Abstract
Background
Pancreatic cancer (PC) poses a significant public health challenge in China because of high mortality and increasing incidence, necessitating an analysis of its burden from 1990 to 2023 to inform future prevention.
Methods
Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023, we estimated absolute numbers, age-standardized rates (ASRs), and age-stratified crude rates. Joinpoint regression was employed to calculate average annual percentage changes (AAPCs). We quantified the burden attributable to specific risk factors and conducted a segmented analysis to compare trends between the pre-pandemic and pandemic periods. All estimates are presented with 95% uncertainty interval (UI).
Results
In 2023, China was estimated to have 118,381 incident PC cases (95% UI 103,773-135,339), 114,949 deaths (95% UI 101,214-131,619), 102,845 prevalent cases (95% UI 89,758-117,757), and 2,765,626 DALYs (95% UI 2,455,494-3,137,032). The age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR), and age-standardized disability-adjusted life year rate (ASDR) remained stable. The age-standardized prevalence rate (ASPR) increased slightly (AAPC 0.38%, 95% CI 0.06 to 0.70). The burden was consistently higher in males than in females. Age-specific analysis highlighted rising incidence rates in both 15–49 years and ≥75 years age groups. In 2023, high fasting plasma glucose (HFPG) accounted for a higher attributable burden than smoking. Pandemic-era sensitivity analysis suggested a possible change in the direction of ASIR and ASMR trends after 2019, but the observed post-2019 increases were not statistically significant and require further validation.
Conclusion
The increasing absolute burden was mainly associated with population aging, while risk-attributable analysis suggested a growing contribution of metabolic factors. Prevention strategies should integrate metabolic management to tackle the dual challenges of an aging society and emerging risks in younger people.
Keywords: age-specific trends, China, global burden of disease, joinpoint, pancreatic cancer
Introduction
Pancreatic cancer is one of the most fatal malignancies and imposes a substantial public health burden worldwide (1, 2). In China, the cancer burden and the patterns of risk exposure have been changed by population aging, urbanization, and shifts in diet and lifestyle over recent decades (3–6). Updated estimates of pancreatic cancer burden are needed to guide prevention priorities, health resource allocation, and clinical decision making. Previous studies have examined the burden of pancreatic cancer in China, but most relied on earlier GBD estimates and may not fully reflect recent changes in population structure and risk exposure (7, 8). Rapid aging, urbanization, and metabolic transition in China may have altered the scale of the pancreatic cancer burden and the relative importance of modifiable risk factors (9, 10). These changes could raise the absolute burden even when ASRs change little. They could also shift the underlying risk profile. The COVID-19 pandemic, which disrupted cancer diagnosis and treatment, may have affected short-term trends, but such effects are uncertain and require cautious interpretation (11, 12).
We assessed the burden of pancreatic cancer in China from 1990 to 2023 using the most recent GBD 2023 data. The indicators included incidence, mortality, prevalence, and disability-adjusted life years (DALYs). Compared with previous GBD-based studies, this analysis extends the observation period to 2023 and uses updated GBD risk-attributable estimates. We further examined sex- and age-specific trends, decomposed the drivers of burden changes, and explored short-term trend patterns before and after 2019.
Methods
Data source and study design
We analyzed data from the Global Burden of Disease Study (GBD) 2023, coordinated by the Institute for Health Metrics and Evaluation, to examine the longitudinal burden of pancreatic cancer in China (1990–2023). By synthesizing diverse data sources, including vital registration, cancer registries, and censuses, through standardized modeling, the GBD framework provides comparable estimates of health loss across 204 countries and territories (13, 14). The extracted indicators included incident cases, deaths, prevalent cases, DALYs, ASRs, age-specific rates, and risk-attributable estimates. All estimates are reported with 95% UI to account for modeling variance.
For this study, pancreatic cancer was defined as malignant neoplasms of the pancreas, classified under ICD-10 code C25 (15).
