Abstract
Objectives:
We examined how incidence of pancreatic neuroendocrine and exocrine cancers changed during the COVID-19 pandemic.
Methods:
Using population-based cancer registry data from the Centers for Disease Control and Prevention's National Program of Cancer Registries and the National Cancer Institute's Surveillance Epidemiology, and End Results program, we examined incidence rates of pancreatic neuroendocrine and exocrine cancers before, during, and after the COVID-19 pandemic onset.
Results:
Age-adjusted incidence rates for both pancreatic neuroendocrine and exocrine cancer decreased from 2019–2020, rebounded from 2020–2021, and stabilized from 2021–2022. Differences were observed by sex, race, age, and stage at diagnosis. Notably, the proportion of pancreatic cancers diagnosed at localized stage increased from 2020 to 2021.
Conclusion:
Incidence rates of pancreatic neuroendocrine and exocrine cancers have returned to pre-pandemic levels. The increase in cases diagnosed at a localized stage from 2020–2021 suggests that people resumed their routine medical care following the onset of the COVID-19 pandemic, resulting in earlier detection and diagnosis of these cancers. Continuing to monitor pancreatic cancer incidence data is essential to better understand the pancreatic cancer disease burden.
Keywords: COVID-19, exocrine, pancreatic cancer, pancreatic neuroendocrine tumor (PNET), exocrine pancreatic ductal adenocarcinoma (PDAC), United States Cancer Statistics (USCS)
Introduction
Despite overall declines in cancer incidence and mortality in the United States over the past two decades, pancreatic cancer incidence and deaths have continued to rise.1,2 Pancreatic cancer incidence increased by 1% annually from 2015–2019,1,3 and in 2022, pancreatic cancer ranked as the fifth leading cause of cancer deaths in the United States.2 Pancreatic cancer is a genetically heterogenous disease, with the two most common subtypes being pancreatic neuroendocrine tumors (PNETs) and exocrine pancreatic ductal adenocarcinomas (PDACs).4 The less aggressive nature of PNETs compared to PDACs results in higher overall 5-year survival rates for PNETs, but relative to some other cancers, the 5-year survival estimates for both pancreatic cancer types are still low.2,5,6 Given the aggressive nature of pancreatic cancer and limited treatment options, pancreatic cancer is projected to remain a leading cause of death through 2040.1,7
Starting in March 2020, the COVID-19 pandemic disrupted healthcare delivery systems, resulting in fewer diagnosed pancreatic cancer cases.8,9 In 2021, after implementation of vaccination programs and enhanced safety measures to reduce COVID-19 transmission, many patients resumed routine or postponed healthcare services.10 Given the rise in cases and the aggressive nature of this disease, it is important to assess how pancreatic diagnoses changed during the COVID-19 pandemic. This study provides the most up-to-date national incidence data on pancreatic cancer, stratified by demographic and socioeconomic characteristics, for PNETs and PDACs before, during, and after the COVID-19 pandemic. We also examine how the incidence rates of PNET and PDAC changed from 2019–2020, 2020–2021, and 2021–2022, and whether these differences were statistically significant across demographic and socioeconomic subgroups.
Methods
Data source
Data from the U.S. Cancer Statistics 2001–2022 incidence database11 were analyzed. U.S. cancer statistics data were collected by population-based central cancer registries supported by the Centers for Disease Control and Prevention's National Program of Cancer Registries or the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program and have met high-quality data standards. The incidence data cover 100% of the U.S. population.11
Patients and study design
Malignant pancreatic cancer cases diagnosed during 2019–2022 were identified using the World Health Organization's International Classification of Diseases for Oncology, Third Edition (ICD-O-3) topography codes C250-C254, C257-C259 and classified into two main subtypes: PNET (ICD-O-3 morphology codes of 8013, 8041, 8150–8156, 8158, 8240–8242, 8246, 8249, 8683) and PDAC (8000–8012, 8014–8040, 8042–8149, 8160–8231, 8243–8245, 8247, 8248, 8250–8682, 8690–8700, 8720–8790, 8971). Analyses were restricted to microscopically confirmed cases (99% of PNET and PDAC cases). Cases reported through autopsy or death certificate only were excluded.
