Country context

China, a high middle-income country, has undergone rapid economic development over the last four decades, lifting over 800 million citizens out of poverty. The country is facing a significant demographic shift, with projections indicating that 402 million, or 28 percent of its population, will be age 60 or older by 2040. NCDs represent a major public health challenge in China, where the NCD mortality rate rose by 28.5 percent between 2012 and 2018. Lung cancer is the fourth-highest cause of death in China at 38.7 deaths per 100,000 population as of 2019, and the country’s leading cause of cancer mortality.

Since the 1990s, China has recorded a higher number of new lung cancer cases than the Asia Pacific regional average. More recently, there has been a steady rise in incidence from 42.75 per 100,000 in 2016 to 44.01 in 2021 (Figure 1). Lung cancer mortality among men is more than double that of women at 56.45 deaths per 100,000 versus 24.42 deaths per 100,000 for women in 2021. However, a 2022 study showed that between 2000 and 2016, the incidence of lung cancer for women grew more rapidly than for men: a 2.1 percent growth rate for women versus negative 0.1 percent for men. Incidence rates in rural areas also increased more rapidly than in urban areas.

There are a range of behavioral and environmental risk factors associated with lung cancer in China. Smoking is the leading risk factor of lung cancer for men, but only 1.7 percent of women in China smoke. Instead, an estimated 81.56 percent of lung cancer cases among women in China are linked to risk factors aside from smoking, such as secondhand smoke, occupational exposures to carcinogens, and family history, highlighting the need for lung cancer control strategies that are tailored to contextually relevant risk factors. Moreover, air pollution across China is a serious challenge, and a risk factor for both men and women, with levels 10 times higher than the WHO standard. Notably, 36 percent of the population still lacked access to clean cooking fuels in 2022, a leading cause of air pollution and related illnesses.

Lung cancer exerts a heavy socioeconomic burden on China. In 2017, a study estimated that the total economic burden of lung cancer was USD 25 billion (0.12 percent of GDP). The direct costs, including medical expenses, were estimated at USD 11 billion, while the indirect costs were even higher at USD 14 billion, with USD 1.5 billion due to disability and USD 12.5 billion due to premature deaths. Post diagnosis costs are also high: end-of-life care represented around 40 percent of health care expenses for terminal cancer patients in 2022, with an average per capita cost of USD 13,572 for patients in urban areas and USD 6,510 in rural areas over their final three months of life. Considering these vast costs and given the increase in incidence and mortality rates in recent years, an updated estimate of the burden of lung cancer could reveal an even more substantial impact on the country’s economy and health care system.

Assessing policies and programs

The primary policy currently addressing cancer in China is the Healthy China Initiative—A Plan to Implement Cancer Prevention and Treatment (2019–2022), a program within the broader Healthy China 2030 agenda to achieve health-focused SDGs. The cancer prevention and treatment plan outlines clear objectives to improve the levels of screening, early diagnosis, and early treatment, in order to curb rising incidence and mortality rates. Actions include improving public health education and awareness around cancer prevention, promoting healthy lifestyles, strengthening environmental protections, and improving prevention and treatment capabilities. To that end, the plan emphasizes dedicating specialized cancer treatment centers in each of China’s seven regions to lead on diagnosis, treatment, and research, and improving treatment facilities in rural and community health centers.

In recent years, China has introduced several strategies and policies specifically to address the heavy burden of lung cancer. Since 2010, the government has conducted two nationwide screening programs aimed at individuals within certain risk categories. The first, the Rural People’s Republic of China Screening Program (RURASCP), was focused specifically on rural populations in six regions and facilitated the screening of around 13,000 high-risk individuals, using low-dose computed tomography (LDCT), resulting in a national cancer detection rate of 1 percent. In some provinces, such as Yunnan, home to the world’s largest tin mining industry, and thus a very high incidence of cancer, the implementation of RURASCP has shifted the proportion of participants diagnosed with stage I cancer from 37.5 percent in 2014 to 75 percent in 2019, greatly increasing their likelihood of survival and preservation of quality of life. The second national program, the Cancer Screening Program in the Urban People’s Republic of China (CanSPUC), began in 2012, focused on city dwellers, and by 2017 had resulted in over 521,000 participants identified as eligible, and over 160,000 undergoing LDCT screening. As of 2020, a third screening program, the People’s Republic of China National Cancer Early Screening Trial, had recruited more than 10,000 people, but data on outcomes is not yet available.

