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Cancer
Current and projected incidence rates of pancreatic cancer in 43 countries: an analysis of the Cancer Incidence in Five Continents database
  1. Songting Shou1,
  2. Rui Liu1,
  3. Jie He2,
  4. Xiaochen Jiang1,
  5. Fudong Liu1,
  6. Yi Li1,
  7. Xiyuan Zhang1,
  8. Geer En1,
  9. Zhiqing Pu1,
  10. Baojin Hua1,
  11. Bo Pang1,
  12. Xing Zhang1
  1. 1Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
  2. 2Department of Health Management, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, China
  1. Correspondence to Dr Xing Zhang; zhangxing{at}bucm.edu.cn; Dr Bo Pang; drpangbo{at}gmail.com; Dr Baojin Hua; huabaojinxs{at}126.com

Abstract

Objective The aetiology of pancreatic cancer is complex, and there is limited research on its incidence. We aimed to investigate the incidence trends of pancreatic cancer in 43 countries and predict trends up to 2030.

Methods The annual incidence of pancreatic cancer was obtained from the Cancer Incidence in Five Continents database, which comprises 108 cancer registries from 43 countries. Based on available data, we calculated age-standardized incidence rates (ASRs) per 100 000 people for 1988–2012. A Bayesian age-period-cohort model was used to predict the number of new cases and incidence rates up to 2030.

Results From 1988 to 2012, the global incidence rate of pancreatic cancer showed a continuously increasing trend, with the ASR increasing from 5.89 in 1988 to 6.78 in 2012, representing an overall average annual percentage change of 8.45%. This increasing trend is expected to persist in most selected countries, whereas a few countries are projected to exhibit a declining trend by 2030.

Conclusion It appears that the future global incidence of pancreatic cancer is on the rise, but the rate of increase varies among different countries, with some showing a declining trend.

  • PANCREATIC CANCER
  • CANCER
  • CANCER EPIDEMIOLOGY

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. All data relevant to the study are included in the article or uploaded as supplementary information. The original data from the Cancer Incidence in Five Continents (CI5plus) database used in the study are available online (https://ci5.iarc.who.int/ci5plus/download).

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjgast-2024-001544

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Current research suggests that the global burden of pancreatic cancer is projected to rise significantly in the coming years.

    WHAT THIS STUDY ADDS

    • Our global analysis across 43 countries revealed disparate pancreatic cancer burden trends, with rapid growth in some, and slow increments or declines in others.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • This study will furnish policymakers with critical data to substantiate investments in pancreatic cancer services and research in regions where incidence rates are anticipated to rise.

    Introduction

    In 2022, pancreatic cancer was ranked twelfth in global incidence and sixth in mortality among all cancers. It is characterised by poor prognosis, demonstrating a remarkably close correlation between case numbers and mortality rates.1 The incidence of pancreatic cancer is not uniform worldwide, with rates in countries with high Human Development Index (HDI) being more than four times higher than those in countries with low HDI.2In high HDI countries, the age-standardised incidence rate (ASR) of pancreatic cancer is 7.2 cases per 100 000 men and 5.0 cases per 100 000 women. By contrast, in low HDI countries, the ASR is 1.6 cases per 100 000 men and 1.0 cases per 100 000 women. The regions with the highest incidence rate are Europe and North America.2 According to US statistics, the incidence of pancreatic cancer is most pronounced in individuals aged 70 years and older, with a median age at diagnosis of 71 years.3 In several studies conducted across Europe, the ages of patients with pancreatic cancer range from 57 years to 74 years.4 Globally, the incidence of pancreatic cancer is most prevalent among individuals aged 65–75 years, with the risk markedly increasing as age advances.5 Pancreatic cancer is frequently asymptomatic in its early stages, and diagnostic modalities often lack specificity, rendering the disease susceptible to underdiagnosis.6 Approximately 20% of patients receive a diagnosis at an early stage.7 When identified at an early stage, survival may be prolonged through interventions such as radiotherapy and surgical resection.8 A 2017 study covering 28 European countries posited that pancreatic cancer is poised to surpass breast cancer as the third leading cause of cancer-related mortality by 2025.9 The aetiological factors contributing to pancreatic cancer remain insufficiently elucidated; however, established risk factors include smoking, diabetes, obesity, dietary factors, alcohol abuse and advanced age.3

