Kidney cancer burden in China from 1990 to 2023: A retrospective population-based observational study

Abstract

Objective

To assess long-term trends in kidney cancer burden in China from 1990 to 2023 and estimate the proportion of this burden attributable to major modifiable risk factors.

Methods

This retrospective, population-based observational study used China-specific estimates from the Global Burden of Disease Study (2023). All-age numbers and age-standardized rates for incidence, mortality, prevalence, and disability-adjusted life years, along with 95% uncertainty intervals, were obtained. Joinpoint regression was used to calculate the average annual percentage change by sex and age group.

Results

In 2023, there were 61,323 new kidney cancer cases and 21,784 kidney cancer-related deaths in China. Compared with 1990, the incident and prevalent cases increased by 214.48% and 251.46%, respectively. The age-standardized incidence rate, age-standardized mortality rate, and age-standardized prevalence rate increased, whereas the age-standardized disability-adjusted life year rate declined. The kidney cancer burden was higher in men than in women. The prevalence was highest in the 50–74 years age group, whereas the ≥75 years age group demonstrated the greatest relative increase. Smoking, high body mass index, and trichloroethylene exposure accounted for substantial estimated attributable kidney cancer deaths and disability-adjusted life years.

Conclusions

The absolute burden of kidney cancer in China increased substantially from 1990 to 2023, particularly among men and older adults. These findings may support age- and sex-informed prevention strategies, tobacco control, weight management, occupational exposure reduction, and improved monitoring of high-risk populations.

Keywords

Kidney cancer China global burden of disease Joinpoint regression risk factors

Introduction

Cancer remains a major global public health challenge and a leading cause of death and health loss worldwide. With ongoing population growth, accelerated population aging, and changing patterns of risk-factor exposure, the global cancer burden continues to evolve; disparities in incidence, mortality, and disease management across countries and regions have attracted increasing attention.¹ Therefore, long-term epidemiological trend analyses of specific cancers are important not only for describing changes in disease burden but also for identifying disproportionately affected populations, understanding potential drivers of disease burden, and informing cancer prevention, early detection, and health resource allocation. Moreover, the significance of epidemiological trends extends beyond changes in case numbers alone, as these trends are closely linked to shifts in disease management, clinical practice, and public health priorities.²

Kidney cancer (KC) is one of the most common malignancies of the urinary system and represents an important component of the global cancer spectrum.³ According to the International Agency for Research on Cancer (IARC) Global Cancer Observatory (GLOBOCAN) 2022 estimates, KC is the 14th most common malignancy worldwide and shows marked sex differences, ranking 10th among men and 13th among women.⁴ Previous studies have demonstrated that the incidence of KC has been increasing in many countries and regions and that its burden varies substantially by age and sex, with men and older adults generally bearing a higher burden.³ However, these changes in the KC burden are unlikely to have been driven by any single factor; rather, they probably reflect the combined influence of population aging, evolution of modifiable risk factors, changing occupational exposures, and variations in diagnostic practice and healthcare access.³ Therefore, temporal changes in KC burden should be interpreted with caution and considered in the context of demographic transition, risk-factor exposure, and changes in healthcare access.

As one of the most populous countries in the world, China faces substantial public health implications owing to changes in the burden of KC. Even modest increases in incidence or mortality may translate into large absolute numbers of cases and deaths, thereby imposing sustained pressure on the healthcare system and society.^5,6 In addition, China’s cancer spectrum is shifting from that typically seen in developing countries toward that of developed countries.^5,6 Population growth and rapid aging have further increased the overall cancer burden.^7–9 Previous studies have shown that modifiable environmental and lifestyle-related factors are associated with KC risk.^10,11 Among these, smoking, high body mass index (BMI), and occupational exposures have received particular attention.^3,12–14 Additionally, improvements in public health awareness and healthcare services may have influenced observed incidence trends. Therefore, a long-term and systematic assessment of the KC burden in China, together with stratified analyses by age, sex, and major modifiable risk factors, is important for understanding its epidemiological patterns and informing prevention priorities.

Although previous studies have described the epidemiological characteristics of KC, systematic evaluations of the long-term changes in its disease burden in China from 1990 to 2023 remain limited, particularly with respect to the integrated assessment of incidence, mortality, prevalence, and disability-adjusted life years (DALYs) as well as the simultaneous evaluation of sex-, age-, and risk-specific patterns.³ The Global Burden of Disease Study (GBD) 2023 integrates multiple data sources and provides a unified framework for long-term, comparable, and stratified analyses of disease burden and attributable risk factors.¹⁵ Based on this framework, in the present study, we used the GBD 2023 data for China to systematically examine long-term trends in KC incidence, mortality, prevalence, and DALYs from 1990 to 2023. We further assessed sex- and age-specific patterns as well as the attributable burden related to smoking, high BMI, and occupational exposure to trichloroethylene (TCE), with the aim of informing the identification of priority populations, guiding prevention priorities, and optimizing KC control strategies in China.

Methods

Data source and acquisition

This retrospective, population-based observational study used China-specific estimates from the GBD 2023 data cycle to analyze long-term trends in the KC burden in China from 1990 to 2023. The GBD 2023 data, compiled by the Institute for Health Metrics and Evaluation (IHME) using a unified modeling approach, integrates multi-source data, including vital registration, cancer registration, surveys, and administrative records. It quantifies the burden of 375 diseases and injuries and 88 risk factors across 204 countries and regions worldwide. All estimates are stratified by age, sex, year, and region and are presented with 95% uncertainty intervals (UIs) to ensure comparability.¹⁵

Specifically, this study extracted data on KC incidence, mortality, prevalence, and DALYs for the total population, men, and women in China during this period, including absolute numbers for all age groups and age-standardized rates (age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR), age-standardized prevalence rate (ASPR), and age-standardized disability-adjusted life year rate (ASDR), unit: per 100,000 population). Data extraction was performed using predefined selections for location, cause, year, sex, age group, measure, metric, and risk factor in the GBD Results Tool.