Measures of burden
We assessed the disease burden of pancreatic cancer using four core indicators: incidence, mortality, prevalence, and DALYs. DALYs were defined as the sum of years of life lost (YLLs) and years lived with disability (YLDs) (16):
To eliminate age structure differences, we calculated the ASRs per 100,000 population using the GBD global standard population. We also calculated the crude rate for each age group to evaluate the overall burden on the healthcare system.
Decomposition analysis
We performed a decomposition analysis to quantify the relative contributions of population growth, population aging, and epidemiological change to changes in pancreatic cancer burden between 1990 and 2023. In this analysis, epidemiological change refers to changes in age-specific rates after accounting for population size and age structure (17, 18).
Risk factor quantification
We used the GBD Comparative Risk Assessment framework to quantify the burden of pancreatic cancer attributable to modifiable risk factors (19). Based on the Global Burden of Disease Study 2023, we focused on four key risk factors: smoking, HFPG, high body mass index (BMI), and high alcohol use. Risk-attributable estimates were obtained from the GBD 2023 Comparative Risk Assessment framework. The burden attributable to each risk factor was quantified using population attributable fractions (PAFs), which were estimated by GBD based on exposure distributions, relative risks, and theoretical minimum risk exposure levels. We extracted PAFs and corresponding 95% UI, which were derived from the 2.5th and 97.5th percentiles of 1,000 posterior draws.
Statistical analysis
Joinpoint regression analysis was performed using Joinpoint Regression Program version 5.2.0.0 (20). The model was fitted on the logarithm of the ASR and allowed a maximum of five joinpoints. The optimal number of joinpoints was selected using Monte Carlo permutation tests with an overall significance level of 0.05. APC was calculated for each segment, and AAPC was estimated as a weighted average of APCs across the study period. The AAPC was calculated as follows:
where APCi represents the APC of the i-th segment, Li denotes the length of the corresponding segment, and k is the total number of segments.
To explore short-term trend patterns around the COVID-19 pandemic, we conducted a segmented analysis comparing the AAPC during the pre-pandemic period (2010 to 2019) and the pandemic period (2019 to 2023). The year 2019 was used as the dividing point because it preceded the major disruption of health services caused by COVID-19 (21). A p-value less than 0.05 was considered statistically significant.
Statistical analyses were performed using R software (version 4.3.1), Joinpoint Regression Program (version 5.2.0.0), and JD_GBDR (version 2.37). Data processing was conducted using the tidyverse and data.table packages. Figures were generated using ggplot2, ggpubr, and patchwork. Joinpoint regression was applied to estimate temporal trends and calculate AAPCs. Decomposition analysis was performed using custom R scripts based on the Das Gupta method to quantify the contributions of population growth, population aging, and epidemiological changes to changes in pancreatic cancer burden.
Results
Temporal trends in the burden of pancreatic cancer in China, 1990–2023
From 1990 to 2023, the absolute burden of pancreatic cancer in China increased substantially, but most ASRs remained relatively stable. In 2023, China reported 118,381 incident cases (95% UI 103,773–135,339), 102,845 prevalent cases (95% UI 89,758–117,757), and 114,949 deaths (95% UI 101,214–131,619). The disease burden reached 2,765,626 DALYs (95% UI 2,455,494–3,137,032). Compared with 1990, the numbers of incident cases, prevalent cases, deaths, and DALYs increased by 169.18%, 169.00%, 168.92%, and 125.46%, respectively. Among the age-standardized indicators, only ASPR showed a statistically significant increase, rising from 4.19 to 4.51, with an AAPC of 0.38% (95% CI 0.06 to 0.70) (Figure 1; Table 1).
Figure 1.
Trends in pancreatic cancer indicators in China by age group (1990-2023). Age-specific rates are shown for three age groups: 15–49 years, 50–74 years, and ≥75 years, with different colors representing different age groups. The age-standardized curve represents the all-age standardized rate. (A) Incidence rate; (B) prevalence rate; (C) mortality rate; (D) disability-adjusted life year (DALY) rate. All rates are expressed per 100,000 population.
Table 1.