    Currently, well-established risk factors can be categorised into two major classes: modifiable and non-modifiable.10 Modifiable factors include smoking, alcohol abuse, obesity and dietary habits. Non-modifiable factors include sex, age, ethnicity, diabetes and family history of pancreatic cancer. In the smoking population, the risk of pancreatic cancer increases with higher daily cigarette consumption, whereas non-smokers have a lower risk of pancreatic cancer.11 In countries with varying smoking rates, areas with a reduced smoking prevalence corresponded to a decrease in the incidence of pancreatic cancer.12 Heavy alcohol consumption, especially hard liquor, is also a risk factor for pancreatic cancer.13 However, other studies have reported the association between alcohol consumption and pancreatic cancer is often influenced by smoking; many of the participants with drinking habits also smoke.14 Obesity is a risk factor for multiple types of cancer, including pancreatic cancer.15 Obesity can lead to increased incidence and mortality of pancreatic cancer.16 17 However, compared with adult weight gain or maintenance, weight loss increases the risk of pancreatic cancer.18 Previous research reports patients with pancreatic cancer rarely develop the disease before the age of 40 years, with the majority of patients being over 50 years.3 Most patients with pancreatic cancer are >71 years old, with peak incidence between 60 years and 80 years of age.3 African-Americans have a higher incidence of pancreatic cancer than other racial groups, which may be related to the different lifestyle habits of the various racial groups.19 Genetic differences among the different populations may be a cause.20 Therefore, determining pancreatic cancer statistics and predictions for different countries will contribute to an in-depth understanding of pancreatic cancer incidence patterns.

    Prediction of ASR of cancer worldwide is of significant importance. First, such predictions can aid the formulation of public health policies and resource allocation to address the cancer burden in different countries. Second, forecasting global cancer incidence rates contributes to disease prevention and early detection efforts, thereby minimising cancer incidence and improving survival rates. In the past, statistical studies on pancreatic cancer have often focused on specific countries, with relatively limited research on global incidence, particularly regarding the lack of future incidence trend predictions.10 21–23 Therefore, we aim to conduct research on the incidence of cancer in different continents and countries, and to provide predictive support for relevant scholars based on the findings.

    Methods

    Overview

    In this study, we used data from the Cancer Incidence in Five Continents (CI5plus) database,24 which included annual case numbers and corresponding population data for 124 selected populations classified by sex, 5-year age groups and cancer types. Data were sourced from 108 cancer registries with verified data available for at least 15 consecutive years (up to 2012) and classified according to the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). We analysed pancreatic cancer data from 43 countries. All data used in this study were obtained from publicly available databases; therefore, ethical approval was not required. This study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines (https://www.strobe-statement.org/) (online supplemental file 1).

    Definitions

    Pancreatic cancer was defined as a ‘malignant neoplasm of the pancreas’, per the ICD-10 code C25.25 New case and population data for each country were extracted directly from the CI5plus database. Data from various registration areas within each country were aggregated to determine the incidence rates. Online supplemental table 1 presents numerical information regarding the registration areas of each country. We divided the countries based on geographical location to investigate how regional factors may affect pancreatic cancer.

    Data analysis

    ASR per 100 000 persons for pancreatic cancer was calculated using the Segi-Doll world standard population for all ages and truncated age groups (40–59 years and >60 years). Given the rarity of pancreatic cancer in patients under 40 years of age, and based on the WHO definition of elderly as individuals aged 60 years and older, we conducted this age stratification.26 27 We used a hotspot map to illustrate the temporal trends and variances across the chosen countries from 1988 to 2012. The incidence of pancreatic cancer was calculated using a classification method based on the HDI with a threshold of 0.88, categorising these countries into high-income and low-income to middle-income groups.28

    A joinpoint regression model was used to assess the significant changes in the overall ASR trend. The annual percentage change (APC) was calculated under the assumption that ASR changes at a constant percentage compared with the rate in the previous year, where APC is represented by the slope coefficient i = [Exp(bi) − 1] × 100 bi for the specified range of years.29 The average annual percentage change (AAPC) was determined as the weighted average of the APCs from the joinpoint model, with weights assigned based on the length of the APC interval.30 Pancreatic cancer incidence projections up to 2030 were derived using Bayesian age-period-cohort (BAPC) models. Age-period-cohort models employed in descriptive epidemiology were used to scrutinise trends in cancer incidence and mortality.31 The analysis encompassed three distinct temporal dimensions: age, period and cohort, serving as surrogate measures indicative of the fundamental aetiologies of pancreatic cancer.32