Measurement indicators and definitions

The main outcome indicators of this study were the number of new KC cases (incidence), number of deaths (mortality), number of prevalent cases (prevalence), and DALYs. The extracted data included absolute numbers for all (ASIR, ASMR, ASPR, and ASDR) calculated using the GBD direct standardization method with the GBD world standard population as the reference, allowing comparisons across years and populations with different age structures.

For the age-specific analysis, we adopted three composite age groups defined in the GBD: (a) 15–49 years; (b) 50–74 years; and (c) ≥75 years. The relevant results were presented together with age-standardized data series. The analysis of risk-attributable deaths and DALYs of KC in 2023 followed the GBD comparative risk assessment framework. This framework defines the theoretical minimum risk exposure level by clarifying the exposure distribution across different ages, sexes, regions, and years and integrates exposure–response functions and mediating structures to effectively avoid double-counting of relevant risk factors. According to the study dataset, the risk factors associated with KC included smoking, high BMI, and occupational exposure to TCE. In the GBD 2023, KC corresponds to the International Classification of Diseases, Tenth Revision (ICD-10) codes: C64-C65.9, 189–189.1, 189.5–189.6, and 223.0–223.1. In this study, data on malignant tumors were derived from household surveys, population censuses, vital statistics, and other health-related data sources.¹⁶ High BMI was defined as a BMI >23 kg/m² for individuals aged ≥20 years; occupational exposure to TCE was defined as the percentage of individuals aged ≥15 years who had been occupationally exposed to TCE at different intensity levels.¹⁷

Statistical analyses

The Joinpoint segmented log-linear regression model was used to quantify the long-term trends of annual age-standardized indicators (ASIR, ASMR, ASPR, and ASDR, unit: per 100,000 population) from 1990 to 2023. This model can detect non-monotonic trends and identify statistically significant changes in slopes. It is a widely used trend analysis tool in the field of cancer epidemiology and surveillance. It allows the identification of significant inflection points and enables concise comparisons across indicators and subgroups using the average annual percentage change (AAPC).¹⁸ In this study, the standard Joinpoint log-linear model with default settings was used for trend estimation. The final number of joinpoints was selected using the Monte Carlo permutation test implemented in the Joinpoint Regression Program, with a two-sided significance level of α = 0.05.

In the analysis, a model was constructed on the logarithmic scale, and a log-linear model ln(y) = α + βx + ε was fitted within each data segment (where y is the age-standardized indicator and x is the calendar year). The maximum number of joinpoints was set at 6 as the maximum candidate number for the annual time series, and no additional model adjustments were applied. AAPC values were used to summarize the overall trend across the full study period from 1990 to 2023. The AAPC was calculated using the formula: 100 × [exp(β) − 1]. The direction of the trend was determined based on the 95% confidence interval (CI) of AAPC:

1. CI >0 indicated an upward trend;

2. CI <0 indicated a downward trend; and

3. CI including 0 indicated a stable trend.¹⁹

In this study, models were constructed separately for the total population age-standardized series, different age groups (15–49, 50–74, and ≥75 years), and sex groups, and the corresponding AAPC results for each subgroup were reported. In addition, age- and sex-specific trends in mortality and DALY rates attributable to smoking, high BMI, and occupational exposure to TCE were descriptively examined using the same Joinpoint approach. Data processing and visualization were performed using R statistical software (version 4.3.0). Segmented regression and AAPC estimation were performed using the Joinpoint Regression Program (version 5.2.0.0). This study was based on annual GBD point estimates; therefore, 95% UIs were used to describe the uncertainty of disease burden estimates. No additional sensitivity analyses using alternative modeling approaches were performed.

Ethics and reporting standards

This study used publicly available, aggregated, and de-identified estimates from the GBD 2023 and did not involve individual-level patient data or personally identifiable information. Therefore, additional institutional review board approval or individual informed consent was not required. The study was conducted in accordance with the principles of the Declaration of Helsinki of 1975, as revised in 2024, where applicable. All documentation describing the underlying data sources, analytical methods, related analysis tools, and comparative risk assessment framework of the GBD has been made publicly available and can be accessed through the Global Health Data Exchange (GHDx) platform of the IHME and the GBD Results Tool (https://ghdx.healthdata.org/gbd-results-tool). The reporting of this study conforms to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER)²⁰ and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.²¹

Study results

National overall burden in 2023 and changes during the study period

In 2023, the estimated number of new KC cases in China was 61,323 (95% UI: 47,511–82,874), with 21,784 deaths (95% UI: 16,907–29,113), 348,196 prevalent cases (95% UI: 255,999–478,478), and 582,244 DALYs (95% UI: 450,635–790,768) (Table 1). Compared with 1990, the number of new cases had increased by 214.48% (from 19,500 in 1990) and the number of prevalent cases by 251.46% (from 99,071 in 1990); during the same period, the number of deaths had increased by 151.53% (from 8661 in 1990), and DALYs had risen by 78.6% (from 326,005 person-years in 1990). From 1990 to 2023, the ASMR of KC in China increased from 0.99 to 1 per 100,000 population, with an AAPC of 0.12% (95% CI: −0.36 to 0.6); the ASDR decreased from 32.69 to 29.48 per 100,000 population, with an AAPC of −0.25% (95% CI: −0.56 to 0.06); the ASIR of KC increased from 1.99 to 3.24 per 100,000 population, and the ASPR increased from 9.32 to 19.72 per 100,000 population. The AAPC summarizes the long-term trends of these indicators (Table 1). The crude incidence rate for all age groups was 1.65 per 100,000 population in 1990 and 4.29 per 100,000 population in 2023 (AAPC: 2.95%; 95% CI: 2.69–3.21) (Tables 1 and 2, Figure 1). These results indicate that the ASIR, ASPR, and ASMR of KC in China increased from 1990 to 2023, whereas the ASDR showed a declining trend. However, the observed increase in the incidence rate should be interpreted cautiously because improved access to imaging and diagnostic services may have contributed to increased case detection rates, particularly for asymptomatic or early-stage disease. Nevertheless, the substantial increase in the absolute numbers of incident and prevalent cases indicates a growing healthcare burden in China. These findings support the need for continued improvement in early detection and clinical management, along with strengthening of prevention strategies targeting modifiable risk factors such as smoking, high BMI, and occupational exposures.