Statistical analysis
Annual age-adjusted incidence rates were calculated using SEER*Stat software, version 9.0.40.1.12 Incidence rates were presented per 100,000 person-years and age-adjusted to the 2000 U.S. standard population. Corresponding 95% confidence intervals (CIs) were calculated using the Tiwari method.13 Percentage changes in incidence rates were calculated by dividing the difference in incidence rates between 2 consecutive years by the incidence rate of the earlier year. Rates and percentage changes were calculated for PNET and PDAC overall and by the characteristics described below.
Cases were stratified by sex, race and ethnicity, age, stage at diagnosis, county-level rural-urban classification, and county-based economic status.14 Race and ethnicity were categorized into five mutually exclusive groups: non-Hispanic American Indian or Alaska Native, non-Hispanic Asian or Pacific Islander, non-Hispanic Black, Hispanic, and non-Hispanic White. Stage at diagnosis was defined as localized, regional, distant, or unknown stage based on merged summary stage variables.14 Counties were classified as metropolitan or non-metropolitan using the U.S. Department of Agriculture Economic Research Service 2013 vintage rural-urban continuum classification scheme.15 County-based economic status was grouped into three categories based on the Appalachian Regional Commission's county economic classification:16 lowest 25% (counties categorized as at-risk or distressed), middle 25–75% (counties categorized as transitional), and highest 25% (counties categorized as attainment and competitive). This activity was reviewed by CDC and determined to be public health surveillance; thus, institutional review board was not needed.
Results
PNET
This study included 4,907; 4,701; 5,172; and 5,302 new PNET cancer cases, reported in 2019, 2020, 2021, and 2022, respectively (Table 1). The annual age-adjusted incidence rate per 100,000 persons was 1.24, 1.17, 1.27, and 1.29 for those years, respectively. The PNET incidence rate decreased by 5.8% (95% CI: −9.6, −1.8) from 2019–2020, increased by 8.8% (95% CI: 4.4, 13.3) from 2020–2021, and remained stable at 1.3% (95% CI: −2.7, 5.4) from 2021–2022.
Table 1.
Pancreatic Neuroendocrine Tumor (PNET) Age-Adjusted Incidence Rates,* Counts, and Percentage Change by Selected Characteristics † ‡— United States, 2019–2022
| 2019 | 2020 | 2019–2020 | 2021 | 2020–2021 | 2022 | 2021–2022 | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Characteristic | Count (%) | Rate (95% CI) | Count (%) | Rate (95% CI) | Rate-PC (95% CI) | Count (%) | Rate (95% CI) | Rate-PC (95% CI) | Count (%) | Rate (95% CI) | Rate-PC (95% CI) |
| Overall | 4907 (100) | 1.24 (1.21, 1.28) | 4701 (100) | 1.17 (1.13, 1.20) | −5.8 (−9.6, −1.8)§ | 5172 (100) | 1.27 (1.24, 1.31) | 8.8 (4.4, 13.3)¶ | 5302 (100) | 1.29 (1.25, 1.32) | 1.3 (−2.7, 5.4) |