FIGURE 2

GRIP: Gains, Risks, Innovations, Prospects in Policies and Programs

China has also begun to introduce laws and policies addressing the behavioral factors driving lung cancer incidence in the country. Several national and subnational laws and policies ban smoking in many public spaces, near schools, and on public transit. Two laws also heavily restrict the advertising of tobacco products: the 1991 Tobacco Monopoly Law and the 1994 Advertising Law of the People’s Republic of China, most recently amended in 2015, the combination of which ban tobacco advertising in mass media, public places, and public transit, and outdoors. Air pollution, including from biomass cooking sources, is another driver of lung cancer. In recognition of this health risk, the Healthy China 2030 strategy, which lays out clear goals and tracking metrics across the spectrum of health and well-being, specifies the target of achieving “good air quality” in 80 percent of cities by 2030.

Patients diagnosed with lung cancer can access treatment—including radiotherapy, immunotherapy, and surgery—at relatively low costs through the nationally-available basic medical insurance, but disparities in quality of care persist. However, a study of lung cancer response in China in 2020 found that multidisciplinary treatment of lung cancer has become the standard of care even in smaller cities, and many cancer drugs are covered in full by the national health insurance scheme. Seeking to reduce costs and other barriers to cancer medications, the government has shortened the review and approval process for cancer drugs already available in other markets. The number of lung cancer-related clinical trials taking place within China has also increased in recent years, with 2,114 trials taking place between 2013 and 2021, 150 of which had multi-regional scope, thus increasing patient access. In particular, the Chinese government and pharmaceuticals industry have been leading the way in developing and testing alternatives to chemotherapy for early-stage, post-operative patients, in pursuit of therapeutics that can improve the five-year survival rate, with one such drug being approved for widespread use in 2021. For example, since their approval by the U.S. FDA in 2014, immunotherapies addressing non-small cell lung cancer—the leading cause of cancer mortality in China—have become increasingly available through clinical trials, although they do not yet appear to be offered through the national health care system. The government is also beginning to approve the use of companion diagnostics and biomarker testing for specific types of lung cancer, and including those treatments on national health care reimbursement lists to make them available at low or no cost to patients.

Opportunities ahead

Despite a clear commitment to managing and reducing the burden of lung cancer, the disease remains the leading cause of cancer mortality in China. Limited access to high-quality care remains a challenge for Chinese cancer patients and high-risk individuals. Those in rural and low-income areas of the country are still unable to access care of the same quality as their peers in major cities. As the Healthy China 2030 plan moves into its later stages, opportunities abound to improve health and well-being through greater access to health care. Innovative pilots, such as the telehealth and mobile LDCT screening program conducted in the city of Mianzhu—and recently extended to the regions around Lonquan, Ganzi, and Guangan cities—are achieving success on a small scale, with promising uptake of mobile screenings and an improved cancer detection rate as a result. Expanding and standardizing similar programs, and extending access to clinical trials for new treatments and therapeutics to patients outside of cities, can go a long way toward improving and equalizing standards of care. Furthermore, cancer prevention will hinge on changing behavior such as reducing tobacco consumption while improving environmental factors by alleviating outdoor and indoor air pollution. With Chinese companies having raised over RMB 19.3 billion (USD 3 billion) in financing in 2020, China has a rapidly growing market for genomics. Next-generation sequencing therefore presents an exciting opportunity for early identification, diagnosis, and intervention of individuals at high risk for lung cancer.

While China has a number of plans, policies, and laws aimed at improving prevention and early diagnosis of cancer, less attention has been paid to the system of care for survivors or terminal patients. The introduction of integrated palliative care could be an opportunity for greater support and surveillance of cancer survivors, which can create the conditions for early intervention in case of recurrence or metastasis. To date, primary care providers, rehabilitation teams, and community groups have been disconnected from care for cancer survivors. Greater integration, through the creation of clear guidelines, can improve continuity of care and support better outcomes for survivors.