Table 1.

Age-standardized rates and burden of kidney cancer in China, 1990–2023.

Sex	Indicator	Number (1990, 95% UI)	Number (2023, 95% UI)	% change (number)	ASR (1990, 95% UI)	ASR (2023, 95% UI)	AAPC of ASR (95% CI)
Both	DALYs	326,005 (243,466–418,133)	582,244 (450,635–790,768)	78.6	32.69 (24.78–42.25)	29.48 (23.22–40.36)	−0.25 (−0.56 to 0.06)
Female		111,097 (74,281–152,501)	171,734 (124,575–256,823)	54.58	22.29 (15.1–30.82)	18.16 (13.65–28.63)	−0.63 (−0.9 to −0.36)^a
Male		214,908 (148,564–297,084)	410,510 (294,301–577,612)	91.02	43.29 (30.51–60.64)	41.06 (30.58–57.7)	−0.07 (−0.36 to 0.22)
Both	Deaths	8661 (6727–11,437)	21,784 (16,907–29,113)	151.53	0.99 (0.78–1.31)	1 (0.77–1.34)	0.12 (−0.36 to 0.6)
Female		2881 (1980–4138)	6865 (4886–9915)	138.27	0.64 (0.45–0.93)	0.61 (0.43–0.91)	−0.15 (−0.49 to 0.2)
Male		5780 (4220–8356)	14,919 (10,518–21,204)	158.14	1.39 (1.03–2.01)	1.42 (1.03–2.01)	0.19 (−0.14 to 0.51)
Both	Incidence	19,500 (14,325–24,151)	61,323 (47,511–82,874)	214.48	1.99 (1.49–2.5)	3.24 (2.52–4.47)	1.55 (1.27–1.83)^a
Female		7394 (5008–10440)	20203 (14,542–31,522)	173.24	1.5 (1.02–2.11)	2.32 (1.64–3.64)	1.34 (1.07–1.61)^a
Male		12,106 (8383–17,010)	41,120 (29,821–58,781)	239.67	2.53 (1.8–3.57)	4.2 (3.16–6.05)	1.65 (1.32–1.98)^a
Both	Prevalence	99,071 (68,884–123,662)	348,196 (255,999–478,478)	251.46	9.32 (6.52–11.63)	19.72 (14.55–27.69)	2.29 (2.06–2.53)^a
Female		41,256 (25,920–60,261)	118,851 (82,991–181,929)	188.09	7.9 (5.01–11.53)	15.1 (10.4–23.46)	2.01 (1.73–2.29)^a
Male		57,816 (37,894–80,317)	229,345 (163,106–343,054)	296.68	10.73 (7.13–15.03)	24.42 (17.68–36.91)	2.54 (2.32–2.77)^a

AAPC: average annual percentage change; ASR: age-standardized rate; CI: confidence interval; DALY: disability-adjusted life year; UI: uncertainty interval.

Table 2.

Age-specific trends in the kidney cancer burden in China, 1990–2023.

Metric	Measure	Number (1990, 95% UI)	Number (2023, 95% UI)	% change (number)	Rate (1990, 95% UI)	Rate (2023, 95% UI)	AAPC of rate (95% CI)
Mortality	All ages	8661 (6727–11,437)	21,784 (16,907–29,113)	151.53	0.73 (0.57–0.97)	1.52 (1.18–2.03)	2.34 (2.03–2.65)^a
Mortality	15–49 years	1620 (1234–2107)	1989 (1,465–2753)	22.77	0.24 (0.18–0.32)	0.31 (0.23–0.43)	0.85 (0.30–1.39)^a
Mortality	50–74 years	4697 (3653–6512)	12,183 (9559–16,351)	159.39	2.71 (2.11–3.76)	2.68 (2.10–3.59)	0.05 (−0.25 to 0.36)
Mortality	75+ years	1420 (1080–1959)	7263 (5389–9659)	411.61	7.30 (5.55–10.07)	9.37 (6.95–12.46)	0.86 (0.45–1.28)^a
DALY	All ages	326,005 (243,466–418,133)	582,244 (450,635–790,768)	78.60	27.65 (20.65–35.46)	40.70 (31.50–55.27)	1.27 (1.01–1.54)^a
DALY	15–49 years	87,843 (66,168–114,829)	103,890 (78,180–142,043)	18.27	13.14 (9.90–17.17)	16.09 (12.11–22.00)	0.72 (0.31–1.13)^a
DALY	50–74 years	135,831 (103,922–188,061)	349,012 (271,096–471,386)	156.95	78.48 (60.04–108.66)	76.64 (59.53–103.51)	0.03 (−0.27 to 0.34)
DALY	75+ years	20,609 (15,705–28,553)	97,795 (73,960–130,387)	374.53	105.96 (80.75–146.81)	126.20 (95.44–168.25)	0.63 (0.24–1.03)^a
Incidence	All ages	19,500 (14,325–24,151)	61,323 (47,511–82,874)	214.48	1.65 (1.21–2.05)	4.29 (3.32–5.79)	2.95 (2.69–3.21)^a
Incidence	15–49 years	4913 (3662–6239)	11,676 (8808–16,523)	137.67	0.73 (0.55–0.93)	1.81 (1.36–2.56)	2.89 (2.56–3.21)^a
Incidence	50–74 years	7900 (6104–10,575)	34,496 (26,285–46,734)	336.64	4.56 (3.53–6.11)	7.57 (5.77–10.26)	1.58 (1.31–1.85)^a
Incidence	75+ years	1577 (1195–2142)	11,020 (8175–14,944)	598.97	8.11 (6.14–11.02)	14.22 (10.55–19.28)	1.83 (1.48–2.18)^a
Prevalence	All ages	99,071 (68,884–123,662)	348,196 (255,999–478,478)	251.46	8.40 (5.84–10.49)	24.34 (17.89–33.44)	3.27 (3.04–3.49)^a
Prevalence	15–49 years	30,259 (20,677–39,594)	86,234 (61,925–126,556)	184.99	4.53 (3.09–5.92)	13.36 (9.59–19.60)	3.38 (3.21–3.55)^a
Prevalence	50–74 years	28,743 (20,686–38,147)	198,140 (147,592–269,665)	589.34	16.61 (11.95–22.04)	43.51 (32.41–59.21)	2.99 (2.78–3.21)^a
Prevalence	75+ years	2344 (1667–3172)	30,848 (21,217–41,749)	1216.11	12.05 (8.57–16.31)	39.81 (27.38–53.87)	3.83 (3.56–4.09)^a

