This chapter presents past, current and future trends in cancer and its risk factors in OECD, OECD accession and selected partner countries, European Union (EU27) member states and Group of 20 (G20) countries. It shows that while age‑adjusted cancer incidence and mortality have decreased, population ageing will increase the absolute cancer burden. It also looks at the prevalence of key cancer risk factors, such smoking, alcohol consumption, diet, physical activity, overweight and air pollution, and shows how some population groups are more likely to be exposed to these risks.
Tackling the Impact of Cancer on Health, the Economy and Society
OECD Health Policy Studies
Abstract
Despite significant advances, cancer remains a large and growing public health challenge
Our battle against cancer has seen great progress. In almost all OECD countries, age‑standardised cancer mortality rates have dropped, with the average decreasing by 26% over the past three decades.
Despite the advances made in cancer prevention and treatment, cancer remains a leading cause of death and disability. In 2019, 28% of all deaths were due to cancer in the OECD, and 29% in the EU.
In women, lung, breast and colorectal cancer accounted for nearly half of all cancer deaths in 2019 in OECD and EU countries (46%), while for men, nearly half of all cancer deaths (49%) were from lung, colorectal and prostate cancer.
Age‑standardised cancer incidence rates vary more than 3‑fold across OECD countries, which is driven in part by differences in exposure to major cancer risk factors:
Tobacco smoking is the leading cause of cancer, and smoking rates vary nearly four‑fold across OECD countries, from 7.2% of the population smoking daily in Iceland to 28% in Türkiye.
There is considerable variation between countries in alcohol consumption, ranging from nearly zero to over 12 litres of pure alcohol per capita per year, equivalent to 133 bottles of wine.
Over half of the population is either pre‑obese or obese in most OECD countries.
The proportion of adults who meet the WHO recommended 150 minutes of physical activity per week ranges from 5% to 76%.
Despite progress on air pollution, exposure to PM2.5 remains above the WHO guideline of 5μg/m3 in all OECD countries, with five‑fold variation across countries in 2020.
There is also variation within countries, as people with lower education and on lower incomes are more likely to be exposed to risk factors and less likely to participate in screening.
Age is an important factor in determining a person’s cancer risk. This means that, as populations continue to age in the future, governments are facing an even larger cancer burden. The number of cancer cases in OECD countries is expected to grow by 44% on average over the next 30 years (30% in the EU).
In our battle against cancer (Box 2.1), considerable progress has been made. Our understanding of causes and risk factors has improved, and new treatments are being developed constantly. Because of these advances, the chance of dying from cancer at a certain age has decreased substantially over the last three decades. In almost all OECD and EU countries, age‑standardised cancer mortality rates have dropped, with the OECD average decreasing by 26% between 1987/8 and 2017/8 (20% in the EU) (Figure 2.1).
Age‑standardised mortality rates (per 100 000 population) for all cancer sites, in 1987/8 and 2017/8
Note: Age‑standardised to world population, all sites excluding non-melanoma skin cancer.
Source: IARC (n.d.[1]), Global Cancer Observatory, https://gco.iarc.fr/.
Cancer is a disease that occurs when the body’s cells start to grow uncontrollably. Normally, cells grow, divide, and die in a regulated way. But in cancer, this process goes haywire, and cells keep dividing. This can result in a lump called a tumour. Cancer can start almost anywhere in the human body – there are more than 200 different types of cancer. Treatment often involves removing the tumour, killing the cancer cells, stopping their growth, or preventing them from spreading further.
Cancer is a genetic disease, in that it is caused by changes, or mutations, in genes that control cell growth and division. It is important to note that it typically takes several gene mutations for a cell to become cancerous. These mutations are often in genes involved in cell growth and division, genes that normally suppress cell growth, or genes repairing other genes.
As cancer originates in our genes, genetic predisposition is an important risk factor. Mutations associated with cancer can be inherited from parents. For some cancer types, genes have been identified that significantly increase one’s cancer risk. For example, people with a mutation in the BRCA (BReast CAncer) 1 or 2 gene have a 50% chance of getting breast cancer before the age of 70, compared to only 7% in people without such a mutation (CDC, 2023[2]).
