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Cancer remains a leading cause of morbidity and mortality worldwide, with nearly 20 million new cases and 9.7 million deaths reported in 2022. Incidence is projected to rise substantially by 2050, with Eastern Europe carrying a disproportionate burden. A growing concern is the increase in early-onset cancers (< 50 years), particularly breast, colorectal, cervical, thyroid, and lung malignancies. Against this background, this study examined cancer trends in Sarajevo Canton from 2019 to 2024, focusing on incidence, prevalence, mortality, and age-specific patterns. Data were obtained from the population-based Cancer Registry of Sarajevo Canton, maintained in accordance with national reporting legislation. Incidence, prevalence, and mortality rates were calculated per 100,000 population using sex-specific denominators for breast, cervical, and prostate cancers. Trends were assessed annually, with emphasis on cancers diagnosed before age 50. A marked decline in new cancer diagnoses during pandemic years (20–40% across major sites), consistent with COVID-19–related underdiagnosis. Incidence increased after 2022, coinciding with large-scale opportunistic screening. Prevalence rose from 776.9 per 100,000 in 2020 to 1235.1 in 2023 before falling to 943.0 in 2024. Mortality declined overall, from 274.5 to 239.8 per 100,000. APC analyses showed significant reductions in lung cancer mortality (− 8.6%, p = 0.006) and colorectal cancer mortality (− 7.6%, p = 0.038), while prostate cancer incidence increased modestly (+ 9.9%, p = 0.065). Early-onset cancers contributed notably: 18–27% of breast, 11–15% of colorectal, 10–16% of lung, and 30–52% of cervical cancers occurred in individuals under 50. Sarajevo Canton is experiencing rising cancer incidence but declining mortality, suggesting improved detection and treatment.