The AAPC was statistically significant, with the 95% CI not including 0.

AAPC: average annual percentage change; CI: confidence interval; UI: uncertainty interval.

Figure 1.

Trends in kidney cancer indicators in China by age group (1990–2023). (a) Mortality rate; (b) DALY rate; (c) Incidence rate; (d) Prevalence rate.

Sex-specific burden

In 2023, there were 41,120 new cases of KC among Chinese men (95% UI: 29,821–58,781), 14,919 deaths (95% UI: 10,518–21,204), 229,345 prevalent cases (95% UI: 163,106–343,054), and up to 410,510 DALYs (95% UI: 294,301–577,612); among women, there were 20,203 new cases (95% UI: 14,542–31,522), 6865 deaths (95% UI: 4886–9915), 118,851 prevalent cases (95% UI: 82,991–181,929), and 171,734 DALYs (95% UI: 124,575–256,823) (Table 1). From 1990 to 2023, the number of KC deaths in women increased by 138.27%, DALYs increased by 54.58%, and the ASDR decreased from 22.29 to 18.16 per 100,000 population; among men, the number of KC deaths increased by 158.14%, DALYs increased by 91.02%, and the ASDR decreased from 43.29 to 41.06 per 100,000 population. In 2023, the ASMR for men was 1.42 per 100,000, whereas that for women was 0.61 per 100,000 population; the ASPR among men was higher than that among women (24.42 vs. 15.1 per 100,000 population). Sex-specific AAPC values are presented in Table 1. These results indicate that men consistently exhibited higher absolute and relative KC burden during the study period (Table 1, Figure 2).

Figure 2.

Age-standardized rate and absolute number trends for kidney cancer in China (1990–2023) by sex. (a) Age-standardized rate; (b) Absolute number. ASR: age-standardized rate; DALY: disability-adjusted life year.

Age distribution of KC burden in 2023

In 2023, the burden of KC varied markedly by age group. The number of new cases in individuals aged ≥75 years was 11,020 (compared with 1577 in 1990, representing an increase of 598.97%), and the number of deaths was 7263 (compared with 1420 in 1990, representing an increase of 411.61%); in 2023, the crude incidence rate in this age group was 14.22 per 100,000 population, and the crude mortality rate was 9.37 per 100,000 population, the highest among all age groups. The DALYs in individuals aged ≥75 years reached 97,795 (95% UI: 73,960–130,387) in 2023, reflecting an increase of 374.53% compared with that in 1990 (20,609 per 100,000 population); the crude DALY rate in this age group increased from 105.96 to 126.20 per 100,000 population (Table 2).

The 50–74 years age group had a higher absolute burden in 2023; there were 34,496 new cases (95% UI: 26,285–46,734), 12,183 deaths (95% UI: 9559–16,351), and 349,012 DALYs (95% UI: 271,096–471,386); in 2023, the crude mortality rate in this age group was 2.68 per 100,000 population, and the crude DALY rate was 76.64 per 100,000 population. The 15–49 years age group had 11,676 new cases, 1989 deaths, and 103,890 DALYs in 2023; the crude prevalence rate in this age group increased from 4.53 per 100,000 population in 1990 to 13.36 per 100,000 population in 2023 (Table 2, Figure 1).

Age-specific long-term trends

There were differences in time trends among the three age groups. In terms of incidence rate, the crude incidence rate in the 50–74 and 15–49 years age groups increased from 1990 to 2023 (AAPC: 1.58%, 95% CI: 1.31–1.85 and AAPC: 2.89%, 95% CI: 2.56–3.21, respectively) (Table 2). The crude incidence rate of the population aged ≥75 years increased from 8.11 to 14.22 per 100,000 population (AAPC: 1.83%, 95% CI: 1.48–2.18), and the absolute number of new cases increased by 598.97%. In 2023, although the absolute number of new cases was the highest in the 50–74 years age group, the crude incidence rate was the highest in the population aged ≥75 years.

In terms of mortality rate during the study period, the crude rates of young and middle-aged populations increased or remained stable (15–49 years age group: AAPC: 0.85% (95% CI: 0.30–1.39) and 50–74 years age group: AAPC: 0.05% (95% CI: −0.25 to 0.36)). The crude mortality rate of the population aged ≥75 years was 9.37 per 100,000 population in 2023. The overall crude mortality rate increased from 0.73 to 1.52 per 100,000 population (AAPC: 2.34%, 95% CI: 2.03–2.65); from 1990 to 2023, the number of prevalent cases in the population aged ≥75 years increased from 2344 to 30,848, representing an increase of 1216.11%, far exceeding the overall population level (Table 2, Figure 1). This pattern may reflect the combined effects of population aging, cumulative exposure to behavioral and occupational risk factors, improved diagnostic ascertainment among older adults, and possible differences in tumor biology or clinical characteristics across age groups.

