Temporal Trends in Mortality of Female Cancers Among Women and the Impact of COVID-19 in Low- and Middle-Income Countries, 1990–2023: An Age-Period-Cohort Analysis from the Global Burden of Disease Study 2023

Haolin Zhong,1 Shengjian Yu,2 Yitong Huang,3 Feng Xuan2 1Department of Obstetrics and Gynecology, Zhuji Maternal and Child Health Hospital, Shaoxing, Zhejiang, People’s Republic of China; 2Department of Radiation Oncology, Zhuji Affiliated Hospital of Wenzhou Medical University, Shaoxing, People’s Republic of China; 3Department of Internal Medicine, Zhuji Maternal and Child Health Hospital, Shaoxing, Zhejiang, People’s Republic of ChinaCorrespondence: Feng Xuan, Email [email protected]: Female cancers—breast cancer (BC), cervical cancer (CC), ovarian cancer (OC), and uterine cancer (UC)—among women disproportionately affect low- and middle-income countries (LMICs). We quantified mortality patterns and disentangled age, period, and cohort drivers using Global Burden of Disease Study 2023 data.Methods: We assessed age-standardized mortality rates (ASMRs) in LMICs—upper-middle-income countries (UMCs), lower-middle-income countries (LMCs), and low-income countries (LCs)—from 1990 to 2023, estimated average annual percent change (AAPC) and post-2020 annual changes. Age–period–cohort analysis was applied to disentangle age, period, and cohort effects.Results: From 1990 to 2023, total deaths from female cancers among women more than doubled in LMICs, increasing from 410,667 to 1,053,147. LMCs overtook UMCs to become the largest contributor in 2023. ASMR did not move in a single direction across LMICs. While ASMRs declined in UMCs (AAPC: – 0.77%), they increased in LMCs (AAPC: 0.71%) and LCs (AAPC: 1.40%). After 2020, ASMRs rose in all income groups, with the steepest rise in LCs. BC remained the leading cause of death in UMCs and LMCs, while CC predominated in LCs. Age-period-cohort analysis showed period rate ratios declining in UMCs but increasing in LMCs/LCs. For CC in LMCs/LCs, period rate ratios fluctuated slightly and exhibited a minor uptick in 2019– 2023. Cohort rate ratios fell across generations in UMCs but rose in LMCs/LCs.Conclusion: Temporal trends in mortality of female cancers among women in LMICs exhibited stratified patterns rather than uniform improvement: ASMRs declined in UMCs but rose persistently in LMCs and LCs, while absolute deaths increased across all income groups. Distinct subtype-specific trajectories further highlight the need for targeted strategies addressing the unique epidemiological and health system challenges of each cancer. Scaling up screening programs, human papillomavirus vaccination, and access to timely treatment is essential to reverse these trends and achieve equitable reductions in female cancer mortality in LMICs.Keywords: GBD 2023, mortality, female cancers, COVID-19, low- and middle-income countries, age-period-cohort effect