Age-standardized rates and burden of pancreatic cancer in China, 1990-2023.
| Indicator | Sex | Number (1990, 95%UI) | Number (2023, 95%UI) | Percent change (%) | ASR (1990, 95%UI) | ASR (2023, 95%UI) | AAPC of ASR (95% CI) |
|---|---|---|---|---|---|---|---|
| Death | Both | 42731(36787,49928) | 114949(101214,131619) | 169.00 | 5.06(4.35,5.92) | 4.97(4.37,5.70) | -0.14 (-0.65 to 0.38) |
| Female | 17569(14286,21859) | 44882(36240,57512) | 155.45 | 4.09(3.33,5.11) | 3.69(2.99,4.69) | -0.48 (-0.79 to -0.16)* | |
| Male | 25162(20574,32058) | 70067(60025,82318) | 178.46 | 6.11(4.98,7.81) | 6.32(5.42,7.43) | 0.22 (-0.32 to 0.76) | |
| DALY | Both | 1226645(1062371,1439160) | 2765626(2455494,3137032) | 125.46 | 132.16(114.24,154.80) | 120.60(106.58,136.65) | -0.08 (-0.42 to 0.25) |
| Female | 478088(393469,584508) | 984617(824039,1222325) | 105.95 | 103.99(85.37,127.85) | 82.47(69.13,101.35) | -0.58 (-0.89 to -0.26)* | |
| Male | 748558(611242,941878) | 1781009(1519033,2082466) | 137.93 | 160.47(131.07,203.71) | 159.13(136.06,184.47) | -0.02 (-0.32 to 0.28) | |
| Incidence | Both | 43978(37940,51580) | 118381(103773,135339) | 169.18 | 5.05(4.34,5.91) | 5.13(4.48,5.88) | -0.04 (-0.54 to 0.47) |
| Female | 17841(14548,22131) | 45701(37103,57589) | 156.15 | 4.06(3.31,5.06) | 3.78(3.07,4.72) | 0.00 (-0.23 to 0.23) | |
| Male | 26136(21374,33249) | 72680(62030,85513) | 178.08 | 6.09(4.96,7.80) | 6.53(5.59,7.69) | 0.33 (-0.19 to 0.85) | |
| Prevalence | Both | 38244(33099,44391) | 102845(89758,117757) | 168.92 | 4.19(3.63,4.87) | 4.51(3.92,5.19) | 0.38 (0.06 to 0.70)* |
| Female | 15184(12372,18223) | 39398(32696,48491) | 159.48 | 3.34(2.71,4.03) | 3.33(2.77,4.08) | 0.01 (-0.33 to 0.35) | |
| Male | 23060(19072,28536) | 63447(53846,72578) | 175.14 | 5.05(4.17,6.25) | 5.71(4.86,6.56) | 0.48 (0.01 to 0.95)* |
AAPC, average annual percentage change; ASR, age-standardized rate; CI, confidence interval; DALY, disability-adjusted life year; UI, uncertainty interval. The symbol * indicates p < 0.05. Trends with 95% CIs including 0 were considered statistically non-significant.
Sex-specific trends
The absolute burden of pancreatic cancer increased in both males and females in China from 1990 to 2023, and was consistently higher in males. In 2023, males had 72,680 incident cases (95% UI 62,030-85,513), 63,447 prevalent cases (95% UI 53,846-72,578), 70,067 deaths (95% UI 60,025-82,318), and 1,781,009 DALYs (95% UI 1,519,033-2,082,466), compared with 45,701 (95% UI 37,103-57,589), 39,398 (95% UI 32,696-48,491), 44,882 (95% UI 36,240-57,512), and 984,617 (95% UI 824,039-1,222,326) in females. Compared with 1990, the absolute numbers of incident cases, prevalent cases, deaths and DALYs in males increased by 178.08%, 175.14%, 178.46%, and 137.93%. In females, the corresponding increases were 156.15%, 159.48%, 155.45% and 105.95%. The ASIR was statistically stable in both sexes. The ASPR increased significantly in males, from 5.05 to 5.71, with an AAPC of 0.48% (95% CI 0.01 to 0.95), but it was stable in females. Among females, the ASMR declined from 4.09 to 3.69, with an AAPC of −0.48% (95% CI −0.79 to −0.16), and the ASDR declined from 103.99 to 82.47, with an AAPC of −0.58% (95% CI −0.89 to −0.26). The ASMR and ASDR in males showed no statistically significant long-term changes (Figure 2; Table 1).
