ABSTRACT
Aim
This nationwide observational study investigated recent trends in pancreatic cancer (PC) incidence and surgical management in Japan.
Methods
Annual data on PC incidence (2016–2021) and surgical procedures (2016–2023) were obtained from the Cancer Information Database and the National Database of Health Insurance Claims and Specific Health Checkups (NDB), respectively. Surgical procedures were categorized by type (distal pancreatectomy (DP, 2016–2023)/pancreatoduodenectomy (PD, 2020–2023)) and approach (open/laparoscopic). Crude and age‐adjusted rates per 100 000 person‐years were calculated. Temporal trends were evaluated using linear and Poisson regression to estimate annual risk ratios (RRs).
Results
Over the study period, the annual average PC incidence was 43 015, and the average number of PC surgery was 13 899. Age‐adjusted PC incidence rates rose significantly among males, females, and both sexes (RR = 1.007, 1.016 and 1.011, respectively; p < 0.0001). A particularly notable rise was observed among females aged 10–29 years (RR range: 1.347–1.449; all p < 0.0009). DP rates increased significantly among males, females, and both sexes (RR = 1.033, 1.032, and 1.033, respectively; p < 0.0001), with marked increases among individuals aged 65–89 years for both sexes (RR range: 1.018–1.114; all p < 0.0012). PD volumes also rose during 2020–2023, although the limited analytic window precluded formal rate‐based trend evaluation. In 2023, PD comprised 65.6% of PC surgeries (9444/14397), while DP comprised 34.4% (4953/14397).
Conclusion
These nationwide findings highlight age‐ and sex‐specific signals—notably an apparent rise among young women and increased DP use among older adults—that warrant further validation.
Keywords: distal pancreatectomy, early‐onset cancer, national database, pancreatic cancer, surgical epidemiology
This nationwide claims‐based study analyzed recent trends in pancreatic cancer incidence (2016–2021) and surgery (2016–2023) in Japan. The study revealed a rising incidence of pancreatic cancer, notably among young women, and an increasing use of distal pancreatectomy among older adults. These age‐ and sex‐specific patterns warrant further investigation and could guide public health and surgical planning.
1. Introduction
The pancreatic cancer (PC) incidence has been rising globally [1, 2, 3]. According to the Global Cancer Observatory (GLOBOCAN) 2022 data [4], there were 510 992 new cases of PC worldwide (ranking 12th among all cancers) and 467 409 deaths (ranking 6th in cancer‐related mortality). Geographically, Japan reported the highest crude incidence rate (37.9 per 100 000) and the third‐highest age‐standardized incidence rate (9.8 per 100 000), following Uruguay (11.4) and Hungary (10.4) in the regions [4]. In 2023, PC was the third leading cause of cancer‐related death among both men and women in Japan, accounting for 40 175 deaths [5]. Notably, both incidence and mortality rates have continued to rise annually in the Japanese population.
An emerging global concern is the disproportionate increase in early‐onset PC [6]. This trend is particularly concerning among younger women in Western nations [7, 8]. While previous Japanese studies have documented a steady increase in pancreatic surgery volumes between 2012 and 2021 [9], nationwide data on recent trends in PC incidence and surgical management remain limited. Specifically, there is a lack of comprehensive data detailing contemporary demographic distributions, surgical approaches (laparoscopic vs. open), and procedure types (pancreatoduodenectomy vs. distal pancreatectomy).
Standard surgical treatment for PC typically involves pancreatectomy with lymph node and nerve plexus dissection, and, when necessary, en bloc resection of adjacent organs or vascular structures. In Japan, an increasing trend toward laparoscopic procedures for pancreatic diseases has been documented through nationwide questionnaire surveys [10]. However, the broader adoption of minimally invasive procedures remains controversial. Meta‐analyses of randomized controlled trials [11, 12, 13, 14] have reported favorable outcomes for minimally invasive distal pancreatectomy, while safety concerns persist regarding the safety of minimally invasive pancreatoduodenectomy.
