Spatiotemporal Patterns of Esophageal Cancer Burden Attributable to Behavioral, Metabolic, and Dietary Risk Factors From 1990 to 2019: Longitudinal Observational Study

Esophageal cancer (EC) is the sixth leading cause of cancer-related burden with distinct regional variations globally. Although the burden of EC has decreased, the specific reasons for this decline are still unclear.This study aims to uncover the spatiotemporal patterns of EC risk-attributable burden in 204 countries and territories from 1990 to 2019 so that prevention and control strategies of EC can be prioritized worldwide.We extracted EC risk-attributable deaths, disability-adjusted life years (DALYs), age-standardized mortality rates (ASMRs), and age-standardized DALY rates (ASDRs) from the global burden of disease (GBD) study from 1990 to 2019, in terms of behavioral, metabolic, and dietary factors by age, sex, and geographical location. Average annual percentage change (AAPC) was used to assess the long-term trends in the ASMRs and ASDRs of EC due to specific risk factors.Between 1990 and 2019, the greatest decrease in EC burden was attributed to low intake of fruits and vegetables. An AAPC of -2.96 (95% CI -3.28 to -2.63) and -3.12 (95% CI -3.44 to -2.79) in ASMR and ASDR was attributable to a low-fruit diet, while an AAPC of -3.60 (95% CI -3.84 to -3.36) and -3.64 (95% CI -3.92 to -3.35) in ASMR and ASDR was attributed to a low-vegetable diet. However, the trends in ASMRs and ASDRs due to high BMI showed significant increases with an AAPC of 0.52 (95% CI 0.29-0.75) in ASMR and 0.42 (95% CI 0.18-0.66) in ASDR from 1990 to 2019 compared to significant decreases in other attributable risks with AAPC<0 (P<.05). East Asia had the largest decrease in EC burden due to low-vegetable diets, with an AAPC of -11.00 (95% CI -11.32 to -10.67) in ASMR and -11.81 (95% CI -12.21 to -11.41) in ASDR, followed by Central Asia, whereas Western Sub-Saharan Africa had the largest increase in ASMR and ASDR due to high BMI, with an AAPC of 3.28 (95% CI 3.14-3.42) and 3.09 (95% CI 2.96-3.22), respectively. China had the highest EC burden attributed to smoking, alcohol use, high BMI, and low-fruit diets. Between 1990 and 2019, there was a significant decrease in EC burden attributable to smoking, alcohol use, chewing tobacco, low-fruit diets, and low-vegetable diets in most countries, wherein a significant increase in the EC burden was due to high BMI.Our study shows that smoking and alcohol consumption are still the leading risk factors of EC burden and that EC burden attributable to low intake of fruits and vegetables has shown the largest decline recently. The risks of ASMRs and ASDRs of EC showed distinct spatiotemporal patterns, and future studies should focus on the upward trend in the EC burden attributed to high BMI.