Figure 2.
The disease burden of pancreatic cancer in China by sex, 1990–2023. The absolute numbers and age-standardized rates are presented for (A) incidence, (B) prevalence, (C) deaths, and (D) disability-adjusted life years (DALYs). Bars represent absolute numbers, and lines represent age-standardized rates per 100,000 population. Different colors indicate males and females.
Age-specific trends
Pancreatic cancer burden varied across the 15–49, 50–74, and ≥75 years age groups from 1990 to 2023. The ≥75 years age group consistently had the highest burden. In this group, the incidence rate increased from 31.64 to 43.08, with an AAPC of 0.89% (95% CI 0.36 to 1.42). The incidence rate also increased in the 15–49 years age group, from 1.05 to 1.38, with an AAPC of 0.87% (95% CI 0.68 to 1.06). The incidence rate for the 50–74 years age group remained relatively stable. Prevalence rosed most rapidly in the ≥75 years group. The prevalence rate rose from 19.03 to 29.81, with an AAPC of 1.33% (95% CI 0.83 to 1.83), and the number of prevalent cases increased by 524.14% from 1990 to 2023. The 15–49 years age group also showed a significant increase in the prevalence rate, with an AAPC of 1.01% (95% CI 0.84 to 1.19), but the rate for the 50–74 years age group remained stable. The mortality rate in the ≥75 years age group reached 46.32 in 2023, with an AAPC of 0.73% (95% CI 0.08 to 1.39), and the absolute number of deaths increased by 400.30%. A significant rise was also observed in the 15–49 years age group, with an AAPC of 0.78% (95% CI 0.57 to 1.00). The mortality rate for the 50–74 years age group declined from 17.22 to 15.79, with no statistically significant long-term trend. The DALY rate was highest in the ≥75-year age group across the study period (Figure 1; Table 2).
Table 2.
Age-specific trends in pancreatic cancer burden in China, 1990-2023.
| Metric | Measure | Number (1990, 95%UI) | Number (2023, 95%UI) | Percent change (%) | Rate (1990, 95%UI) | Rate (2023, 95%UI) | AAPC of rate (95% CI) |
|---|---|---|---|---|---|---|---|
| Death | 15–49 years | 5753(4889,6826) | 7141(5788,8615) | 24.12 | 0.86(0.73,1.02) | 1.11(0.90,1.33) | 0.78 (0.57 to 1.00)* |
| 50–74 years | 29804(25518,34997) | 71914(62671,83657) | 141.29 | 17.22(14.74,20.22) | 15.79(13.76,18.37) | -0.08 (-0.51 to 0.35) | |
| 75+ years | 7174(6126,8659) | 35894(28788,43870) | 400.30 | 36.89(31.50,44.52) | 46.32(37.15,56.61) | 0.73 (0.08 to 1.39)* | |
| All ages | 42731(36787,49928) | 114949(101214,131619) | 169.00 | 3.62(3.12,4.23) | 8.03(7.07,9.20) | 2.48 (2.09 to 2.88)* | |
| DALY | 15–49 years | 288235(246164,340716) | 337145(273693,406208) | 16.97 | 43.11(36.81,50.96) | 52.22(42.39,62.92) | 0.53 (0.37 to 0.69)* |
| 50–74 years | 835216(715321,983128) | 1953579(1689016,2245121) | 133.90 | 482.57(413.30,568.03) | 428.97(370.87,492.98) | -0.51 (-0.77 to -0.25)* | |
| 75+ years | 103195(88413,124624) | 474902(384354,576315) | 360.20 | 530.59(454.59,640.77) | 612.82(495.98,743.69) | 0.42 (-0.10 to 0.93) | |
| All ages | 1226645(1062371,1439160) | 2765626(2455494,3137032) | 125.46 | 104.03(90.10,122.05) | 193.31(171.64,219.27) | 1.90 (1.52 to 2.29)* | |