Risk-attributable burden

In 2023, there were 3085 smoking-related KC deaths (95% UI: 1861–4670), with related DALYs reaching 77,725 (95% UI: 46,681–117,197). Compared with 1990, the number of smoking-related KC deaths increased by 194.58%, whereas the age-standardized smoking-related KC mortality rate remained stable, increasing from 0.12 to 0.13 per 100,000 population (AAPC: 0.29%, 95% CI: −0.05–0.64); the smoking-related ASDR increased from 3.23 3.32 per 100,000 population (AAPC: 0.18%, 95% CI: −0.16–0.52) (Table 3, Figure 3). Smoking remained an important contributor to the estimated attributable burden of KC.

Table 3.

Burden of kidney cancer attributable to risk factors in China, 2023.

Measure	Risk	Number (1990, 95% UI)	Number (2023, 95% UI)	Percent change (%)	ASR (1990, 95% UI)	ASR (2023, 95% UI)	AAPC of ASR (95% CI)
Deaths	High body mass index	561 (202–983)	2643 (1141–4456)	370.67	0.06 (0.02–0.11)	0.12 (0.05–0.2)	2.08 (1.79–2.37)^a
	Occupational exposure to trichloroethylene	6 (1–12)	22 (5–42)	247.07	0 (0–0)	0 (0–0)	1.16 (0.93–1.38)^a
	Smoking	1047 (603–1695)	3085 (1861–4670)	194.58	0.12 (0.07–0.2)	0.13 (0.08–0.2)	0.29 (−0.05–0.64)
DALYs	High body mass index	18,923 (6957–32,547)	73,801 (32,103–122,773)	290.01	1.9 (0.69–3.27)	3.36 (1.46–5.54)	1.83 (1.55–2.11)^a
	Occupational exposure to trichloroethylene	221 (46–432)	694 (155–1292)	214.18	0.02 (0–0.04)	0.03 (0.01–0.06)	1.08 (0.86–1.29)^a
	Smoking	29,394 (17,185–48,466)	77,725 (46,681–117,197)	164.42	3.23 (1.87–5.31)	3.32 (2–4.99)	0.18 (−0.16–0.52)

AAPC: average annual percentage change; ASR: age-standardized rate; CI: confidence interval; DALY: disability-adjusted life year; UI: uncertainty interval.

Figure 3.

Burden of kidney cancer attributable to risk factors in China (2023). (a) Number of deaths and DALYs; (b) ASRs of death and DALYs. ASR: age-standardized rate; DALY: disability-adjusted life year.

In 2023, there were 22 KC deaths related to occupational exposure to TCE (95% UI: 5–42), with related DALYs reaching 694 (95% UI: 155–1292); the AAPC in the age-standardized KC mortality rate related to occupational exposure to TCE was 1.16% (95% CI: 0.93–1.38) (Table 3, Figure 3).

In 2023, there were 2643 KC deaths related to high BMI (95% UI: 1141–4456), with related DALYs reaching 73,801 (95% UI: 32,103–122,773); the age-standardized DALY rate related to high BMI increased from 1.9 to 3.36 per 100,000 population (AAPC: 1.83%, 95% CI: 1.55–2.11) (Table 3, Figure 3). The age-standardized KC mortality rates and DALY rates of the above three risk factors were all higher in 2023 than in 1990. Within the GBD comparative risk assessment framework, smoking and high BMI accounted for a larger attributable burden of KC than occupational exposure to TCE in 2023. By contrast, the attributable burden related to occupational TCE exposure remained relatively small at the population level, likely reflecting the narrower size of the exposed population (Table 3, Figure 3).

Age- and sex-specific stratified analyses further showed that the attributable burden of major risk factors was not uniform across subgroups (Figure 4). The increase in high BMI–attributable burden was more apparent in older adults, particularly those aged ≥75 years, whereas smoking-attributable burden showed a relatively greater increase in the 15–49 years age group. In addition, the burden attributable to occupational TCE exposure remained consistently higher in men than in women. These subgroup patterns were descriptive and were intended to provide additional context for the interpretation of risk-attributable burden within the GBD framework.

Figure 4.

Trends in kidney cancer deaths and DALY rates attributable to risk factors in China by age group and sex (1990–2023). (a) Death rates attributable to risk factors by age group; (b) DALY rates attributable to risk factors by age group; (c) Death rates attributable to risk factors by sex; (d) DALY rates attributable to risk factors by sex. AAPC: average annual percentage change; DALY: disability-adjusted life year.

Discussion

Based on the GBD 2023 data and Joinpoint model analysis, this study observed a trend of increasing ASIR, ASMR, and ASPR; decreasing ASDR; a rise in the absolute number of cases; and an approximately fourfold increase in the number of prevalent cases. Men have consistently borne a greater disease burden than women, and older individuals (especially those aged ≥75 years) exhibit higher rates of all indicators associated with KC burden. The long observation period reduced the influence of short-term fluctuations during 2020–2022 on the interpretation of overall temporal patterns.

KC represents a heterogeneous group of cancers, among which, renal cell carcinoma (RCC) is the most common type, accounting for more than 90% of all solid renal tumors.²² As a disease with a continuously rising incidence worldwide, there are approximately 400,000 new KC cases each year, with an associated global annual mortality rate of approximately 175,000. According to existing predictions, the incidence rate will continue to rise over the next decade, highlighting the urgency of addressing this major global health issue.³ It is estimated that by 2030, the global number of KC cases will further increase to 475,400; however, the ASIR is expected to decrease slightly to 4.46 per 100,000 population.^23,24 Notably, although the overall KC mortality rate has remained relatively stable, an increase in KC incidence has been observed over recent decades, which could be attributed not only to underlying epidemiological changes but also to the widespread use of abdominal imaging, which has increased the incidental detection of small and previously asymptomatic renal masses.^25,26 Therefore, the rising ASIR observed in the present study should not be interpreted as solely reflecting a true increase in the underlying occurrence of KC. Instead, it may reflect a combination of changes in disease occurrence and improvements in case ascertainment. In addition, there are significant global geographical differences in the incidence and mortality rates of KC, which are mainly affected by factors such as dietary structure, obesity prevalence, and access to healthcare. The existence of social differences further exacerbates the imbalance in the disease burden of KC.³