The purpose of this study was to investigate recent trends and demographic patterns in PC incidence and surgical management in Japan. We utilized two large‐scale, nationwide datasets: the Cancer Information Database, which covers the entire Japanese population [15], and the National Database of Health Insurance Claims and Specific Health Checkups (NDB), which captures more than 95% of medical insurance claims in Japan [16]. Based on previous nationwide studies in gastroenterological surgery [17, 18, 19], this study provides updated insights into the evolving landscape of PC incidence and treatment in Japan.
2. Methods
2.1. Study Design and Data Sources
This retrospective observational epidemiological study utilized three publicly available databases. In accordance with the Japanese ethical guidelines, institutional review board approval and informed consent were not required, as all data were anonymized and publicly accessible. To protect patient anonymity, the NDB Open Data Japan [20] omits data for procedures performed fewer than 10 times per reporting unit.
Annual sex‐ and age‐stratified data on PC incidence were obtained from the Cancer Information Database (2016–2021) [15]. Data on surgical procedures were extracted from the NDB Open Data Japan (2016–2023) [20], which is an open‐access subset of the National Database of Health Insurance Claims and Specific Health Checkups (NDB). Population denominators were obtained from the Ministry of Internal Affairs and Communications population statistics (MIAC) [21] to calculate incidence and surgery rates per 100 000 population.
2.2. Case Definition and Data Collection
We used the ICD‐10 codes C25 (malignant neoplasm of pancreas) to identify PC cases. Surgical procedures for pancreas were categorized by anatomical location (distal or head pancreas) and by surgical approach (open or laparoscopic). The relevant procedure codes were as follows:
K702 Distal pancreatectomy
With splenic resection
With lymph node and nerve plexus dissection
With resection of surrounding organs
With resection of vessels (vein and/or artery)
With spleen preservation.
K702‐2 Laparoscopic distal pancreatectomy
With splenic resection
With spleen preservation
With splenic resection using robotic assistance
With spleen preservation using robotic assistance
K703 Pancreatic head resection
Pancreaticoduodenectomy
With lymph node and nerve plexus dissection
Duodenum‐sparing pancreatic head resection
With resection of surrounding organs
With resection of vessels (vein and/or artery)
K703‐2 Laparoscopic pancreatic head resection
Pancreaticoduodenectomy
Pancreaticoduodenectomy using robotic assistance
With lymph node and nerve plexus dissection
With lymph node and nerve plexus dissection using robotic assistance
K704 Total pancreatectomy
2.3. Procedure Categorization for Pancreatic Cancer Surgery
To focus on oncologically relevant procedures, only pancreatectomies involving lymph node and nerve plexus dissection, resection of surrounding organs, or vessels (vein and/or artery) were included in the analysis. The K704 code (total pancreatectomy) was excluded due to its broader indications, which include benign conditions.
We defined the two major types of pancreatic cancer surgeries as follows:
Distal pancreatectomy (DP): K702 (2), (3), and (4), and K702‐2: (1) and (3)
Pancreatoduodenectomy (PD): K703: (2), (4), and (5), and K703‐2: (3) and (4)
Surgical approaches were classified as follows:
Open surgery: K702 (2), (3), and (4), and K703: (2), (4), and (5)
-
Laparoscopic surgery: K702‐2: (1) and (3), and K703‐2: (3) and (4)
Among laparoscopic surgeries, the following was further classified:
Robotic‐assisted surgery: K702‐2: (3), and K703‐2: (4)
Due to changes in coding definitions, data for oncologically relevant PD, laparoscopic, robotic‐assisted and open surgeries were available only from 2020 to 2023, while DP data were available from 2016 to 2023.
2.4. Overview Analysis
Over the study periods, we calculated the cumulative crude PC incidence and total number of surgical procedures—including all anatomical sites and surgical approaches—along with their annual average rates per 100 000 population. We also computed the overall male‐to‐female ratios for both incidence and procedure rates. Additionally, a demographic peak analysis was conducted by examining sex‐ and age‐stratified incidence and procedure rates per 100 000 person‐years.
2.5. Annual Trend Analysis
Annual trends were evaluated based on both the incidence/number and rate of procedures. The linear regression model was used to assess annual trends in incidences and procedure numbers over time.
