-middle-SDI regions demonstrate the largest absolute economic burden in our results, this pattern primarily reflects system-level factors rather than a disproportionately higher disease burden (38). Health systems in these settings typically achieve greater diagnosis coverage, wider access to treatment, and longer survival, all of which increase medical spending and raise the monetized value of health losses (39). In addition, high-SDI countries often utilize more advanced—and therefore more costly—technologies for screening, diagnosis, and therapy, resulting in higher per-patient expenditures (40). These patterns remained stable across multiple elasticity scenarios economic projections, underscoring the robustness of the anticipated geographic and demographic shift in financial burden.

To the best of our knowledge, this is the first study to quantitatively explore the complex relationship among population aging indicators, health status, and the global burden of TBL cancer across diverse regions and sexes. This analysis offers a foundation for devising precise TBL cancer prevention and control strategies, tailored to the economic realities of diverse regions. Furthermore, it emphasizes the necessity of adjusting our response plans based on the latest disease burden data. By quantifying the economic burden of TBL cancer across various geographic and demographic contexts worldwide, we estimated the significant financial losses to society caused by this disease. This approach emphasizes the importance of using current data to inform and refine strategies for effective TBL cancer management and prevention. The findings and recommendations from this study contribute directly to achieving the SDGs by promoting equitable healthcare access, reducing health disparities, and supporting the development of sustainable and inclusive health systems.

We acknowledge certain limitations in our research, primarily the statistical uncertainties associated with the GBD study, which stem from the use of various subnational data sources. The decomposition approach used in this study showed the observed changes in deaths and DALYs into mathematical components. These components reflect the quantitative share of change rather than causal effects and therefore should not be interpreted as determinants of disease burden. Although the VSL approach quantifies the monetary and non-monetary impacts of TBL cancer, it does not account for broader economic effects on caregivers, including opportunity costs and financial strain on caregivers (41). Our reliance on the World Bank's 2023 income classification of countries may constrain the forward-looking accuracy of our analysis, particularly considering potential economic fluctuations. Additionally, our predictions of future economic burdens assume that current levels will remain stable, which may introduce inaccuracies. This approach does not consider the possible variations in economic conditions, advancements in healthcare, or shifts in population demographics that could significantly impact the economic landscape over time. In particular, future trends in TBL cancer incidence were not explicitly modeled in our projections. Instead, the economic burden estimates for 2030–2050 were derived under the assumption that age-specific disease rates observed in 2021 remain constant over time. As such, potential future changes in incidence driven by evolving risk-factor profiles, screening uptake, treatment innovations, or health system performance were not incorporated. Therefore, while our forecasts offer a valuable starting point for understanding the economic implications of TBL cancer, they should be interpreted with caution, as real-world dynamics may lead to deviations from these projections. Moreover, although the COVID-19 pandemic has been shown to disrupt cancer screening, diagnosis, and treatment pathways globally, potentially altering long-term incidence and mortality patterns (3), current evidence suggests that no immediate change in the burden of TBL cancer was observed during the pandemic period (5). Nevertheless, delayed diagnoses and interruptions in care may exert lagged effects on cancer outcomes that are not yet fully captured in available data. Continued population-level surveillance and longitudinal analyses will therefore be essential to assess the longer-term impact of the pandemic on TBL cancer burden.

Overall, our study provides a comprehensive analysis of the global, regional, and sex-specific disease and economic burden of TBL cancer, offering novel insights into its key components and disparities. We identified adult population growth as the primary factor contributing to the increasing global burden of TBL cancer, while improvements in fatality and severity rates had a more limited impact, particularly among females and in lower SDI regions. Additionally, our findings highlight a sharp rise in the burden among females and a dramatic shift in the highest economic impact from high-SDI to high-middle SDI regions by 2050, underscoring the urgent need for targeted public health strategies. Policymakers should prioritize tailored prevention efforts, expanded access to early detection, and equitable healthcare interventions to mitigate the social and economic consequences of TBL cancer, particularly in vulnerable regions and populations.