| Incidence | 15–49 years | 7018(5958,8274) | 8900(7220,10709) | 26.82 | 1.05(0.89,1.24) | 1.38(1.12,1.66) | 0.87 (0.68 to 1.06)* |
| 50–74 years | 30806(26338,36178) | 76096(65832,87604) | 147.01 | 17.80(15.22,20.90) | 16.71(14.46,19.24) | -0.16 (-0.61 to 0.30) | |
| 75+ years | 6154(5257,7454) | 33385(26343,41532) | 442.52 | 31.64(27.03,38.33) | 43.08(33.99,53.59) | 0.89 (0.36 to 1.42)* | |
| All ages | 43978(37940,51580) | 118381(103773,135339) | 169.18 | 3.73(3.22,4.37) | 8.27(7.25,9.46) | 2.32 (2.05 to 2.58)* | |
| Prevalence | 15–49 years | 8311(7091,9942) | 11247(9481,12976) | 35.32 | 1.24(1.06,1.49) | 1.74(1.47,2.01) | 1.01 (0.84 to 1.19)* |
| 50–74 years | 26231(22773,30467) | 68494(60946,77831) | 161.12 | 15.16(13.16,17.60) | 15.04(13.38,17.09) | 0.04 (-0.39 to 0.47) | |
| 75+ years | 3702(3092,4428) | 23104(18527,28573) | 524.14 | 19.03(15.90,22.77) | 29.81(23.91,36.87) | 1.33 (0.83 to 1.83)* | |
| All ages | 38244(33099,44391) | 102845(89758,117757) | 168.92 | 3.24(2.81,3.76) | 7.19(6.27,8.23) | 2.38 (2.16 to 2.60)* |
AAPC, average annual percentage change; CI, confidence interval; UI, uncertainty interval. The symbol * indicates p < 0.05. Trends with 95% CIs including 0 were considered statistically non-significant.
Decomposition analysis
Decomposition analysis showed that the increases in deaths, incidence, and prevalence were mainly driven by population aging, followed by population growth. Epidemiological change had a limited effect on incidence, deaths, or prevalence. But the increase in DALYs was due mainly to epidemiological change, with additional contributions from population growth and a smaller effect of aging. In this analysis, epidemiological change refers to changes in age-specific rates after accounting for population size and age structure (Figure 3).
Figure 3.
Decomposition of changes in pancreatic cancer burden in China from 1990 to 2023. The total change in (A) incident cases, (B) prevalent cases, (C) deaths, and (D) DALYs was decomposed into contributions from population growth, population aging, and epidemiological change.
Risk-attributable burden
From 1990 to 2023, the risk-attributable burden of pancreatic cancer showed different patterns across the four assessed risk factors. For HFPG, the attributable ASMR increased from 1.08 to 1.29 per 100,000, with an AAPC of 0.39% (95% CI 0.14 to 0.65). The attributable ASMR and ASDR for high alcohol use decreased significantly, with AAPCs of −0.56% (95% CI -0.78 to -0.33) and −0.30% (95% CI -0.61 to -0.00), respectively. Trends for smoking were not statistically significant. In 2023, HFPG accounted for higher attributable deaths and DALYs than smoking, particularly in the ≥75 years age group (Figures 4, 5; Table 3).
Figure 4.
Age-specific burden of pancreatic cancer attributable to major risk factors in China, 1990 and 2023. Attributable death rates in (A) 1990 and (B) 2023; attributable DALY rates in (C) 1990 and (D) 2023. Rates are expressed per 100,000 population. The assessed risk factors included smoking, high fasting plasma glucose, high body-mass index, and high alcohol use. BMI, body-mass index; HFPG, high fasting plasma glucose.
Figure 5.
