Burden of incidence
In 2019, the number of ovarian cancer incident cases was 294422 (260649 to 329727). The overall burden of ovarian cancer was on the rise, especially in the number of cases, with a percentage change of 107.8% (76.1 to 135.7%) compared to 1990 (Table 1, Fig. 1). But the percentage changes of global age-standardized incidence rate kept stable during the same time period. All three groups (15–49, 50–69, and 70 + age groups) showed an increasing trend in the number of cases between 1990 and 2019, with the highest cases number in 2019 in the 50–69 age group. The age group of largest percentage change in the number of incident cases was 70 + age group, were 119.9% (92.9 to 143.9%) (Table 1, Fig. 2a).
The disease burden of ovarian cancer varies significantly across SDI regions. In 2019, the number of ovarian cancer incident cases was highest in the high SDI region, corresponding to value of 80454 (70504 to 91461), and lowest in the low SDI region. All regions showed an increasing trend during 1990–2019, while the high SDI region was the region with the lowest increase in morbidity burden, but the low-middle SDI region was the highest one, increased by 326.0% (158.8 to 470.5%) (Table 1) for new cases.
Similarly, the high SDI quintile had a negative change of ASIR during this period, accounting for 18.8% (-28.6 to -3.8%). In contrast, the disease burden in low-middle SDI quintile increased substantially (91.3% (17.8 to 157.1%) for ASIR) (Table 2, Fig. 3).
The region with the highest number of incident cases was Western Europe in 1990, while East Asia and South Asia in 2019. And the age-standardized incidence rate of Central Europe was the highest among all world regions, reached 11.7 (10.0 to 13.7), while the rate of Central sub-Saharan Africa seemed lowest at the same time, showed 3.2 (2.1 to 5.1) (Table 2). In both regions, the highest number of incident cases was found in the 50–69 age group (Supplementary Table 1). However, from 1990 to 2019, Caribbean—the third lowest number of morbidity and mortality among all regions in 2019, showed the highest percentage increase in incident cases, with a number of 444.5% (152.5 to 582.7%). At the same time period, Western Europe turned out to be the region with no change (Table 1, Fig. 1, Supplementary Fig. 1a). From 1990 to 2019, United States of America and China were consistently the top countries with the highest number of cases (Table 1, Fig. 4), while Guatemala has seen an incredible increase in the number of cases in 30 years (1150.3% (469.1 to 1652.0%)) (Fig. 1). Focusing on age-standardized incidence rate per 100,000 people, Monaco ranked first both in the past 1990 and 2019, while Pakistan and Brunei Darussalam also climbed rapidly in recent years (Table 2, Supplementary Table 2, Fig. 3).
Burden of deaths and DALYs
In 2019, the number of deaths for women due to ovarian cancer was 198412 (175357 to 217665), and the number of DALYs was 5.36 million (4.69 to 5.95), compared to 2.73 million (2.49 to 3.17) in 1990, and a percentage of DALYs increased by 96.1% (65.0 to 120.5%) (Table 1). Meanwhile, the percentage change of global age-standardized death rate and DALY rate were relatively flat. The age-standardized death rate due to ovarian cancer was 4.6 (4.0 to 5.0) per 100,000 in 2019 (Table 2). Of these, all three age groups were trending upward in the number of deaths and DALYs, with the highest number of deaths and DALYs in 2019 in the 50–69 age group(Table 1, Fig. 2b-c), but the largest percentage change was in the 70 + age group, with the number of 121.3% (95.7 to 140.3%) (Table 1). For DALYs, only the 15–49 age group in high SDI region showed a decrease in DALYs. And it should be noted that among all regions, the greatest increase in the percentage of DALYs was all observed in the 70 + group, with the highest number being in the low-middle SDI region (384.1% (209.8 to 546.5%)), followed by the middle SDI region (338.9% (215.1 to 431.3%)) (Supplementary Table 3).
From a global perspective, the burden of ovarian cancer reflected in DALYs and mortality was similar to that of morbidity. The high SDI region saw the highest deaths and DALYs in 2019, with the number of 56639 (50391 to 61318) and 1.23 million (1.13 to 1.32), and lowest in the low SDI area, while the high SDI region was the area that DALYs and death burden of which changed least, rising by 15.8% (6.5 to 35.4%) and 30.3% (19.1 to 47.3%). But the area with the largest deaths and DALYs number increase was low-middle SDI quintile with a percentage change of 308.6% (151.3 to 445.8%) and 282.1% (129.6 to 412.9%), respectively (Table 1). As for age-standardized rates of deaths and DALY, from 1990 to 2019, the high SDI region was in a decreasing trend, and with a significant decrease corresponding to 24.0% (-30.3 to -12.3%), and 27.5% (-33.1 to -14.2%), respectively. The same as the burden of incidence, the low-middle SDI quintile showed a striking increase (75.1% (10.1 to 134.4%) for ASDR and 75.1% (6.9 to 134.6%) for ASDALYR) (Table 2).