Identifying the risk factors of KC is crucial for formulating early detection programs, implementing prevention and control strategies, and guiding subsequent research.³ In the present study, stratified analyses of risk-attributable burden suggested that these patterns varied across age and sex strata. However, these subgroup differences should be interpreted as descriptive findings within the GBD comparative risk assessment framework rather than as formal interaction effects. Their main value is to provide additional epidemiological context for identifying populations that may warrant greater attention with respect to prevention strategies. In terms of the composition of risk factors, although genetic susceptibility can only explain <5% of KC cases, hereditary factors confer the highest disease risk. In contrast, modifiable risk factors account for 40% of the increased risk and are extremely common in the general population.²⁷ Most host factors are non-modifiable, whereas environment-related factors are, to a certain extent, intervenable. Increasing evidence suggests that modifiable risk factors are associated with RCC occurrence and progression.^28–30 Studies with different levels of evidence have confirmed that various factors are associated with RCC, among which hypertension, smoking, and obesity are well-established risk factors.²² Other studies have reported that long-term intake or abuse of non-steroidal anti-inflammatory drugs commonly used as over-the-counter analgesics has been associated with a higher KC risk.³¹ Cumulative exposure to multiple KC risk factors is common, with the superposition of occupational and lifestyle factors being a typical example. A 2004–2010 report by the US Centers for Disease Control and Prevention states that the annual average smoking rate (30%) in occupational groups at high risk of KC, such as those working in the mining, construction, and extraction industries, is significantly higher than that in the general adult population (19.3%).³²

There are significant sex-based differences in the disease burden of urinary system diseases, with the burden of urinary system cancers mainly borne by men. Studies have confirmed that smoking, alcohol consumption, and obesity are risk factors for urinary system cancers, and men are more likely to be exposed to such risk factors for a long time.³³ In addition, industries with a higher proportion of male employees are often more likely to expose workers to occupational hazards associated with the occurrence of urinary system cancers.³⁴ This sex-based difference is particularly evident in KC related to occupational TCE exposure. First, there is a significant gap in occupational TCE exposure levels between men and women. TCE is widely used in industrial paint removers, degreasers, and industrial cleaning agents, and occupations involving TCE exposure risks are predominantly concentrated in machine processing workshops.^35,36 Since the number of men engaged in such positions is usually much higher than that of women, men have significantly higher frequency and duration of TCE exposure than women. This exposure difference may partly explain the higher estimated burden of occupational TCE–attributable KC among men. Relevant reports have indicated that the occupational TCE exposure level in men is approximately twice that in women.³⁷ In addition, studies on tumors related to occupational carcinogen exposure have also shown that the disease burden in males is significantly higher than that in women, which is likely related to the higher proportion of men employed in high-exposure risk positions.³⁸ More notably, there is evidence supporting the theory that sex-based differences exert a significant impact on the epidemiological characteristics of KC.³⁹ Men are more affected, with an approximately twofold higher risk of developing KC and mortality from KC than women. Differences in hormone signaling and sex-related behavioral patterns may partly underlie this gap. Therefore, fully understanding these sex-based differences is crucial for formulating targeted prevention and treatment strategies in KC prevention and treatment to reduce the occupational TCE–attributable burden of KC and promote health equity.³

The age-specific pattern observed in this study is broadly consistent with the established epidemiological profile of KC, in which the incidence and mortality generally increase with age, and the highest burden is often observed among older adults. Previous cancer registry-based evidence from China has also shown marked age-specific differences in cancer incidence and mortality overall, providing a broader epidemiological context for interpreting age-related differences in the cancer burden reported by population-level analyses.⁴⁰ In addition, epidemiological studies of RCC have reported that KC is more common in older adults, with diagnosis occurring more frequently in older populations.⁴¹ However, the higher burden among people aged ≥75 years should not be interpreted solely as a direct biological consequence of aging. It may reflect the combined influence of demographic aging and longer cumulative exposure to established KC risk factors, including smoking, hypertension, obesity, and occupational exposure to carcinogens.^36,41 Increased diagnostic ascertainment through abdominal imaging may also have contributed to the higher observed incidence among older adults by increasing the incidental detection of small or asymptomatic renal masses.^25,26 Previous studies have also suggested that KC occurs following long-term occupational TCE exposure, supporting the potential relevance of cumulative exposure when interpreting age-specific burden.³⁶

From a biological perspective, aging may contribute to KC development through accumulated somatic mutations, cellular senescence, chronic inflammation, immune dysregulation, and reduced DNA repair capacity.^42,43 Nevertheless, KC is a heterogeneous disease. RCC accounts for most cases of KC; however, its major histological subtypes, including clear-cell, papillary, and chromophobe RCCs, differ in clinicopathological and molecular characteristics.⁴¹ Evidence from Chinese RCC cohorts has suggested that histological subtype distribution may vary by age, sex, and tumor size.⁴⁴ These findings advocate the consideration of disease heterogeneity and subtype distribution when interpreting the age-specific KC burden. However, because the GBD estimates do not provide detailed information on tumor stage, histological subtype, treatment, imaging utilization, survival, or molecular profile, the present study could not directly assess how these factors contributed to the observed age-specific patterns. Future studies using national cancer registry datasets, hospital-based cohorts, and molecular epidemiological data are needed to further validate these age-specific findings and clarify whether the observed age-related burden reflects true differences in disease occurrence, diagnostic practice, tumor biology, or clinical outcomes.