| Sex | |||||||||||
| Male | 2751 (56.06) | 1.46 (1.40, 1.51) | 2748 (58.46) | 1.43 (1.37, 1.48) | −2.1 (−7.3, 3.4) | 2962 (57.27) | 1.53 (1.47, 1.58) | 7.1 (1.4, 13.0)§ | 2993 (56.45) | 1.52 (1.46, 1.57) | −0.7 (−5.8, 4.7) |
| Female | 2156 (43.94) | 1.06 (1.01, 1.11) | 1953 (41.54) | 0.95 (0.91, 0.99) | −10.4 (−15.9, −4.5)§ | 2210 (42.73) | 1.05 (1.01, 1.10) | 11.0 (4.2, 18.3) § | 2309 (43.55) | 1.10 (1.05, 1.15) | 4.2 (−2.0, 10.8) |
| Race-Ethnicity | |||||||||||
| American Indian/Alaska Native, NH | 21 (0.43) | 0.72 (0.44, 1.13) | 30 (0.64) | 1.04 (0.69, 1.50) | 43.8 (−22.3, 170.8) | 40 (0.77) | 1.35 (0.95, 1.87) | 29.9 (−22.7, 120.4) | 34 (0.64) | 1.17 (.80, 1.66) | −13.3 (−47.8, 43.4) |
| Asian Pacific Islander, NH | 191 (3.89) | 0.87 (0.75, 1.01) | 188 (4.00) | 0.82 (0.71, 0.95) | −6.1 (−23.9, 15.9) | 230 (4.45) | 0.96 (0.84, 1.10) | 17.4 (−3.9, 43.6) | 243 (4.58) | 0.99 (0.86, 1.12) | 2.2 (−15.2, 23.3) |
| Black, NH | 606 (12.35) | 1.39 (1.28, 1.51) | 597 (12.70) | 1.34 (1.23, 1.46) | −3.9 (−14.6, 8.2) | 577 (11.16) | 1.28 (1.17, 1.39) | −4.8 (−15.6, 7.3) | 634 (11.96) | 1.39 (1.28, 151) | 9.3(−2.9, 23.0) |
| Hispanic | 463 (9.44) | 0.98 (0.89, 1.08) | 472 (10.04) | 0.97 (0.88, 1.07) | −1.3 (−13.8, 13.1) | 546 (10.56) | 1.07 (0.98, 1.17) | 10.7 (−2.8, 26.1) | 582 (10.98) | 1.09 (1.00, 1.19) | 1.9 (−9.8, 15.3) |
| White, NH | 3603 (73.43) | 1.29 (1.24, 1.33) | 3376 (71.81) | 1.20 (1.15, 1.24) | −7.0 (−11.5, −2.2)§ | 3747 (72.45) | 1.32 (1.27, 1.36) | 10.2 (4.9, 15.8)§ | 3769 (71.09) | 1.31 (1.27, 1.36) | −0.6 (−5.3, 4.3) |
| Age (years) | |||||||||||
| 0–44 | 494 (10.07) | 0.23 (0.21, 0.25) | 461 (9.80) | 0.21 (0.19, 0.23) | −7.2 (−18.5, 5.6) | 539 (10.42) | 0.25 (0.23, 0.27) | 15.8 (2.0, 31.5)§ | 532 (10.03) | 0.24 (0.22, 0.26) | −3.1 (−14.3, 9.5) |
| 45–54 | 690 (14.06) | 1.65 (1.52, 1.77) | 663 (14.10) | 1.60 (1.48, 1.73) | −2.9 (−12.8, 8.3) | 690 (13.34) | 1.67 (1.54, 1.79) | 4.2 (−6.5, 16.1) | 696 (13.13) | 1.68 (1.56, 1.81) | 0.9 (−9.3, 12.3) |
| 55–64 | 1274 (25.96) | 2.94 (2.78, 3.10) | 1226 (26.08) | 2.81 (2.65, 2.97) | −4.3 (−11.6, 3.6) | 1320 (25.52) | 3.05 (2.89, 3.22) | 8.5 (.3, 17.4)§ | 1296 (24.44) | 3.02 (2.86, 3.19) | −0.8 (−8.3, 7.2) |
| 65–74 | 1517 (30.92) | 4.80 (4.56, 5.05) | 1471 (31.29) | 4.50 (4.27, 4.74) | −6.3 (−12.9, 0.8) | 1632 (31.55) | 4.83 (4.60, 5.07) | 7.4 (0.0, 15.3) | 1665 (31.40) | 4.87 (4.64, 5.11) | 0.8 (−6.0, 8.0) |
| ≥75 | 932 (18.99) | 4.74 (4.43, 5.07) | 880 (18.72) | 4.45 (4.15, 4.76) | −6.2 (−14.7, 3.3) | 991 (19.16) | 4.78 (4.48, 5.10) | 7.4 (−2.3, 18.0) | 1113 (20.99) | 5.11 (4.81, 5.43) | 7.0 (−2.1, 16.9) |
| Rural-urban continuum || | |||||||||||
| Metro counties | 4218 (86.53) | 1.27 (1.23, 1.31) | 4015 (85.73) | 1.19 (1.15, 1.23) | −6.9 (−10.9, −2.6)§ | 4425 (86.19) | 1.29 (1.25, 1.33) | 9.2 (4.5, 14.1)§ | 4535 (86.08) | 1.31 (1.27, 1.35) | 1.0 (−3.2, 5.4) |
