Temporal trends, risk factors, and future projections of gastric cancer burden in China, India, and the United States: a GBD 2023 analysis.

BACKGROUND: The prevalence of gastric cancer (GC) in China, India, and the USA has different epidemiology, but comparative analyses with regard to their time trends and causes are underdeveloped. METHODS: Using the 2023 Global Burden of Disease (GBD) database (1990-2023), we evaluated GC trends via Joinpoint regression. Das Gupta decomposition and comparative risk assessment quantified demographic/epidemiological drivers and behavioral risks. ARIMA models projected the burden through 2040. RESULTS: Globally, gastric cancer age-standardized incidence rates (ASIR) declined from 26.31 to 14.00 per 100,000 between 1990 and 2023, whereas absolute incident cases increased from 1.05 to 1.28 million. China maintained the highest disease burden in 2023 (ASIR: 25.04/100,000) despite achieving the steepest reductions in age-standardized incidence, mortality, and DALY rates. India demonstrated the slowest decline in age-standardized rates, while incident cases nearly doubled from 42,800 to 85,400 during the study period. Joinpoint analysis identified significant upward ASIR trends after 2020 in China (APC = 3.62) and globally (APC = 1.61). Smoking remained the leading attributable risk factor, particularly in China. Decomposition analysis showed that population aging and growth were the principal drivers of increasing absolute burden. ARIMA projections suggested that China will continue to carry the highest gastric cancer burden through 2040. CONCLUSION: Despite declining standardized rates, population aging and growth continue to drive absolute case numbers upward. To mitigate this evolving burden, China requires optimized early screening and stringent behavioral risk control; India needs expanded cancer registry coverage and equitable rural healthcare access; while the USA should prioritize targeted strategies to mitigate internal disparities among subpopulations.