For the analysis of annual incidence rates and procedure rates, Poisson regression models were applied. Due to the limited time span of available records for pancreatic head resections, Poisson regression was performed primarily for pancreatic cancer incidence and DP procedures. Models were adjusted for sex and age group. Risk ratios (RRs) were calculated for the overall cohorts and age‐stratified subgroups by sex, with RRs > 1.0 indicating an annual increase and RRs < 1.0 indicating a decrease.
2.6. Statistical Analyses
Age‐standardization was performed using the direct method, based on the 2015 Japanese standard population [22]. Linear regression models assessed annual changes in procedure counts. Poisson regression models were applied to evaluate changes in procedure rates, with the number of procedures as the dependent variable, and the time‐point (year) and sex as independent variables. The model included the logarithm of the population as an offset term and incorporated age adjustment using a direct method with consistent age structure. Subgroup analyses stratified by sex and age were also conducted.
All statistical analyses were performed using R version 3.6.2 Statistical Computing Program (R Foundation; www.r‐project.org). Statistical significance was set at two‐sided p‐values of < 0.05 for the linear regression analysis. For Poisson regression models, significance thresholds were adjusted for multiple comparisons using the Bonferroni correction: p < 0.0167 (0.05/3) for all ages analyses; p < 0.0009 (0.05/57) for age‐stratified analyses of PC incidence; and p < 0.0012 (0.05/42) for age‐stratified DP analyses.
3. Results
3.1. Overview
From 2016 to 2021, a cumulative crude PC incidence amounted to 258 091 cases across Japan, with rates of 34.1 per 100 000 person‐years. The overall male‐to‐female incidence ratio was 1.1:1. Age‐stratified analysis revealed an increasing distribution in incidence rate, peaking in the over 90 age group (Figure 1A). In this group, the annual incidence rates per 100 000 person‐years were 169.8 for males, 148.4 for females, and 153.7 for both sexes combined. Additionally, 83.4% of all PC cases occurred in people aged ≥ 65 years.
FIGURE 1.
Age‐stratified pancreatic cancer incidence and surgery rates in Japan. (A) Incidence rates (2016–2021) and (B) surgery rates (2020–2023) per 100 000 person‐years. (C) Estimated age‐stratified surgery‐to‐incidence ratios. Panels A and B are derived from distinct databases with different observation periods; therefore, the ratios in Panel C represent estimated values.
From 2020 to 2023, a cumulative crude number of all PC surgeries (across all surgical types and approaches) amounted to 55 595 procedures across Japan, with rates of 14.3 per 100 000 person‐years. The overall male‐to‐female procedure ratio was 1.4:1. Age‐stratified analysis revealed a unimodal distribution in procedure rate, peaking in the 75–79 age group (Figure 1B). In this group, the annual procedure rates per 100 000 person‐years were 56.0 for males, 35.0 for females, and 44.4 for both sexes combined. Overall, 79.2% of all PC surgeries were performed on individuals aged ≥ 65 years.
The estimated overall surgery‐to‐incidence ratio for PC was 0.316. This ratio exhibited a bimodal distribution, with peaks observed in the 40–44 and 70–74 age groups: 0.256 (20–24 years), 0.281 (25–29 years), 0.344 (30–34 years), 0.351 (35–39 years), 0.404 (40–44 years), 0.401 (45–49 years), 0.387 (50–54 years), 0.389 (55–59 years), 0.393 (60–64 years), 0.390 (65–69 years), 0.411 (70–74 years), 0.404 (75–79 years), 0.270 (80–84 years), 0.079 (85–89 years), and 0.001 (≥ 90 years) (Figure 1C).
3.2. Procedural Breakdown in 2023
In fiscal year 2023, a total of 14 397 PC surgeries were performed in Japan. Their breakdown is shown in Figure 2, and age‐stratified counts are presented in Figure S1. The most common procedure was pancreatic head resection with lymph node and nerve plexus dissection (n = 6607, 45.9%), followed by pancreatic head resection with resection of vessels (n = 1862, 12.9%) and laparoscopic DP with splenic resection (n = 1803, 12.5%). Robotic assistance was utilized for DP (n = 877, 6.1%) and for pancreatic head resections (n = 394, 2.7%).