But mutations are not just inherited, they can also be acquired during the lifetime. This can be due to random errors during cell division, or external factors. These can be environment factors (e.g. air pollution, asbestos, or sun exposure) or behavioural factors (e.g. tobacco smoking, alcohol use, diet). Some infections, such as human papillomavirus (HPV) and hepatitis B and C, can also introduce changes in the genetic material.
Source: American Cancer Society (2022[3]), Gene changes and cancer, www.cancer.org/cancer/understanding-cancer/genes-and-cancer/gene-changes.html; National Cancer Institute (2021[4]), What Is Cancer?, www.cancer.gov/about-cancer/understanding/what-is-cancer; Cancer Research UK (n.d.[5]), What is cancer?, www.cancerresearchuk.org/about-cancer/what-is-cancer.
But despite this progress, cancer remains a major public health concern. In women, one in four deaths (25%) are due to cancer in the OECD and EU (Figure 2.2). Men are even more likely to die from cancer, with nearly one in three deaths being due to cancer (31% in OECD, 33% in EU). In the G20, where mortality rates from other causes (e.g. infectious diseases, chronic respiratory disease and injuries) are larger, the relative burden of cancer is smaller. Nevertheless, cancer still accounts for around one in five deaths. Cancer also causes disability among those living with the disease. Combined with its impact on mortality, cancer is responsible for 15% of all disability-adjusted life years (DALYs1) lost in women in the OECD and EU, and 19% of DALYs in men (Global Burden of Disease Collaborative Network, 2020[6]).
Percentage of all deaths by cause, 2019
Note: CVD: Cardiovascular disease; CRD: Chronic respiratory diseases.
Source: Global Burden of Disease Collaborative Network (2020[6]), Global Burden of Disease 2019, https://vizhub.healthdata.org/gbd-results/.
In women, lung, breast and colorectal cancer accounted for nearly half of all cancer deaths in 2019 in OECD and EU countries (46%) (Figure 2.3). For men, nearly half of all cancer deaths (49%) were from lung, colorectal and prostate cancer.
Percentage of all cancer deaths by cancer type, for females and males, in the OECD and EU combined, 2019
Note: CNS: central nervous system; MM: multiple myeloma; Skin: malignant skin melanoma; Gallbl: gallbladder and biliary tract; Bladd: Bladder.
Source: Global Burden of Disease Collaborative Network (2020[6]), Global Burden of Disease 2019, https://vizhub.healthdata.org/gbd-results/.
There are considerable differences between countries in terms of cancer incidence and mortality. Age‑standardised cancer incidence rates vary more than 3‑fold across OECD countries, and 1.5‑fold across EU countries (Figure 2.4). This can be due to genetic predisposition, but it is also driven by different levels of exposure to behavioural and environmental risk factors. In the OECD, 46% of cancer deaths are attributable to risk factors, and 47% of cancer deaths in the EU (IHME, 2019[7]). Major risk factors for cancer include tobacco smoking, alcohol use, diet, low physical activity, overweight and obesity (high body mass index, or BMI), and air pollution – covered below and in Chapter 5. Chapter 6 also looks at the impact of HPV vaccination on preventing cervical cancer. However, it is important to note there are many more risk factors that can be addressed to prevent cancer (Box 2.2).
Major cancer risk factors covered in this report are tobacco smoking, alcohol use, diet, low physical activity, overweight and obesity, air pollution and infection with the HPV virus. While these risk factors are responsible for the majority of risk-related cancer cases, there are other risk factors that policy makers should consider when developing cancer prevention plans. These include:
Sun exposure: Ultra violet (UV) radiation, which comes from sun exposure and from UV emitting devices such as sunbeds, are the main risk factor for the three main types of skin cancer (Greinert et al., 2015[8]; IARC, 2012[9]).
Sedentary behaviour: Many studies have suggested a direct positive relationship between sedentary behaviour and risk of cancer, independent of BMI or physical activity (Schmid and Leitzmann, 2014[10]; Leitzmann et al., 2015[11]). For example, sitting for six hours or more a day compared to less than three hours was associated with a 55% increase in ovarian cancer risk (Patel et al., 2006[12]; Leitzmann et al., 2015[11]).
