Epidemiological trends, projections, and attributable risk factors of esophageal cancer: a comparative study of four Western Pacific countries, 1990–2040

Background Esophageal cancer (EC) is the 11th most commonly diagnosed cancer and the 7th leading cause of cancer-related death worldwide, yet comparative evidence across the Western Pacific remains limited. Methods Data on EC incidence, mortality, and DALYs were obtained from GBD 2023. Age- and sex-specific patterns were examined, and Joinpoint regression, age-period-cohort analysis, decomposition analysis, and ARIMA modeling were applied. Risk factor attribution was analyzed for EC mortality. A complementary analysis of a retrospective EC cohort from Fujian Medical University Union Hospital (FJMU) examined the co-occurrence of recorded smoking and heavy drinking histories and the association between recorded heavy drinking history and overall survival among male patients with a recorded smoking history. Results From 1990 to 2023, EC burden showed marked age and sex disparities, with higher rates in males and after age 60. All age-standardized rates declined across countries, though magnitudes varied; China had the highest burden in 1990, whereas Mongolia ranked highest in 2023. Population aging drove absolute burden increases, offset by epidemiological improvements. Smoking was the leading mortality risk factor, with the highest attributable fraction in China and lowest in Mongolia. In the FJMU cohort, recorded smoking and heavy drinking histories frequently co-occurred. Among male patients with a recorded smoking history, positive heavy drinking history was associated with poorer overall survival after adjustment for age group, BMI category, and TNM stage (HR = 1.731, 95% CI: 1.105–2.710, P = 0.016). Projections to 2040 suggested heterogeneous changes across the region. Conclusions Although EC burden has declined across all four countries, it remains a major public health challenge with substantial national heterogeneity. Strengthened tobacco control, integrated lifestyle interventions, and age-targeted screening are needed to reduce the future EC burden.