| Non-metro counties | 655 (13.45) | 1.06 (0.98, 1.15) | 659 (14.25) | 1.08 (0.99, 1.17) | 2.4 (−8.8, 14.9) | 700 (13.77) | 1.14 (1.05, 1.24) | 6.5 (−4.9, 19.4) | 723 (13.90) | 1.17 (1.08, 1.27) | 2.5 (−8.3, 14.6) |
| County economic status^ | |||||||||||
| Lower 25% | 387 (7.89) | 1.08 (0.97, 1.20) | 370 (7.87) | 1.04 (0.93, 1.15) | −4.1 (−17.6, 11.5) | 386 (7.46) | 1.10 (0.99, 1.22) | 5.8 (−9.1, 23.2) | 414 (7.81) | 1.08 (0.97, 1.19) | −1.6 (−15.1, 14.1) |
| Middle 25%-75% | 2730 (55.63) | 1.21 (1.17, 1.26) | 2536 (53.95) | 1.14 (1.10, 1.19) | −5.9 (−11.0, −0.5)§ | 2695 (52.11) | 1.22 (1.17, 1.27) | 6.7 (0.8, 12.9)§ | 2762 (52.09) | 1.27 (1.23, 1.32) | 4.5 (−1.1, 10.4) |
| Highest 25% | 1742 (35.50) | 1.33 (1.27, 1.40) | 1758 (37.40) | 1.25 (1.19, 1.31) | −6.2 (−12.5, 0.4) | 2033 (39.31) | 1.39 (1.33, 1.45) | 10.9 (3.8, 18.5)§ | 2070 (39.04) | 1.36 (1.30, 1.42) | −2.2 (−8.2, 4.3) |
Abbreviations: PNET = pancreatic neuroendocrine tumor, CI = confidence interval, NH = non-Hispanic
Rates represent the number of cases per 100,000 persons and are age-adjusted to the 2000 U.S. standard population (19 age groups—US Census P25-1130).
Incidence data are compiled from central cancer registries supported by the Centers for Disease Control and Prevention's National Program of Cancer Registries or the National Cancer Institute's Surveillance, and Epidemiology and End Results (SEER) Program and have met high-quality data criteria for all years, 2019–2022. The incidence data cover 100% of the U.S. population.
Characteristic values with other, missing, or blank results are not included in this table. Total counts may not match.
Differences in rates were significant at P<.05.
Defined based on U.S. Department of Agriculture Economic Research Service 2013 Rural-Urban Continuum Codes. Rural-urban Continuum data for Kansas are not available.
This variable is based on the Appalachian Regional Commission's County economic classification. The variable is defined as: lower 25%-at risk and distressed, Middle 25%-75%-transitional; Highest 25%-attainment and competitive. Due to incomplete county information, data from Kansas was excluded from this analysis.
Compared to men, women had a larger decrease in PNET incidence rates from 2019–2020 and a larger increase from 2020–2021. By race and ethnicity, rates changed significantly only among non-Hispanic White persons; in this group, incidence fell by 7.0% (95% CI: −11.5, −2.2) from 2019–2020, rose by 10.2% (95% CI: 4.9, 15.8) from 2020–2021, and remained stable from 2021–2022. By age, the largest change occurred among persons aged 0–44 years, with rates increasing by 15.8% (95% CI: 2.0, 31.5) from 2020–2021; the change in rates from 2019–2020, although not significant, was also highest in this age group (7.2% [95% CI: −18.5, 5.6]).