Temporal trends in the burden of pancreatic cancer attributable to major factors in China, 1990–2023. Age-standardized rates attributable to major risk factors are displayed as separate curves, with different colors indicating different risk factors. The assessed risk factors include smoking, high fasting plasma glucose, high body-mass index, and high alcohol use. (A) Age-standardized disability-adjusted life year (DALY) rates. (B) Age-standardized mortality rates. All rates are expressed per 100,000 population. BMI, body-mass index; HFPG, high fasting plasma glucose.
Table 3.
Burden of pancreatic cancer attributable to risk factors in China, 1990-2023.
| Measure | Risk factors | Number (1990, 95%UI) | Number (2023, 95%UI) | Percent change (%) | ASR (1990, 95%UI) | ASR (2023, 95%UI) | AAPC of ASR (95% CI) |
|---|---|---|---|---|---|---|---|
| Deaths | Smoking | 9148(7187,11413) | 22860(18949,27858) | 151.14 | 1.05(0.82,1.30) | 0.97(0.81,1.19) | -0.12 (-0.71 to 0.47) |
| High alcohol use | 1002(147,1667) | 2165(418,3430) | 116.87 | 0.11(0.02,0.18) | 0.09(0.02,0.15) | -0.56 (-0.78 to -0.33)* | |
| High body-mass index | -684(-2112,5) | -847(-5177,1637) | 23.54 | -0.08(-0.23,0.00) | -0.04(-0.22,0.07) | NA | |
| High fasting plasma glucose | 8966(5999,12897) | 30021(23516,38383) | 236.45 | 1.08(0.74,1.55) | 1.29(1.01,1.65) | 0.39 (0.14 to 0.65)* | |
| DALYs | Smoking | 265123(209110,335055) | 585652(484319,708327) | 121.88 | 28.42(22.40,35.77) | 25.28(20.92,30.58) | -0.28 (-0.75 to 0.18) |
| High alcohol use | 33208(4595,56053) | 64270(11840,103410) | 94.14 | 3.37(0.48,5.66) | 2.90(0.52,4.69) | -0.30 (-0.61 to -0.00)* | |
| High body-mass index | -20544(-64214,285) | -16683(-121572,46075) | -19.01 | -2.16(-6.69,0.02) | -0.73(-5.35,1.99) | NA | |
| High fasting plasma glucose | 248664(161199,367206) | 681555(537021,869608) | 175.29 | 27.39(18.06,39.77) | 29.05(22.83,37.12) | 0.03 (-0.21 to 0.26) |
AAPC, average annual percentage change; ASR, age-standardized rate; CI, confidence interval; DALY, disability-adjusted life year; UI, uncertainty interval. The symbol * indicates p < 0.05. Trends with 95% CIs including 0 were considered statistically non-significant.
Pandemic-era sensitivity analysis
The pandemic-era sensitivity analysis compared AAPCs for 2010–2019 and 2019–2023 (Table 4). From 2010 to 2019, ASIR, ASMR, and ASDR all declined significantly, with AAPCs of −0.84% (95% CI −1.40 to −0.29), −0.98% (95% CI −1.55 to −0.41), and −1.09% (95% CI −1.59 to −0.58). During 2019–2023, the AAPC point estimates for ASIR, ASMR, and ASDR were positive, at 1.52% (95% CI −7.99 to 11.04), 1.18% (95% CI −8.35 to 10.71), and 1.04% (95% CI −8.57 to 10.65). However, all three confidence intervals were wide and included 0. These results indicate substantial statistical uncertainty in the short-term 2019–2023 trend estimates (Table 4).
Table 4.
Average annual percentage changes in age-standardized pancreatic cancer rates before and after the COVID-19 pandemic, China.
| Measure | Period | AAPC |
|---|---|---|
| ASMR | 2010–2019 | -0.98 (-1.55 to -0.41)* |
| 2019–2023 | 1.18 (-8.35 to 10.71) | |
| ASDR | 2010–2019 | -1.09 (-1.59 to -0.58)* |
| 2019–2023 | 1.04 (-8.57 to 10.65) | |
| ASIR | 2010–2019 | -0.84 (-1.40 to -0.29)* |
| 2019–2023 | 1.52 (-7.99 to 11.04) | |
| ASPR | 2010–2019 | -0.47 (-0.98 to 0.05) |
| 2019–2023 | 1.45 (-6.87 to 9.77) |
AAPC, average annual percentage change. The symbol * indicates p < 0.05. Trends with 95% CIs including 0 were considered statistically non-significant.