In 1990, Western Europe had the highest burden of both deaths and DALYs globally with 26356 (23607 to 27318) and 624896 (553975 to 645271), while in 2019, the region with the highest DALYs was South Asia (32105 (24894 to 39896)) for deaths and 982473 (748576 to 1238008) for DALYs). Central Europe had the highest ASDR (7.6, 6.6 to 8.9) while Central sub-Saharan Africa had the lowest ASDR (2.6, 1.7 to 4.1). Caribbean became the region with the highest percentage increase in both deaths and DALYs during this period, with changes of 432.7% (152.6 to 569.4%) and 388.3% (138.4 to 518.2%), respectively, while Western Europe had the flattest change in values, with little increase of 16.1% (4.9 to 30.2%) and the value of DALY showed no change. (Table 1, Table 2). High-income North America and Central sub-Saharan Africa had the highest and lowest age-standardized DALY rate, respectively. Similar to the results shown in Fig. 5 and Supplementary Fig. 2b, the values of deaths and DALYs in most of the regions showed numerically bigger with the increase of SDIs (Fig. 5, Supplementary Fig. 1b).
The same as the trend of cases, top three countries with the highest values of deaths and DALYs for ovarian cancer in 1990 were United States of America, China and Russian Federation, while in 2019, China, India, United States of America became the countries with the highest number, Guatemala had the highest change in the number of deaths among all over the world, United Arab Emirates had the biggest increase in DALYs as the same time (Supplementary Table 2, Fig. 6, Supplementary Fig. 2a-b). Based on an assessment conducted every five years, Monaco consistently ranked first in ASDR. As for ASDALYR, Greenland had the highest value in 1990, and then was overtaken by Monaco in 2005. During this period, the ranking changed a lot, and some countries with lower ASDALYR caught up, such as Pakistan and Brunei Darussalam, but as of 2019, the country with the highest ASDALYR was still Monaco (342.1 (248.9 to 436.0)) per 100,000 (Table 2, Supplementary Fig. 3a-b).
Burden of ovarian cancer attributable to leading risk factors
In 2019, the ASDR due to all risk factors remained essentially constant from 1990 to 2019, with the ASDALYR increasing from 12.3 (5.8 to 20.7) per 100,000 to 13.9 (5.7 to 25.3) per 100,000. During the period 1990–2000, the global ASDALYR values were relatively stable, and from 2001 a small increase occurred, and then a small decrease followed by a yearly increase from 2010 to 2019 (Supplementary Table 4).
Among the most specific risk factors attributed to all deaths of ovarian cancer globally in 1990, the top three were high fasting plasma glucose, high body-mass index, and occupational exposure to asbestos, respectively. In 2019, the same pattern of risk factors for the number of ovarian cancer deaths worldwide did not change (Supplementary Table 5–6).
In 2019, of all the risk factors for ovarian cancer death, the risk factor that led to the highest number of deaths was high fasting plasma glucose, accounting for 15736 (3023 to 36227) or age-standardized death rate of 0.4 (0.1 to 0.8) per 100000, the corresponding ASDR has shown an increase over the last 30 years (34.7% (18.6 to 51.4%)) (Supplementary Table 6, 7). Among the SDI regions, the numbers of ASDR due to high fasting plasma glucose showed different dynamics. The high SDI region has the highest ASDR but the smallest overall change of 8.9% (0.6 to 27.8%), but low-middle SDI and low SDI regions had the largest ASDR growth of 169.4% (74.6 to 268.1%) and 151.4% (55.3 to 265.3%), respectively (Table 3). In total, the ASDR for all world regions showed an upward trend over the last 30 years (Fig. 7), but Tropical Latin America showed the smallest increase (10.8% (0.1 to 23.8%)), while Caribbean showed the largest increase with 282.3% (66.1 to 388.6%) (Supplementary Table 6).
Occupational exposure to asbestos was the second leading cause of ovarian cancer deaths globally (Supplementary Table 5–6), with an ASDR of 0.1 (0.1 to 0.2) per 100000, while from 1990 to 2019, value of ASDR caused by this risk factor showed a decreasing trend year by year, and as of 2019, ASDR has decreased by 24.9% (-46.7 to -7.4%). Among all SDI quintiles, only high SDI quintile showed a decreasing trend in ASDR, decreasing by 26.8% (-47.9 to -7.1%), while the changes in other areas were not statistically significant in value (Table 3, Fig. 7, Supplementary Table 6, 8). High body-mass index was the third leading cause of ovarian cancer deaths globally, with an ASDR of 0.1 (0.0 to 0.3) per 100000 (Supplementary Table 6, 9), while from 1990 to 2019, the value showed a slow upward trend with a 16.4% (2.7 to 32.0%) increase (Table 3). However, the middle and low SDI regions showed significant increasing trends, with the number of 152.9% (90.6 to 229.4%) and 208.5% (77.9 to 451.5%), while other regions showed no change (Table 3, Fig. 7).
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