    Bayesian inference considers all unknown parameters as random and incorporates suitable prior distributions.33 Our investigation estimated BAPC models using Integrated Nested Laplace Approximations (INLA). They employed a second-order random walk (RW2) prior, assuming independent mean-zero normal distributions (with unknown variance) for the second differences of all time effects.33 RW2 is a statistical model that builds on the first-order random walk (RW1) by incorporating dependencies not only on the current state but also on the immediately preceding state. While RW1 presumes that each successive state relies solely on its immediate predecessor, RW2’s inclusion of an additional prior state allows for a more sophisticated interpretation of progression patterns, especially where recent historical influences are relevant. In the context of pancreatic cancer, RW2 facilitates a more precise representation of the disease’s temporal evolution by accounting for the impact of both the present and preceding states of the disease. Joinpoint regression analysis was performed using the Joinpoint Regression Program (V.4.9.1.0; Statistical Research and Applications Branch, National Cancer Institute). Forecasts of pancreatic cancer incidence and data visualisation were conducted using R V.4.0.0 (R Foundation for Statistical Computing, Vienna, Austria). The BAPC models were analysed using the BAPC and INLA packages in R.

    Validation

    To validate the model’s predictive accuracy for future ASRs of pancreatic cancer, we will benchmark its projections against the ASRs reported by Cancer Today in 2022.

    Results

    Observed trends

    The ASR of pancreatic cancer per 100 000 individuals for both men and women across various countries from 1988 to 2012 are presented in table 1. Globally, ASR of pancreatic cancer showed an increasing trend between 1988 (6.86 per 100 000) and 2012 (7.44 per 100 000), with an 8.45% change in ASR over this period. In Africa, the incidence rate of pancreatic cancer increased significantly from 1993 to 2012 (from 0.43 to 1.86 per 100 000, a percentage change of 335.12%). In the Americas, the incidence increased from 1988 to 2012 (from 6.94 to 7.46 per 100 000, percentage change of 7.60%). In Asia, the incidence increased from 1988 to 2012 (from 6.01 to 6.53 per 100 000, percentage change of 8.74%). In Europe, the incidence rate increased from 1988 to 2012 (from 6.48 to 7.25 per 100 000, a percentage change of 11.96 %). In Oceania, the incidence increased from 1988 to 2012 (from 5.89 to 6.78 per 100 000, percentage change of 15.27%). Overall, the incidence of pancreatic cancer is increasing worldwide, with notable increases observed in Africa as time progresses. Subsequently, the incidence rates increased in Oceania, Europe, Asia and the Americas.

    View this table:
    Table 1

    Trends in incidence rates of pancreatic cancer among men and women in 43 countries, 1988–2012

    The time trends of ASR of pancreatic cancer from 1988 to 2012 in 43 countries are illustrated in figure 1. Among the 44 registered countries, the Czech Republic, Slovakia, Estonia, Japan and Lithuania were the top five countries with the highest ASR for pancreatic cancer in 1988 (or the year of first registration if not available in 1988). The five countries with the lowest ASR were India, Uganda, Thailand, Ecuador and Kuwait. The countries with the most rapid increases in ASR were Uganda, Costa Rica, France, India and Austria. In contrast, those with the most significant decreases were Iceland, Poland, Ecuador, Colombia and Brazil (table 1).

    Figure 1
    Figure 1

    Heatmap of temporal change in age-standardized incidence rates (ASRs) of pancreatic cancer from 1988 to 2012.