FIGURE 2.
Overview of pancreatic cancer surgery in 2023. The chart illustrates the procedural breakdown of 14 397 surgeries. DP, distal pancreatectomy; Lap, laparoscopic; LND, lymph node and nerve plexus dissection; PHR, pancreatic head resection; RA, robotic‐assisted; RSO, resection of surrounding organs; SR, splenic resection; VR, vascular resection.
Notably, PD accounted for 65.6% of all PC surgeries (9444/14 397), while DP accounted for 34.4% (4953/14 397). In terms of surgical approach, open surgery comprised 77.0% (11 079/14 397), laparoscopic surgery accounted for 23.0% (3318/14 397), and robotic‐assisted surgeries represented 8.8% (1271/14 397) of the total.
3.3. Annual Trend Analysis From 2016 to 2023
3.3.1. Annual Trends in Pancreatic Cancer Incidence and Surgical Procedure Counts
A significant increasing trend was observed in the age‐adjusted PC incidence between 2016 and 2021 (p < 0.05) (Figure 3A). A significant increasing trend was observed in the age‐adjusted number of DP and laparoscopic surgery performed between 2016 and 2023 (p < 0.0001, and p = 0.0007, respectively) (Figure 3B). In contrast, the number of overall PC surgery, PD, and open surgery showed no significant trend (p = 0.0811, 0.4701, and 0.0633, respectively).
FIGURE 3.
Trends in age‐adjusted pancreatic cancer incidence (2016–2021) (A) and surgical procedures (2016–2023) (B) in Japan. Surgical procedures are further categorized by type (pancreatoduodenectomy/distal pancreatectomy) and approach (open/laparoscopic). * indicates a statistically significant trend (p < 0.05). DP, distal pancreatectomy; Lap, laparoscopic; PC, pancreatic cancer; PD, pancreatoduodenectomy.
3.3.2. Annual Trends in Pancreatic Cancer Incidence and Procedure Rates
The age‐adjusted PC incidence rates per 100 000 person‐years increased significantly from 2016 to 2021 among males, females and both sexes combined (RR = 1.007, 1.016, and 1.011, respectively; p < 0.0001; Table 1). Subgroup analyses revealed distinct age‐specific patterns (Figure 4A–C; detailed RRs in Table S1). A marked annual increase was noted among young females aged 10–29 years (RR range: 1.347–1.489; all p < 0.0009), and a gradual but significant rise was observed in both sexes aged 70 years and above. In contrast, a slight but significant decrease was observed among males aged 65–69 years.
TABLE 1.
Poisson regression analysis of annual trends in age‐adjusted pancreatic cancer incidence and distal pancreatectomy rates across all ages per 100 000 person‐years.
| Outcome | Sex | RR | 95% CI (low) | 95% CI (high) | p |
|---|---|---|---|---|---|
| Pancreatic cancer incidence | Male | 1.007 | 1.003 | 1.010 | < 0.0001 |
| Female | 1.016 | 1.013 | 1.020 | < 0.0001 | |
| Male and Female | 1.011 | 1.009 | 1.014 | < 0.0001 | |
| Distal pancreatectomy | Male | 1.033 | 1.026 | 1.039 | < 0.0001 |
| Female | 1.032 | 1.025 | 1.040 | < 0.0001 | |
| Male and Female | 1.033 | 1.028 | 1.038 | < 0.0001 |
Note: RR reflects the relative risk per one‐year increase (time variable entered as continuous).
Abbreviations: CI, confidence interval; RR, risk ratio.
FIGURE 4.
Risk ratios (RRs) for age‐stratified pancreatic cancer incidence per 100 000 person‐years, derived from Poisson regression models: Males (A), females (B) and both sexes combined (C). CI, confidence interval; RR, risk ratio. Black dots represent significant, and gray dots represent non‐significant.