Smoking is the most important modifiable carcinogenic risk factor in the Chinese population, and its impact on cancer burden exhibits significant sex-based differences.⁵ Among men, approximately 24.5% of cancer incidence can be attributed to smoking, a proportion similar to that reported in the United States (23.6%) and higher than that in the United Kingdom (17.7%).¹⁰ The active smoking rate among Chinese women is relatively low (approximately 3%), associated with a cancer attribution risk of 2.4%.^5,10 However, it is worth noting that the problem of second-hand smoke exposure among Chinese women is more prominent, with a related cancer attribution risk of 3.4%,¹⁰ compared with only 0.3% among American women.¹¹ This phenomenon may further increase the potential public health concern related to tobacco exposure among Chinese women. The most recent epidemiological data also reflect the persistent challenge posed by the tobacco epidemic in China. According to the results of the “2024 China Adult Tobacco Survey” officially released on the 38th World No Tobacco Day in 2025 (https://www.chinacdc.cn/), although the national smoking rate has shown a continuous downward trend and public awareness and willingness to quit smoking have steadily improved, the overall smoking rate among population aged ≥15 years remains as high as 23.2%. Among them, the smoking rate in men has increased to 43.9%, and the second-hand smoke exposure rate for nonsmokers has reached 46.5%. The large proportion of population exposed to smoking poses enormous challenges for the prevention and control of KC and other related diseases. Studies have highlighted that smoking is closely related to the risk of RCC and is a well-established risk factor for the disease.²² Specifically, current smokers have a 1.36 times higher risk of developing KC than never smokers.⁴⁵ Approximately 18%–30% of KC cases can be attributed to tobacco exposure,⁴⁵ and smoking intensity, duration, and time since quitting have demonstrated significant dose–response relationship with the risk of KC.⁴⁶ In addition, smoking habits can also affect the prognosis of KC patients, with heavy smokers having significantly worse disease outcomes than light smokers, never smokers, or former smokers.^46,47 The specific mechanism by which smoking induces KC has not been fully elucidated, and the current understanding of this mechanism needs to be deepened. Studies have shown that tobacco smoke contains various carcinogens such as polycyclic aromatic hydrocarbons, aromatic amines, heterocyclic aromatic amines, and N-nitrosamines, which are directly related to the etiology of RCC.^48,49 Its pathogenic pathways may include multiple aspects. Various carcinogenic molecules in cigarettes are filtered by renal tubules, which can cause chronic inflammatory reactions and DNA damage locally in the kidneys;⁵⁰ however, smoking may provide favorable conditions for cancer growth by inhibiting the catabolism of oligosaccharide chains.²² These mechanisms may collectively contribute to an increased risk of KC, and quitting smoking even after KC diagnosis may improve the survival outcome of patients.⁴¹

Within the GBD framework, smoking appears to be an important contributor to the estimated burden of KC in China. Implementing comprehensive tobacco control measures may be important for reducing the future burden of KC. Relevant strategies need to consider various initiatives. Strict tobacco control policies should be formulated and implemented, and public education on healthy lifestyles should be strengthened; additionally, early screening coverage should be promoted, health education should be deepened, and relevant vaccination services should be improved. It is also necessary to continuously raise social awareness regarding the hazards of tobacco and enhance the overall awareness regarding tobacco control among the population to lower the population burden of KC.

High BMI is an important modifiable factor associated with KC incidence and mortality. Globally, approximately 20.07% of KC deaths in 2021 were attributable to high BMI.¹⁷ Several epidemiological studies have confirmed a clear association between high BMI and KC risk. A study based on the European Prospective Investigation into Cancer and Nutrition (EPIC) has highlighted that the relative risk of KC in people with high BMI can reach 2.25;¹³ other studies have consistently shown that obesity is associated with an approximately twofold higher risk of RCC incidence.²² Globally, approximately 20% of KC cases can be attributed to overweight, and the disease risk has the strongest association with central obesity, showing a clear linear relationship—for each 1-unit increase in BMI, the risk of KC incidence increases by 4%.⁵¹ Notably, there is a complex association known as the “obesity paradox” between high BMI and KC, which has not been fully elucidated.⁵² Although obesity has been associated with a higher incidence of KC, for patients with advanced or metastatic RCC, obesity may instead offer survival benefits. The potential mechanism is that immune infiltration of the adipose tissue can promote cancer cell destruction, thereby improving patient prognosis.²² In recent years, changes in the dietary patterns of the Chinese population have led to a general increase in population BMI levels. This change may partly account for the additional variation in the disease burden of KC in China.⁵³ In contrast, the plant-based dietary patterns followed by populations in some parts of the world may exert a potential protective effect against KC, although this speculation currently lacks conclusive data support.⁵⁴

Among numerous occupational carcinogenic factors, TCE is a type of chlorinated solvent that requires special attention. It is commonly used in the production of metal degreasers and dry cleaning agents in industrial production, with application scenarios covering woodworking workshops, plastic product factories, and watch manufacturing factories.^55,56 In 2012, the IARC classified TCE as a human carcinogen because it was confirmed to be significantly associated with the occurrence of KC;⁵⁷ in addition, TCE can also exert toxic effects on multiple physiological systems of the human body, and its carcinogenic spectrum includes malignant tumors such as liver cancer.¹⁴ One study found a noteworthy phenomenon; the risk of KC incidence is negatively correlated with the educational level of the population. This result suggests that groups with lower educational levels are often more likely to engage in high occupational exposure risk jobs such as blast furnace operations, coke oven production, and steel manufacturing, and therefore are at higher risk of KC.⁵⁸ From the perspective of the geographical distribution of disease burden, in the national-level statistical data in 2021, China recorded the highest number of KC deaths and DALYs attributable to occupational TCE exposure in the world.¹² This phenomenon may be closely related to the earlier industrialization process launched in some regions of China—studies have suggested that industrialization increases occupational opportunities involving exposure to carcinogens and is therefore associated with a higher cancer burden.⁵⁹ Given the observed burden attributable to occupational TCE exposure, strengthening relevant prevention and control measures may be warranted. TCE can invade the human body through three pathways: (a) gastrointestinal intake; (b) skin contact; and (c) respiratory inhalation.⁵⁵ Therefore, relevant occupational practitioners need to implement comprehensive protective measures, including wearing professional protective clothing and masks and strictly prohibiting eating and drinking in contaminated areas. Relevant industries should regularly monitor the TCE concentration level in their working environment and conduct regular awareness and education programs to safeguard workers’ health. For groups at high risk of occupational TCE exposure, especially men and middle-aged individuals, it is necessary to further strengthen KC screening efforts because early detection and treatment may help reduce the disease burden of KC in such groups.