    From a sex perspective, in these 43 countries, the incidence rate of pancreatic cancer among men exceeded that among women. In 1988, only five countries exhibited higher incidence rates among women than men: Ecuador, Costa Rica, Thailand, Kuwait and Uganda. By 2012, only three countries—Iceland, Ecuador, and Uganda—showed a trend of gradually increasing incidence rates among men. The highest increase was observed in Costa Rica, where the rate rose from 2.15 per 100,000 in 1988 to 5.21 per 100,000 in 2012, reflecting a percentage change of 142.61%. Conversely, a substantial decrease was noted in Iceland (from 11.26 per 100 000 in 1988 to 5.39 per 100 000 in 2012, a percentage change of −52.11%). Furthermore, an increasing trend in incidence rates among women was also evident, with the most notable increase observed in Malta (from 3.15 per 100 000 in 1988 to 9.13 per 100 000 in 2012, a percentage change of 189.70%) and the most significant decrease observed in Poland (from 5.54 per 100 000 in 1988 to 4.77 per 100 000 in 2012; a percentage change of −13.97%).

    The joinpoint regression analysis of the pancreatic cancer incidence rates is presented in table 2. The global incidence rate of pancreatic cancer is showing an uptrend, with an AAPC of 0.7% (95% CI 0.5%, 0.9%). This trend can be further delineated into two periods: from 1988 to 2002, APC was −0.1 (95% CI −0.7, 0.3), while from 2002 to 2012, APC was 1.8 (95% CI 1.2, 3.0). Substantial differences were observed when examining data from 43 countries. Uganda exhibits the greatest increasing trend, with an AAPC of 8.1% (95% CI 1.3%, 15.5%). Conversely, Poland has the most significant downtrend, with an AAPC of −2.5% (95% CI −3.5%, –1.4%).

    View this table:
    Table 2

    Joinpoint analysis for pancreatic cancer incidence rates in 43 selected countries, 1988–2012

    Table 1 provides the cancer incidence rates based on income levels from 1988 to 2012. Our study results indicate ASR of cancer in high-income countries (increasing from 8.7 per 100 000 in 1988 to 10.1 per 100 000 in 2012; percentage change of 16.1%) is higher than that in middle-income and low-income countries (increasing from 5.2 per 100 000 in 1998 to 6.2 per 100 000 in 2012; percentage change of 20.1%). However, the growth rate of ASR in high-income countries is lower than in middle-income and low-income countries. Among high-income countries, the fastest-growing ASRs were observed in France (107%), Austria (68.1%) and Spain (62.4%). Conversely, among middle-income and low-income countries, the most rapid ASR growth was seen in Uganda (335.1%) and India (79.9%).

    Figure 2 depicts the temporal trends of pancreatic cancer incidence rates by age group (ie, younger group, aged 40–60 years and older group, aged 60 years and above) across 43 high-income, middle-income and low-income countries. Among all selected countries, the incidence rates among the elderly were higher than among the younger population; however, the ASR ratio between the elderly and younger populations varied across different countries and time periods. Furthermore, while the incidence rates of pancreatic cancer among both the younger and older age groups showed an uptrend in most countries, there are instances of a downtrend in certain countries.

    Figure 2
    Figure 2

    Temporal changes in age-standardized incidence rates (ASRs) of pancreatic cancer across different age groups from 1988 to 2012

    Predicted trends

    Figure 3 presents the estimated ASR of pancreatic cancer from 2013 to 2030 based on past data. According to the predictive model, countries worldwide that may face a higher pancreatic cancer burden in the future are Malta, France and Slovakia, with ASRs of 14.44, 13.19 and 12.88, respectively. All three countries are located in Europe. In Asia, the countries with the highest pancreatic cancer burden were Cyprus, Japan and South Korea, with ASRs of 11.7, 9.64 and 8.92, respectively. North American countries, such as Canada and the USA, bear a higher pancreatic cancer burden, with ASRs of 8.53 and 8.44, respectively, whereas the burden is relatively lower in South America, with the highest rate in Martinique at 5.80. In Oceania, New Zealand and Australia had rates of 10.74 and 9.23, respectively, higher than those in the two North American countries. In Africa, Uganda has seen an increase in ASR of 4.98. Among the global trends of increasing ASRs for pancreatic cancer, some countries show a declining trend. By comparing the data from 2012 to the projections for 2030, the countries expected to experience the fastest decline in ASR were Iceland, Poland and Costa Rica, with decreases of 2.46, 2.22 and 2.04, respectively.

    Figure 3
    Figure 3

    Trends in observed (solid lines) and predicted (dashed lines) age-standardized incidence rates (ASRs) of pancreatic cancer in 43 countries.