Similarly, the age‐adjusted DP rates per 100 000 person‐years increased significantly from 2016 to 2023 among males, females and both sexes combined (RR = 1.033, 1.032, and 1.033, respectively; p < 0.0001; Table 1). Subgroup analyses further revealed significant increases among males, females and both sexes aged 65–89 years (RR range: 1.018 to 1.114; all p < 0.0012; Figure 5A–C; detailed RRs in Table S2).
FIGURE 5.
Risk ratios (RRs) for age‐stratified distal pancreatectomy rates per 100 000 person‐years, derived from Poisson regression models: Males (A), females (B) and both sexes combined (C). CI, confidence interval; RR, risk ratio. Black dots represent significant, and gray dots represent non‐significant.
4. Discussion
This nationwide analysis of pancreatic cancer (PC) epidemiology and surgical trends in Japan reveals two critical, demographically distinct phenomena: a steep increase in PC incidence among young Japanese women and a substantial rise in distal pancreatectomy (DP) among older adults. These findings, derived from robust population‐level data, reflect evolving disease and treatment patterns with profound implications for public health policy and surgical resource planning.
The most striking observation is the disproportionately high annual increase in PC incidence among females aged 10–29 years (RR = 1.347–1.449), which far exceeds trends observed in other age‐sex groups (Figures 3 and 4). This trend is consistent with global reports of rising early‐onset PC among young women [7, 8]. While improved diagnostic modalities and healthcare access among younger populations may partially account for this rise, the magnitude and demographic specificity suggest that biological, environmental, or lifestyle‐related factors may be contributing. Potential explanations include increased exposure to endocrine‐disrupting chemicals, a dietary shift toward ultra‐processed foods, and unique genetic susceptibilities such as BRCA or PALB2 mutations [23] that may interact with hormonal factors in young women. These hypotheses require urgent validation through molecular epidemiological studies and pooled biobank analyses. Early identification of high‐risk subgroups could facilitate targeted screening and prevention strategies in this atypical population.
However, it is imperative to interpret this trend with caution regarding histological subtypes. A major limitation of the cancer registry dataset is the reliance on aggregate ICD‐10 C25 codes, which include all malignant pancreatic tumors other than pancreatic ductal adenocarcinoma (PDAC). Prior research from the United States [24] has demonstrated that rising PC incidence rates among young females can be attributable to the increased detection of non‐ductal neoplasms. Because histologic information is unavailable in the aggregate Cancer Information Database, the observed trend among young Japanese females may similarly reflect improved detection of tumors such as solid pseudopapillary neoplasm (SPN) [25, 26] and cystic adenocarcinoma, rather than a true rise in early‐onset PDAC. Furthermore, the absolute number of cases in this young cohort remains relatively small (Table S3).
In contrast, DP procedures and rates have steadily increased, particularly among individuals aged 65–89 years (RR = 1.018–1.114) (Figures 3 and 5). This trend likely reflects improved perioperative management and the growing feasibility of minimally invasive surgery (MIS) in elderly cohorts. Furthermore, this increase may partly reflect more surgery for low‐grade or precancerous lesions rather than for PC alone. The definitions of PC surgery in this study (K702/703) include laparoscopic DP regardless of the extent of lymph node dissection, thereby capturing resections for SPN and cystic neoplasms. Recent work indicates that minimally invasive resection for SPN has increased by 52.3% for DP (cf. 14.8% for PD) over the past decade [27]. Together with the increased detection of incidental pancreatic cystic lesions in older adults via widely used CT/MRI [28, 29], the observed rise in DP among patients aged 65–89 years likely encompasses these evolving surgical indications facilitated by MIS. Moreover, the longer observation window for distal pancreatectomy compared to other procedures may partially explain the magnitude of this trend. Continued longitudinal monitoring is needed to confirm its persistence.
The adoption of laparoscopic surgery (Figure 3) significantly increased during the study period, possibly due to accumulating evidence supporting its non‐inferiority in oncologic outcomes and superior perioperative metrics [11, 12, 13, 14]. In particular, MIS has been associated with shorter hospital stays and reduced intraoperative blood loss, especially in older adults. Our findings regarding the rise in DP among elderly patients (Figure 5) lend partial support to this trend. Nevertheless, longer‐term studies are essential to assess its broader impact and sustainability.