Hormone replacement therapy: Long-term use of combined oestrogen-progesterone hormone replacement therapy (HRT), generally used in the treatment of menopause, is associated with an increased risk of breast cancer. Oestrogen-only menopausal therapy has been causally associated with an increased risk of ovarian cancer and endometrial cancer (Friis et al., 2015[13]; Schüz et al., 2015[14]).
Hepatitis B infection: Infection with the hepatitis B virus (HBV) can lead to chronic liver disease and liver cancer (Villain et al., 2015[15]). Age of infection is a key determinant of whether the infection becomes chronic: newborns have an 80‑90% probability of developing chronic infection if infected, while adults have a less than 10% risk. Chronic infection can result in liver cancer. The most effective intervention against infection with HBV is vaccination, and the WHO has recommended newborn vaccination for HBV since 1997.
Environmental exposures: Many occupational exposures, including chemicals, physical agents and industrial processes, have been identified that cause cancer in humans (Espina et al., 2015[16]). In addition, there is strong evidence that indoor exposure to radon and its decay products is an important cause of lung cancer, second only to tobacco smoking (McColl et al., 2015[17]). Radon is a radioactive gas with that is colourless, odourless, and tasteless, and it is released from bedrock material and then passes up through soil (IAEA, 2023[18]). Radon does not dilute as quickly in indoor air as outside and tends to accumulate in enclosed spaces where it poses risk to human health.
Age‑standardised incidence rates (per 100 000 population) for all cancer sites, 2020
Note: Age‑standardised to world population, all sites excluding non-melanoma skin cancer.
Source: IARC (n.d.[1]), Global Cancer Observatory, https://gco.iarc.fr/.
Tobacco smoking is the leading cause of cancer, and 16% of adults smoked daily in 2021 on average in the OECD (Figure 2.5). In some countries, more than one in four adults smoke. Almost all countries saw a decrease in smoking prevalence between 2011 and 2021, but the greatest drops were seen in countries where rates were already lower. As a result, differences between countries have increased, and rates now vary nearly four‑fold across OECD countries. Regardless, no country has yet achieved the target of a smokefree society, where the prevalence of smoking is below 5% (Balogun, 2023[19]; European Commission, 2021[20]).
Population aged 15 and over smoking daily, 2011 and 2021 (or nearest years)
1. Data from 2019. 2. Data from 2017‑18.
Source: OECD Health Statistics 2023.
Alcohol is linked to seven types of cancer including oral cavity, pharynx, larynx, oesophagus, liver, colon, rectum, and, in women, breast (Boffetta and Hashibe, 2006[21]; Secretan et al., 2009[22]). Contrary to tobacco smoking, alcohol consumption has changed little over the past decade (Figure 2.6). The average per capita consumption in the OECD has gone from 8.9 litres in 2011 to 8.6 in 2021 (10.5 to 10.1 in the EU); and in around 40% of countries the consumption of alcohol increased. There is considerable variation between countries in alcohol consumption, ranging from nearly zero to over 12 litres per capita. Particularly Central and Eastern EU Member States (MS) see high alcohol use.
Recorded alcohol consumption (litres per capita) among the population aged 15 and over, 2011 and 2021 (or nearest year)
1. Data from 2019. 2. Data from 2017.
Source: OECD Health Statistics 2023.
There is strong evidence that diet plays a causal role in cancer, with significant evidence that a diet high in plant floods and whole grain cereals, and low in red and processed meat, salt and salt-preserved foods, reduces the risk of cancer (World Cancer Research Fund/American Institute for Cancer Research, 2018[23]). This report focuses on specific food groups for which there is a proven link to cancer: fruit, vegetables, whole grains, sodium, processed and red meat. However, it is important to note that cancer risk may also be influenced by specific subgroups of food (e.g. leafy greens), nutritional components of foods (e.g. fibre), the combination of foods eaten (e.g. a Mediterranean diet), and the processing that food undergoes (Box 2.3) (WCRF, n.d.[24]; WCRF, 2023[25]; Morze et al., 2020[26]; Cordova et al., 2023[27]).
Ultra-processed foods (UPFs) and highly processed foods are the topic of much discussion in relation to adverse health outcomes (Lawrence and Baker, 2019[28]). The NOVA classification includes four groups, with increasing level of processing (Monteiro et al., 2017[29]):
Group one refers to unprocessed and minimally processed foods such as fruits and vegetables.