Compared to nonmetropolitan counties, metropolitan counties had a larger decrease in 2020 and a larger increase in 2021. Rates were stable from 2021–2022 in counties with the lowest economic status; increased from 2020–2021 and increased (non-significantly) from 2021–2022 in counties with transitional economic status; increased from 2020–2021 and although not significant, decreased from 2020–2021 in counties with the highest economic status.
By stage at diagnosis, approximately half of PNET cases were diagnosed at the localized stage, 16% at the regional stage, and 31% at the distant stage in 2019 (Figure 1). From 2019–2020, the percentage diagnosed at the distant stage increased to 32%, concurrent with a decrease in cases with unknown stage (data not shown); however, this proportion decreased to 29% in both 2021 and 2022. In contrast, the percentage diagnosed at the localized stage increased from 51% in 2020 to 54% in both 2021 and 2022.
Figure 1.
Distribution of Pancreatic Neuroendocrine Tumor (PNET) by Stage at Diagnosis and Year of Diagnosis, United States, 2019–2022
Source: US Cancer Statistics. Stage at diagnosis was categorized as localized, regional, or distant based on directly coded SEER summary stage. The percentage of cases diagnosed at unknown stage was 4.2% in 2019, 3.4% in 2020, 3.2% in 2021, and 3.0% in 2022. Bars represent the percentage of cases diagnosed at each stage. The numbers between bars represent one-year percentage change in these percentages, with arrows representing increase or decrease.
Exocrine Cancer
In 2019, 2020, 2021, and 2022, there were 43,735; 43,517; 45,369; and 45,733 new pancreatic exocrine cancer cases, respectively (Table 2). The annual age-adjusted incidence rate per 100,000 persons was 10.64, 10.38, 10.66, and 10.51 for those years, respectively. Age-adjusted incidence rates decreased by 2.5% (95% CI: −3.8, −1.2) in 2020, increased by 2.7% (95% CI: 1.3, 4.1) in 2021, and decreased by −1.5% (95% CI: −2.8, −0.1) in 2022. This pattern of decline from 2019–2020 and increase from 2020–2021 was seen across nearly all demographic subgroups.
Table 2.
Pancreatic Exocrine Cancer Age-Adjusted Incidence Rates,* Counts, and Percentage Change by Selected Characteristics† ‡— United States, 2019–2022
| 2019 | 2020 | 2019–2020 | 2021 | 2020–2021 | 2022 | 2021–2022 | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Characteristic | Count (%) | Rate (95% CI) | Count (%) | Rate (95% CI) | Rate-PC (95% CI) | Count (%) | Rate (95% CI) | Rate-PC (95% CI) | Count (%) | Rate (95% CI) | Rate-PC (95% CI) |