Discussion
Using the latest GBD 2023 data, we systematically evaluated the disease burden of pancreatic cancer in China from 1990 to 2023. The main finding was that the absolute burden increased markedly, while most ASRs remained generally stable. This suggests that the rising burden of pancreatic cancer in China was mainly reflected in the growing number of affected people, rather than increases in ASRs.
From a global perspective, China’s epidemiologic profile is rapidly converging toward that of high-Socio-demographic Index countries. Previous global assessments indicate that the highest pancreatic cancer incidence has been concentrated in highly industrialized regions, such as Eastern Europe and North America. Our data suggest that China is quickly narrowing this gap (22, 23). Compared with several low-incidence regions, including parts of sub-Saharan Africa and Southeast Asia, China has seen a substantial increase in the absolute burden of pancreatic cancer amid rapid urbanization, population aging, and lifestyle changes (24, 25).
The higher burden in males may reflect more than differences in smoking and alcohol exposure. Biological factors, including sex hormone-related pathways, fat distribution, glucose metabolism, and inflammatory responses, may also contribute to sex-specific differences in pancreatic cancer risk (26–28). In addition, men may delay seeking medical care for vague early symptoms or participate less in routine health examinations, which could affect the timing of diagnosis (29, 30).
The age-specific findings also deserve attention. The ≥75 years age group consistently had the highest burden of pancreatic cancer in China. Given the demographic transition in China, the expansion of the population aged over 75 may further increase the absolute burden of this malignant tumor in the coming decades (15, 31). Recent studies have reported increasing early-onset gastrointestinal cancers worldwide, suggesting that changes in obesity, diabetes, diet, physical activity, and other lifestyle-related factors may be involved (32, 33). For pancreatic cancer, early symptoms are often nonspecific, and clinicians may have lower suspicion in younger adults, which may delay diagnosis. For younger adults, these findings support improved clinical awareness and risk-based evaluation, particularly among individuals with persistent abdominal symptoms, new-onset diabetes, family history, or other high-risk features (32, 34). Given the insidious onset of pancreatic cancer, AI-assisted tools may complement clinical assessment by supporting risk stratification and diagnostic decision-making in patients with atypical or early-onset presentations (35–38).
Decomposition analysis indicated that population aging was the main contributor to the increases in incident cases, deaths, and prevalent cases. For DALYs, the larger contribution of epidemiological change may reflect changes in age-specific disease burden after accounting for population size and age structure. This is because DALYs are influenced not only by the number of deaths, but also by age at death and disability burden. As the elderly population continues to expand in China, the absolute number of pancreatic cancer cases is likely to remain a major challenge for the health system (31).
Regarding risk factors, HFPG showed the largest attributable burden among the four modifiable risk factors assessed in this study. In 2023, HFPG accounted for more attributable deaths and DALYs than smoking, and its ASMR was also higher than that of smoking. This finding suggests that metabolic risk may be playing an increasingly important role in the pancreatic cancer burden in China. The growing contribution of HFPG is biologically plausible. Long-term diabetes and hyperglycemia have been associated with increased pancreatic cancer risk, possibly through insulin resistance, hyperinsulinemia, chronic inflammation, oxidative stress, and changes in the pancreatic microenvironment (15, 39, 40). At the population level, rapid aging, dietary changes, reduced physical activity, and the increasing prevalence of diabetes may further increase the impact of metabolic risk on pancreatic cancer burden in China. These findings suggest that pancreatic cancer prevention should include metabolic risk management, such as better detection and control of diabetes, promotion of healthy diets and physical activity, together with continued tobacco control (41, 42). However, these results should be interpreted within the GBD comparative risk assessment framework and do not indicate that HFPG is the leading risk factor among all possible causes of pancreatic cancer (16). Negative attributable estimates for high body-mass index were retained as extracted from GBD 2023. These values may occur when the modeled exposure distribution is below the theoretical minimum risk exposure level for a specific risk–outcome pair and should therefore be interpreted cautiously (43, 44).