    Validation

    To validate the accuracy of our predicted pancreatic cancer ASR data, we compared the 2022 data with Cancer Today 2022 data. Cancer Today is the website of the International Agency for Research on Cancer, which provides a valuable resource for global cancer epidemiological data and statistical information.34 It coordinates and supports cancer research worldwide, assesses cancer-associated risks, and provides pertinent scientific information and data. This platform allows individuals to access the most recent cancer data, reports and research findings. The average ASR difference across countries was <1. The most accurate prediction was for Martinique, with an ASR difference of 0, whereas the largest difference was observed for Iceland, with an ASR difference of 3. Detailed comparisons of the data are summarised in online supplemental table 2.

    Discussion

    Due to the multiple factors implicated in the pathogenesis of pancreatic cancer, repeated and multidimensional research efforts are necessary to unravel further information, thereby advancing the knowledge and comprehension of this highly lethal disease. The pancreatic cancer burden in the Czech Republic has been consistently high, with ASR ranging from 8 to 10. Research indicates the cancer burden among the Czech population is the world’s highest and is showing an uptrend.35 This may be attributed to a severe ageing population.36 In 2012, Malta, characterised as the global apex in the ASR of pancreatic cancer at 9.5 cases per 100 000 inhabitants, faced analogous issues. The country is witnessing an accelerated process of population ageing influenced by various factors, including immigration patterns and dwindling fertility levels, potentially exacerbating the uptrend in pancreatic cancer ASR.37 In 2012, Japan ranked third in ASR absorption, reaching 8.9. Japan has one of the most rapidly ageing populations in the world.38 Therefore, population ageing may be one of the reasons for the increased pancreatic cancer burden in some countries. When the ageing problem is resolved, the pancreatic cancer burden in corresponding countries may decrease.

    This study found that the incidence of pancreatic cancer is rapidly increasing in middle-income or low-income countries such as Uganda and Costa Rica. We infer that this may be due to the historically inadequate availability of effective cancer diagnostic tools in these countries, compounded by the inherent insidious nature of the disease, further exacerbating the diagnostic challenges. The diagnosis of pancreatic cancer is challenging because it often presents symptoms only in advanced stages, and these symptoms are mostly non-specific.39 Additionally, the diagnostic process may be expensive,40 making it difficult for many patients to undergo further investigations and obtain a clear diagnosis. In countries like Thailand and India, despite the lower incidence rates of pancreatic cancer, a significant number of patients with pancreatic cancer are likely to remain undiagnosed due to issues with healthcare resources. A critical issue in Thailand’s current oncological development is the lack of essential medical personnel such as oncologists, radiation oncologists, surgeons, molecular pathologists and other healthcare professionals.41 This limitation prevents many patients from undergoing pancreatic cancer screening. India faces similar challenges, as research has indicated significant regional disparities across the country in terms of cancer incidence rates and access to basic medical resources. Furthermore, obstacles to diagnosing pancreatic cancer and accurately assessing its incidence in India include patient awareness, inadequate infrastructure and scarcity of well-trained oncology professionals.42 Therefore, the pancreatic cancer burden in these countries may have been greater than anticipated. Many countries face inadequacies in resources and implementation when formulating cancer control plans, particularly low-income and middle-income nations.43 In these countries, there should be extensive and in-depth implementation of screening and diagnostic initiatives to definitively ascertain whether pancreatic cancer incidence rates align with existing statistical data. Should the reported prevalence of pancreatic cancer be notably lower in these locations, this discovery would be highly encouraging and warrants further investigation into the underlying reasons. An understanding of the protective factors, unique environmental conditions, and genetic traits within these areas could shed new light on the aetiology of pancreatic cancer and contribute valuable insights into global prevention strategies and therapeutic approaches.