Group two is processed culinary ingredients such as sugar, vegetable oils and butter.
Group three is processed foods such as canned vegetables in brine, freshly made breads and cheeses.
Group four is ultra-processed foods. Ultra-processed foods are formulations of ingredients, mostly of exclusive industrial use, that result from a series of industrial processes (hence “ultra-processed”). Examples include soft drinks, mass-produced industrial-processed breads, sweet or savoury packaged snacks, breakfast “cereals”, reconstituted meat products and read-to‑eat/heat foods.
There is emerging evidence suggesting that UPFs are associated with increased cancer risk, cancer mortality and other NCDs. When UPF is considered as a share of total diet, a 10 percentage point higher share in UPF were shown to have (Chang et al., 2023[30]):
a 2% higher risk of cancer incidence overall,
a 19% higher risk of ovarian cancer,
a 6% increased risk of cancer death overall,
a 16% increased risk of breast cancer death, and
a 30%increased risk of death from ovarian cancer
UPFs are also associated with other NCDs. Emerging evidence from the EPIC cohort found an increase in cardiovascular disease and diabetes among those with a higher share of UPFs in their diet (Cordova et al., 2023[27]). An umbrella review found that greater exposure to ultra-processed food was associated with a higher risk of adverse health outcomes, especially cardiometabolic, common mental disorder, and mortality outcomes (Lane et al., 2024[31]).
Overall, the study of ultra-processed foods remains an important topic with ongoing research, given its high proportion in diets around the world.
A greater consumption of non-starchy vegetables or fruit protects against a number of cancers (WCRF, n.d.[24]) – yet few people eat enough fruit and vegetables. On average in the OECD, only 15% of adults eats at least five portions of fruit and vegetables daily, ranging from 2% to 33% (OECD, 2023[32]). Central and Eastern EU MS, as well as Türkiye, have particularly low fruit and vegetable consumption. Whole grain intake also varies considerably across countries, but in most European OECD countries the average daily intake falls below a 75g daily, an intake considered adequate by several national agencies (European Commission, 2021[33]).
Being overweight or obese is an established risk factor for 13 different cancer sites and a major contributor to cancer incidence and mortality (World Cancer Research Fund Research/American Institute for Cancer, 2007[34]; IARC, 2002[35]; Lauby-Secretan et al., 2016[36]). Overweight and obesity have been increasing, and over half of the population is now either pre‑obese (BMI≥25 and <30) or obese (BMI≥30) in the OECD and EU (Figure 2.7). Obesity among adolescents are also major public health concerns: 18.3% of adolescents aged 15 years were overweight in 2017‑18 on average across 27 OECD countries (OECD, 2023[32]).
Self-reported pre‑obesity and obesity rates among adults, 2021 (or nearest year)
1. 2017‑19 data. Pre‑obese (people who are overweight but not obese) is defined as a BMI of over 25 but less than 30; while obesity is defined as a BMI of 30 or higher.
Source: OECD Health Statistics 2023.
There is strong evidence that physical activity reduces the risk of developing and dying from various types of cancer (IARC, 2020[37]). This risk reduction is independent of the impact of obesity (Nunez et al., 2017[38]). In other words, although physically activity can help with weight control, which in turn can reduce the risk of cancer, physical activity also decreases the risk of cancer on its own independent of weight. Nevertheless, only 40% of adults in the OECD meets the WHO recommended 150 minutes of physical activity per week. This ranges across countries from 5% to 76%, with notably lower physical activity rates in Central and Eastern EU MS, as well as some Southern EU MS (OECD, 2023[32]).
Air pollution refers to a mixture of pollutants in outdoor (ambient) air, including respirable particulate matter less than 2.5 µm in diameter (PM2.5 or fine particulate matter). Exposure to particulate matter in outdoor air pollution has been shown to cause lung cancer (IARC, 2015[39]). Despite progress over the last two decades, in 2020 exposure to PM2.5 remained above the WHO guideline of 5μg/m3 in all OECD countries except for Finland, with five‑fold variation across countries (Figure 2.8). Some OECD countries have seen marked drops, such as Mexico (from 29.6 in 2000 to 14.4 in 2020) and Italy (25.4 to 14.3). On the other hand, some countries, including Korea and Australia, saw the average level of air pollution increase.