An important and concerning finding is the discordance between the rapidly increasing PC incidence in young women (Figure 4B) and the lack of a clear upward trend in the surgical intervention rate in this cohort (Figure 5B). While this discrepancy suggests that some young patients present with advanced disease or distorted perception of illness limiting surgical options, it must be viewed in light of the histological heterogeneity discussed above. The stable surgical rate may suggest a complex interplay between diagnosis, coding, and surgical selection that warrants further investigation using granular clinical data.
Regarding the surgical intervention rate, the overall surgery‐to‐incidence ratio (SIR) for PC was 0.316 (Figure 1C), which is lower than the SIR previously reported for lung cancer (0.421) [22]. In contrast to lung cancer, where the SIR typically declines with age, the ratio for PC exhibited a bimodal distribution with minor peaks in the 40–44 and 70–74 age groups. Several factors may explain this characteristic pattern. First, the inclusion of non‐ductal malignancies, which are more common in younger women and older adults, may contribute to these age‐specific peaks. Second, age‐related differences in patient referral patterns, comorbidities, and surgical indications may further influence resection rates. Further investigation is needed to clarify the underlying causes.
This study has several limitations. First, the NDB Open data lack patient‐specific clinical information such as cancer staging, histopathology, and comorbidities. As noted, the inability to distinguish PDAC from lower‐grade malignancies is a limitation in interpreting incidence trends in young women. Second, evolving procedural codes (e.g., pancreatic head resection data available only from 2020) limit long‐term trend analysis. Third, the exclusion of procedures with < 10 annual instances may lead to underestimation of rare surgical interventions. Fourth, the surgery‐to‐incidence ratio was estimated using data from two distinct databases with different collection periods and should be interpreted cautiously. Finally, there may be a small subset of procedures for non‐pancreatic cancers (e.g., pancreatic neuroendocrine neoplasm or invasive cancer of adjacent organs), potentially influencing the overall interpretation of the findings. More detailed research is warranted to address these limitations.
These trends necessitate stratified public health responses. For young women, heightened clinical awareness of nonspecific abdominal symptoms is imperative, alongside etiological research targeting early‐life exposures and differentiating histological subtypes. For older adults, healthcare systems must prioritize geriatric‐specific surgical pathways, including enhanced MIS training and outcome optimization for octogenarians undergoing surgery. Resource planning should anticipate escalating demand, particularly for laparoscopic/robotic pancreatectomy in the future.
In conclusion, this study delineates a bifurcated epidemiological shift in Japanese pancreatic cancer: an apparent rise in incidence among young women—potentially influenced by non‐ductal etiologies—and increasing surgical intervention for distal tumors in the elderly. These nationwide findings highlight the need for a tailored public health approach. This includes prioritizing research to validate the histology behind the trend observed in the young, while simultaneously optimizing surgical frameworks for the aged population to mitigate the evolving burden of this lethal malignancy.
Author Contributions
Masamitsu Kido: conceptualization, methodology, investigation, formal analysis, writing – original draft, writing – review and editing, visualization. Ryo Morimura: conceptualization, investigation, formal analysis, writing – review and editing. Yusuke Yamamoto: investigation, formal analysis, writing – review and editing. Tomohiro Arita: writing – review and editing. Shingo Nakashima: writing – review and editing. Katsutoshi Shoda: methodology, writing – review and editing. Taisuke Imamura: investigation, formal analysis, writing – review and editing. Hidemasa Kubo: investigation, formal analysis, writing – review and editing. Kengo Yoshii: validation, writing – review and editing. Iichiroh Onishi: validation, writing – review and editing. Atsushi Shiozaki: supervision.
Funding
The authors have nothing to report.
Ethics Statement
This study did not require institutional board approval or informed consent because of its retrospective nature and the use of legally anonymized public data.
Conflicts of Interest
The authors declare no conflicts of interest for this article.
Supporting information
Data S1: ags370178‐sup‐0001‐TableS1‐S3.docx.
Acknowledgments
The authors have nothing to report.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1: ags370178‐sup‐0001‐TableS1‐S3.docx.