The pandemic-era sensitivity analysis suggested a possible change in the direction of pancreatic cancer trends after 2019. In our analysis, ASIR, ASMR, and ASDR declined significantly during 2010–2019, whereas their AAPC point estimates were positive during 2019–2023. However, the 95% CIs for the post-2019 estimates were wide and included 0, indicating that these short-term changes were not statistically significant. Therefore, the observed changes should be interpreted as possible short-term fluctuations rather than definitive trend reversals. Previous studies have reported that the COVID-19 pandemic disrupted cancer screening, diagnostic testing, endoscopy, surgery, and cancer treatment services (11, 45, 46). For pancreatic cancer, delayed imaging, endoscopy, specialist referral, or surgery may be clinically important because the disease often has a narrow window for curative treatment (34, 47). These findings suggest that pandemic-related healthcare disruption may have contributed to short-term changes in incidence and mortality estimates, but longer follow-up and validation using cancer registry data are needed.
This study is subject to limitations inherent to the GBD methodology (13, 14). Estimates may be biased in settings with sparse high-quality cancer registry data, despite the inclusion of best available evidence. Data aggregation precluded the distinction between specific histological subtypes, such as pancreatic ductal adenocarcinoma and neuroendocrine tumors. Furthermore, this study was conducted at the national level and could not assess provincial or regional heterogeneity. Differences in population aging, risk exposure, healthcare access, cancer registry coverage, and diagnostic capacity may contribute to regional variation in pancreatic cancer burden across China. National estimates may therefore mask local high-burden areas. Future studies using provincial data are needed to support more targeted prevention strategies and resource allocation.
Conclusion
Using the most recent GBD 2023 estimates, this study systematically characterized pancreatic cancer burden trends in China from 1990 to 2023, covering incidence, mortality, prevalence, and DALYs. Despite relatively stable ASRs, the absolute numbers of incident cases, deaths, and prevalent cases increased substantially, largely reflecting population aging. The burden remained higher in males and increased sharply with age. Risk-attributable analysis suggested an increasing contribution of metabolic risk, with HFPG accounting for the largest attributable burden among the four assessed GBD risk factors in 2023. Given the model-dependent nature of GBD estimates, these findings warrant validation against data from the Chinese Cancer Registry and national surveillance systems. Future prevention strategies should integrate metabolic risk management with established tobacco control measures to address the dual challenges of an aging population and an evolving risk landscape.
Funding Statement
The author(s) declared that financial support was received for this work and/or its publication. The article processing charge/publication fee for this study was supported by Jiangsu Fosun Pharmaceutical Sales Co., Ltd. The funder had no role in the study design, data collection, data analysis, interpretation of results, manuscript preparation, or the decision to submit the article for publication.
Footnotes
Edited by: Meng-Yao Li, Shanghai Jiao Tong University, China
Reviewed by: Hanlin Ding, Jiangsu Cancer Hospital, China
Yimao Wu, Guangdong Medical University, China
Author's Note
Hao Wu, the corresponding author (hwu25@mails.jlu.edu.cn), is a GBD Collaborator and led the research.
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethics statement
There was no need to get informed consent or ethical approval for this study again because all of the data were taken from published sources, and the informed consent and approval were received. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants’ legal guardians/next of kin because There was no need to get informed consent or ethical approval for this study again because all of the data were taken from published sources, and the informed consent and approval were received.
Author contributions
ZW: Conceptualization, Data curation, Investigation, Methodology, Software, Writing – original draft. SW: Data curation, Formal Analysis, Writing – original draft. GL: Formal Analysis, Software, Writing – original draft. HW: Supervision, Validation, Visualization, Writing – review & editing. YC: Funding acquisition, Supervision, Validation, Visualization, Writing – review & editing.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Associated Data
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Data Availability Statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.