Mean population exposure to fine particulates (PM2.5) in OECD countries in 2000 and 2020
Source: OECD (2024[40]), OECD Data Explorer: Exposure to air pollution.
The same risk factors that drive differences between countries also contribute to differences within countries. The major risk factors for cancer are consistently more prevalent among people with lower socio‑economic characteristics, such as lower income and education levels (OECD, 2024[41]). One example is tobacco use. Smoking – a major risk factor for cancer – is notably more prevalent among people with a lower education: on average in the EU, 19% of people with lower secondary education or less smoked, compared to 13% of people with tertiary education (Figure 2.9). This is reflected in lung cancer rates, the primary cancer associated with smoking. Preliminary findings from the EUCanIneq study show that lung cancer mortality rates were 2.6 times higher among men with lower education compared to men with higher education, and 1.7 times higher among women with lower levels of education (OECD, 2024[41]).
Daily smokers of cigarettes by educational attainment level, 2019
Note: “low education” is defined as less than primary as well as primary and lower secondary education (levels 0‑2); “high education” is defined as tertiary education (Levels 5‑8).
Source: Data from the European health interview survey (EHIS), accessed through Eurostat (2022[42]), “Daily smokers of cigarettes by sex, age and educational attainment level”, https://ec.europa.eu/eurostat/databrowser/view/hlth_ehis_sk3e/default/table?lang=en.
In addition to differences in risk factors, differences in preventive care can also contribute to inequalities across population groups. Studies in Europe and the United States have shown that people from ethnic majority populations and with a higher socio‑economic status are more likely to get vaccinated against HPV (Fernández de Casadevante, Gil Cuesta and Cantarero-Arévalo, 2015[43]; Xiong et al., 2024[44]).
In addition, people with lower education or income levels are less likely to participate in screening (OECD, 2024[41]). For example, women with lower income are twice as likely to miss out on breast cancer screening: only 7.3% of EU women in the highest income quintile report never having had an X-ray breast examination, compared to 15.2% of women in the lowest income quintile (Eurostat, 2023[45]). Similarly, people with higher educational attainment are more likely to participate in breast, cervical and colorectal cancer screening. Almost 80% of EU women with a tertiary education report having had a cervical smear test within the three years prior, compared to only 61% of women with lower secondary education or less (Figure 2.10). In some countries screening rates among women with higher education are more than double those of women with lower education (Eurostat, 2023[45]).
Proportion of women aged 20 to 69 years having had a cervical smear test within the three years prior to the survey, by educational attainment level, 2019
Note: EU27 average is weighted.
Source: Data from the European health interview survey (EHIS), accessed through Eurostat (2023[45]), “Cancer screening statistics”, https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Cancer_screening_statistics#Breast_cancer_screening.
Age is an important factor in determining a person’s cancer risk. Normally, the body eliminates cells with damaged genes, but its ability to do so diminishes as people age (National Cancer Institute, 2021[4]). Moreover, as people age their cells accumulate genetic mutations over time, increasing the likelihood that they become cancerous. While there is evidence that the incidence rate of cancer in young people has been increasing in recent years (Box 2.4), cancer remains a disease that primarily affects older people: in the OECD, more than 95% of cancer deaths occur in people aged 50 and over, and 50% in people 75 and over (96% and 51%, respectively, in the EU) (Figure 2.11). In the G20, the lower average life expectancy means that there are fewer people in older age bands, and therefore fewer deaths from cancer in those age bands.
Distribution of cancer deaths across age groups, percentage of all cancer deaths in 2019
Source: Global Burden of Disease Collaborative Network (2020[6]), Global Burden of Disease 2019, https://vizhub.healthdata.org/gbd-results/.
Rates of early onset cancer (cancer occurring in people under the age of 50) have been rising for the past several decades (Ugai et al., 2022[46]). Across 24 OECD countries, age‑standardised cancer incidence rates in young people increased by 12% between 2002 and 2017, compared to a 5% increase in the population as a whole (Figure 2.12). This phenomenon is seen for several cancers, but some of the sharpest rates of increase in early-onset cancer are observed for colorectal cancer, a leading cause of cancer-related mortality worldwide and typically a cancer of older adults (Ledford, 2024[47]) (Siegel et al., 2019[48]). On average across 24 OECD countries, the age‑standardised incidence of colorectal cancer remained large stable between 2002 and 2017 in the general population (+1%), while in people under 50 it increased by 38% on average.