The coronavirus disease 2019 (COVID-19) pandemic led to the closure of medical institutions, disruptions in employment and medical insurance, and fear of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), resulting in delays in cancer diagnosis and treatment.⁶⁰ Although the COVID-19 pandemic exerted a significant impact on routine medical activities, and public attention has shifted to pandemic management, this study found no significant fluctuations in KC prevalence or other indicators of disease burden.

Taken together, these findings suggest that the value of long-term burden assessment lies not only in describing temporal changes but also in informing prevention, monitoring, and early detection priorities. In addition to risk-factor control, the epidemiological patterns observed in this study may help guide risk-adapted monitoring strategies. The higher disease burden of KC among men, older adults, smokers, individuals with high BMI, and populations potentially exposed to occupational TCE suggests that future KC prevention should combine population-level interventions with targeted risk assessment in high-risk groups. Currently, population-wide screening for KC is not established, and the clinical pathway for identifying individuals who may benefit from enhanced monitoring remains insufficiently defined. In this context, emerging molecular approaches, including liquid biopsy based on circulating tumor DNA and blood- or urine-derived biomarkers, may provide future opportunities to connect exposure history with tumor-related molecular alterations and refine risk stratification.^61,62 However, these approaches remain investigational for KC screening and require further validation regarding sensitivity, specificity, cost-effectiveness, clinical utility, and applicability in the Chinese population.

The present study was based on aggregated population-level estimates; therefore, it could not capture histological heterogeneity, molecular subtypes, biomarker-defined differences, or the clinical performance of emerging early-detection approaches. Future studies integrating epidemiological trends with clinical, molecular, and biomarker data are needed to provide a more biologically informed interpretation of population-level patterns.⁶³

The advantages of this study include the use of a unified and internally consistent GBD 2023 framework to estimate the incidence, mortality, prevalence, DALYs, and risk-attributable burden of KC in China over a period of >30 years and detailed stratified discussions on the impact of sex, age groups, and different risk factors on KC occurrence. This study has certain limitations. First, GBD estimates are model-based and depend on the completeness and quality of the underlying cancer registry, vital registration, and other data sources, which may introduce uncertainty, particularly in data-scarce settings. Second, because this study relied on aggregated GBD estimates rather than individual-level clinical or registry data, we were unable to distinguish whether the observed increase in incidence was driven by improved detection, such as greater imaging utilization and incidental diagnosis, or by a true increase in disease occurrence. For the same reason, the age- and sex-stratified analyses of risk-attributable burden were descriptive only and should not be interpreted as formal interaction testing. In addition, the lack of individual-level registry and clinical data prevented formal external validation of the age-specific patterns. It also limited our ability to assess the contribution of histological subtype distribution, tumor stage, treatment patterns, imaging utilization, survival, and molecular heterogeneity to the observed age-related burden. Third, owing to the scope of the available GBD framework, we did not explore provincial-level variation or evaluate other potentially relevant risk factors such as hypertension. Fourth, the temporal trend analysis in this study relied primarily on the standard Joinpoint regression framework. Although this method is widely used in cancer surveillance research, we did not perform additional sensitivity analyses using alternative model specifications. Therefore, the estimated inflection points and AAPCs should be interpreted with appropriate caution, particularly given the model-based nature of GBD estimates. Despite these limitations, the overall trends observed during the study period were generally consistent, providing an evidence base for prevention and control measures such as strengthening tobacco control, adjusting dietary patterns, and focusing on older, male populations.

Conclusion

From 1990 to 2023, the absolute burden of KC in China increased substantially, particularly among men and older adults, although the ASDR showed a modest decline. Smoking, high BMI, and occupational exposure to TCE accounted, in part, for the estimated attributable burden. These findings may support age- and sex-informed prevention, tobacco control, weight management, minimization of occupational exposure to TCE, and improved monitoring of high-risk populations. Further validation using registry and clinical data is warranted.

Footnotes

Acknowledgments

We express our gratitude to the Core Facility and Bioinformatics Laboratory of The First Hospital of Jilin University for the training and generous sharing of experiences and codes.

Author contributions

Zhiyuan Bai: Writing-original draft, methodology, investigation, and formal analysis. Shuai Wang: methodology and formal analysis. Hongjie Wang, Yajun Wang, and Gengchen Huang: validation, investigation, and formal analysis. Yuchuan Hou: supervision, resources, project administration, methodology, investigation, funding acquisition, and conceptualization.

Data availability statement

The data used in this paper were obtained from free database downloads and have been described explicitly in the text. Further inquiries can be directed to the corresponding author.

Ethics approval and consent to participate

This study was based exclusively on publicly available, aggregated, and de-identified estimates from the Global Burden of Disease database. No individual-level patient data were accessed. Therefore, additional institutional review board approval and individual informed consent were not required.

Declaration of conflicting interests

The authors declare that they have no conflicts of interest to declare.

Funding

This work was supported by the Jilin Provincial Department of Science and Technology Project (Grant No. YDZJ202601ZYTS410) and the Medical and Health Talent Special Project of the Jilin Provincial Department of Finance (Grant No. JLSRCZX2026-14).

Informed consent statement

Not applicable. This study used only publicly available, aggregated, and de-identified Global Burden of Disease Study (GBD) data and did not involve individual-level patient data.

ORCID iD

Zhiyuan Bai

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