    The incidence of pancreatic cancer in India, Uganda and Thailand shows a different age distribution compared with other countries. Typically, the incidence of pancreatic cancer among individuals aged 60 years and above is generally higher than among those aged 40–60 years. However, this pattern was not observed in these three countries, which may be due to inadequate medical resources. It is well established that the incidence of cancer increases with advancing age, peaking around 85 years and subsequently declining.44 After 60 years, the incidence rate of cancer nearly doubles every 5 years.45 Therefore, the increasing incidence of pancreatic cancer may be associated with an ageing population worldwide. Currently, the population of countries worldwide is ageing. Factors such as increased life expectancy for individuals over 60 years in high-income countries and the decline in mortality rates among younger populations in low-income countries have contributed to this trend.46 Many signs of ageing are closely related to the associated factors of onset of cancer. Genomic instability, epigenetic alterations, chronic inflammation, and dysbiosis are characteristics of ageing, while genomic instability, non-mutational epigenetic reprogramming, inflammation, and polymicrobial microbiomes are factors involved in the development of cancer.47 48 Based on the statistical data on the age of onset in patients with cancer and in conjunction with the mechanisms of cancer occurrence, it was inferred that in the statistical calculation of the ASR for pancreatic cancer, using the age brackets of 40–59 years and 60 years and above, the presence of an intersection or a very small interval separation between the two curves may indicate a need for further refinement of the quality of the data. Therefore, more accurate data and information can be obtained.

    However, given the complex aetiology of pancreatic cancer, it is not appropriate to simply attribute the low ASR to diagnostic levels. Another reason for the low ASR for pancreatic cancer in India and Thailand may be dietary habits. Indian diets incorporate copious amounts of vegetables, fruits and whole grains rich in dietary fibre, conferring protection against cancers.49 Additionally, time-honoured species in Indian culinary traditions have been suggested to possess potential chemopreventive properties.49 It has been ascertained that dietary regimens that are replete with plant-based fares and wholegrain staples mitigate the incidence of said malignancy.50–52 Curcumin in turmeric also demonstrated a positive effect in clinical trials of pancreatic cancer.53 Curries incorporating curcumin merit closer scrutiny of these nations’ gastronomic traditions, as they may hold potential insights into devising preventive measures against pancreatic cancer in susceptible demographics.54 Studies have also indicated that Thailand’s unique spicy sauce negatively correlates with cancer. Cellular and animal studies have demonstrated that capsaicin inhibits pancreatic cancer cell proliferation and promotes apoptosis of these cells.55 56 Moreover, several traditional Thai condiments, such as Pla-ra and Pla-jao, frequently consumed by the Thai population, are rich in lactic acid bacteria.57 A previous study showed that regular consumption of dairy products fermented by lactic acid bacteria is negatively correlated with pancreatic cancer.57 Therefore, dietary habits may have a role in explaining why the incidence rate of pancreatic cancer in both countries is relatively low.

    In the previous section, we introduced the risk factors for pancreatic cancer, including smoking, drinking and genetic factors. When these factors are considered comprehensively, we speculate that the weight of genetic factors in pancreatic cancer may be greater than expected. Although smoking and drinking are influenced by environmental factors, such as public health policies and cultural differences, researchers have found through genetic analysis that they can also be inherited.58 In genetic factors, racial background is a significant risk factor, and black men have consistently been identified as a high-risk group for pancreatic cancer in relevant studies.59 Regarding genetic factors, racial background is a significant risk factor, and black men have consistently been identified as a high-risk group for pancreatic cancer in relevant studies.50 Considering that many black men may not have the opportunity to receive an appropriate medical diagnosis, the actual number of this demographic affected by pancreatic cancer may be even higher.59

    With various natural, economic and cultural changes worldwide, certain countries will see large numbers of immigrants. According to surveys, immigrant populations can impact the incidence of cancer in the local population. For example, in the southern regions of Italy, the majority of immigrants originate from Europe. Compared with non-immigrants, immigrants exhibit a higher proportion of cervical and lung cancers, whereas the statistical incidence of breast and prostate cancers is notably reduced.60 The lifestyle habits of immigrant populations often differ from those of indigenous populations, including smoking, alcohol consumption, and the management of chronic diseases.60 In high-income countries such as France, Austria and Spain, the incidence of pancreatic cancer is rising rapidly, possibly due to immigration. In some regions of Spain and France, European citizens hold the most positive attitudes towards immigration.61 Austria, alongside Germany, another country with a rapidly increasing incidence of pancreatic cancer, has been one of the primary recipient countries in Europe for asylum seekers and refugees.62 Although immigrant populations originate from different sources, the risk factors for various cancers, including pancreatic cancer, are influenced by lifestyle differences, leading to disparities in cancer incidence between indigenous and immigrant populations.63 Mexican Americans have more than twice the rate of pancreatic cancer compared with Mexicans.64 A personalised approach should be adopted in exploring and preventing pancreatic cancer, implementing different management strategies for different population groups, which may be more effective in alleviating the global pancreatic cancer burden.