Percentage change in age‑standardised incidence rate between 2002‑17, for all cancers (excluding non-melanoma skin cancer) and for colorectal cancer, in people of all ages and people under 50 (“early onset”)
Note: Based on age‑standardised (world population) incidence rates to reflect trends in incidence regardless of demographic changes.
Source: OECD analysis of data from IARC (n.d.[1]), Global Cancer Observatory, https://gco.iarc.fr/.
Although the factors causing the rising incidence in younger people are not yet fully known, several theories have been proposed to explain the increase. These include an increased exposure in early life and young adulthood to risk factors such as overweight, physical inactivity, alcohol consumption, unhealthy diet, antibiotics, and environmental chemicals (Ugai et al., 2022[46]; Gupta et al., 2024[49]) One study looking at both genetic and modifiable risk factors found evidence suggesting that higher levels of body size and alcohol drinking increased the risk of early-onset colorectal cancer, in addition to genetic predisposition (Laskar et al., 2024[50]).
It is important to note that the absolute burden of cancer in younger people remains relatively small. While some countries have seen large increases in the age‑standardised incidence rate of early-onset cancer, these incidence rates were low to begin with. Moreover, due to population ageing the number of older people has increased, and thus their relative cancer burden. As a result, on average across 24 OECD countries, the proportion of cancer cases occurring in people younger than 50 was 21% in 2002, and in 2017 this was 19% (Figure 2.13). For colorectal cancer, the proportion of cases occurring in younger people saw a slight increase, from 11% in 2002 to 12% in 2017.
The percentage of cancer (excluding non-melanoma skin cancer) and colorectal cancer cases that occur in people under the age of 50, in 2002 and 2017 (based on crude incidence rates)
Note: Based on crude incidence rates to reflect the actual cancer burden in each country.
Source: OECD analysis of data from IARC (n.d.[1]), Global Cancer Observatory, https://gco.iarc.fr/.
Nevertheless, the upward trend in early onset cancer has important implications. If the increased incidence rates are due to higher or earlier exposure to cancer risk factors, public health interventions should be designed to address this. It also has implications for our health systems, society, and economy (Ugai et al., 2022[46]). With increasing cancer survivorship, there will be greater numbers of people living with and surviving cancer for longer periods of time. Questions on fertility and pregnancy in cancer care will become increasingly important. Additionally, as this affects people of working age, it has greater effects on the labour market and places more importance on the re‑integration of cancer survivors into the labour force following recovery.
The impact of age on cancer incidence and mortality can be observed in the rising crude mortality rates. Most developed countries are dealing with ageing population. As people now live longer than ever, the chances of eventually developing cancer also increase. So while age‑standardised mortality rates have improved over the last three decades due to better prevention and treatment (Figure 2.1), crude rates have increased by 21% on average in the OECD (27% in the EU) (Figure 2.14).
Crude mortality rates (per 100 000 population) for all cancer sites, in 1987/8 and 2017/8
Source: IARC (n.d.[1]), Global Cancer Observatory, https://gco.iarc.fr/.
As populations will continue to age in the future, governments are facing an ever-growing cancer burden. Based on population projections, the number of cancer cases in OECD countries is expected to grow by 44% on average over the next 30 years (30% in the EU) (Figure 2.15). In the EU, this is despite a 3% reduction in overall population size (in the OECD the average population size is expected to increase by 4%). Hand-in-hand with this growing cancer burden come increased healthcare cost and an overall loss of societal well-being. It is crucial that policy makers understand the challenge they are facing, and the potential impact that their policies could have.
Change in number of cancer cases in 2050 compared to 2022
Note: Projections are based on 2022 estimates of the incidence, mortality, and prevalence of 36 specific cancer types, combined with population projections for 2050.
Source: Ferlay, J. et al. (2020[51]), Global Cancer Observatory: Cancer Tomorrow, https://gco.iarc.fr/tomorrow.
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← 1. Disability-adjusted life years (DALYs) combine years of life lost due to premature mortality with the years of life lived in states of less than full health, or years of healthy life lost due to disability. One DALY represents the loss of the equivalent of one year of full health.