    Despite the overall global trend of increasing pancreatic cancer incidence, some countries have a negative incidence rate growth. Iceland, for example, has demonstrated a sustained decrease in pancreatic cancer rates, potentially linked to implementing public health policies. Smoking plays an important role in the development and occurrence of pancreatic cancer. In vitro experiments have demonstrated that the carcinogen 4-(methylnitrosamino)−1-(3-pyridyl)−1-butanone present in tobacco stimulates the proliferation of immortalised human pancreatic ductal epithelial cells through beta-adrenergic transactivation of the epidermal growth factor receptor.65 In mouse experiments, smoking has been shown to increase the levels of Histone Deacetylase 4 (HDAC4) messenger RNA (mRNA) in pancreatic cancer, promoting cancer cell invasion and facilitating the metastasis of Pancreatic Ductal Adenocarcinoma (PDAC) cells to different organs such as the liver and lungs.66 In human samples, in the 2q21.3 region of chromosome 2, a qualitative interaction has been observed between smoking status and genetic variants in the vicinity of Transmembrane Protein 163 (TMEM163) intron 5 and upstream of Cyclin T2 (CCNT2) in relation to pancreatic cancer. Non-smokers exhibited a lower genetic variant-associated risk, whereas smokers demonstrated a higher risk, suggesting a potential association between smoking and pancreatic cancer.67 According to surveys, the percentage of smokers in Iceland has continuously decreased from 31% to 14%.68 Similar circumstances have also occurred in Poland, where the smoking rate among men decreased from 64% to 40% between 1984 and 1998. The successful implementation of the relevant policies has effectively controlled a major modifiable risk factor for pancreatic cancer, which may be worthy of consideration for adoption by other countries.

    Our study is not without limitations, notably the inadequacy of the database in encompassing a comprehensive range of countries. This shortfall may engender discrepancies between the statistical analyses of existing data and real-world situations, as well as the predictive accuracy for future trends. Furthermore, there remains considerable room for exploration and analysis regarding factors such as dietary habits and sanitation policies across different populations. Additionally, we are lacking data on the staging of pancreatic cancer. Integrating these variables with data in future research endeavours holds the potential to enhance the robustness and reliability of our conclusions.

    In summary, our global analysis indicates that by 2030, the incidence of pancreatic cancer in various countries is expected to show a slow but steady increase compared with the present. Population ageing may have contributed to an increase in the incidence of pancreatic cancer in certain countries. Consequently, the global burden of pancreatic cancer is expected to increase. Effective strategies include reducing smoking and alcohol consumption, early screening and preventive measures, and adopting a healthy lifestyle, which may alleviate the burden of pancreatic cancer to some extent.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information. All data relevant to the study are included in the article or uploaded as supplementary information. The original data from the Cancer Incidence in Five Continents (CI5plus) database used in the study are available online (https://ci5.iarc.who.int/ci5plus/download).

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

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    Footnotes

    • SS, RL and JH contributed equally.

    • Contributors BH, BP and XingZ conceived the study and revised the final manuscript. SS, RL and JH collected relevant references and drafted the manuscript. XJ, FL and YL finished the table. XiyuanZ, EG and ZP offered crucial content revision and language polishing. All authors reviewed the manuscript. XingZ is the guarantor.

    • Funding This study was supported by the Innovation Team and Talents Cultivation Program of National Administration of Traditional Chinese Medicine (ZYYCXTD-C-202205), the Scientific and Technological Innovation Project of China Academy of Chinese Medical Sciences (CI2021B009), the High Level Chinese Medical Hospital Promotion Project (HLCMHPP2023085, HLCMHPP2023005), the National Natural Science Foundation of China (81774294, 82174465, 82174463, 82104961, 81904196), the Fundamental Research Funds for the Central public welfare research institutes (ZZ13-YQ-028, ZZ14-YQ-016), CACMS Innovation Fund (CI2021A01814, CI2021A01816, CI2021A01805).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.