| Overall | 43 735 (100) | 10.64 (10.54, 10.75) | 43 517 (100) | 10.38 (10.28, 10.48) | −2.5 (−3.8, −1.2)§ | 45 369 (100) | 10.66 (10.56, 10.76) | 2.7 (1.3, 4.1)§ | 45 733 (100) | 10.51 (10.41, 10.60) | −1.5 (−2.8, −0.1)§ |
| Sex | |||||||||||
| Male | 22 861 (52.27) | 12.06 (11.90, 12.22) | 22 739 (52.25) | 11.73 (11.57, 11.89) | −2.7 (−4.6, −0.9)§ | 23 602 (52.02) | 12.03 (11.88, 12.19) | 2.6 (0.7, 4.5)§ | 23 737 (51.90) | 11.81 (11.66, 11.97) | −1.8 (−3.6, 0.0) |
| Female | 20 874 (47.73) | 9.43 (9.30, 9.56) | 20 778 (47.75) | 9.24 (9.11, 9.37) | −2.0 (−3.9, 0.0)§ | 21 767 (47.98) | 9.51 (9.38, 9.64) | 3.0 (1.0, 5.0)§ | 21 996 (48.10) | 9.41 (9.29, 9.54) | −1.1 (−2.9, 0.9) |
| Race-Ethnicity | |||||||||||
| American Indian/Alaska Native, NH | 265 (0.61) | 9.49 (8.33, 10.76) | 299 (0.69) | 10.79 (9.55, 12.14) | 13.7 (−4.6, 35.7) | 281 (0.62) | 9.56 (8.44, 10.79) | −11.4 (−25.4, 5.4) | 276 (0.60) | 8.99 (7.93, 10.15) | −6.1 (−21.2, 12.0) |
| Asian Pacific Islander, NH | 1553 (3.55) | 7.51 (7.13, 7.90) | 1603 (3.68) | 7.34 (6.98, 7.71) | −2.3 (−9.1, 5.0) | 1774 (3.91) | 7.86 (7.49, 8.24) | 7.1 (−0.1, 14.8) | 1830 (4.00) | 7.69 (7.34, 8.06) | −2.1 (−8.5, 4.6) |
| Black, NH | 5415 (12.38) | 12.67 (12.33, 13.03) | 5420 (12.45) | 12.38 (12.04, 12.72) | −2.3 (−6.1, 1.6) | 5686 (12.53) | 12.81 (12.47, 13.16) | 3.5 (−0.4, 7.6) | 5780 (12.64) | 12.65 (12.32, 13.00) | −1.2 (−4.9, 2.6) |
| Hispanic | 3947 (9.02) | 9.66 (9.35, 9.98) | 3882 (12.45) | 9.02 (8.73, 9.32) | −6.6 (−10.9, −2.2)§ | 4267 (9.40) | 9.44 (9.15, 9.74) | 4.7 (0.0, 9.6)§ | 4420 (9.66) | 9.52 (9.23, 9.82) | 0.9 (−3.5, 5.4) |
| White, NH | 32 407 (74.10) | 10.65 (10.54, 10.77) | 32 144 (73.87) | 10.43 (10.32, 10.55) | −2.1 (−3.6, −0.5)§ | 33 131 (73.03) | 10.62 (10.51, 10.74) | 1.8 (0.2, 3.5)§ | 33 229 (72.66) | 10.50 (10.38, 10.61) | −1.2 (−2.7, 0.4) |
| Age (years) | |||||||||||
| 0–44 | 794 (1.82) | 0.37 (0.35, 0.40) | 825 (1.90) | 0.38 (0.35, 0.41) | 2.1 (−7.5, 12.8) | 955 (2.10) | 0.44 (0.41, 0.47) | 15.0 (4.6, 26.5)§ | 954 (2.09) | 0.44 (0.41, 0.47) | 0.6 (−8.2, 10.2) |
| 45–54 | 3066 (7.01) | 7.23 (6.97, 7.49) | 2894 (6.65) | 6.87 (6.62, 7.12) | −5.0 (−9.8, 0.0)§ | 2979 (6.57) | 7.10 (6.85, 7.36) | 3.4 (−1.8, 8.9) | 2869 (6.27) | 6.86 (6.61, 7.12) | −3.3 (−8.2, 1.8) |
| 55–64 | 9960 (2.28) | 22.76 (22.31, 23.21) | 9684 (22.25) | 22.08 (21.64, 22.52) | −3.0 (−5.7, −0.2)§ | 9833 (21.67) | 22.48 (22.04, 22.93) | 1.8 (−1.0, 4.7) | 9697 (21.20) | 22.3 (21.86, 22.75) | −0.8 (−3.6, 2.1) |
| 65–74 | 15 172 (34.69) | 47.71 (46.95, 48.84) | 15 490 (35.60) | 46.95 (46.21, 47.69) | −1.6 (−3.8, −0.6) | 16 195 (35.70) | 47.40 (46.67, 48.14) | 1.0 (−1.3, 3.2) | 16 246 (35.52) | 47.14 (46.42, 47.88) | −0.5 (−2.7, 1.7) |
| ≥75 | 14 743 (33.71) | 70.73 (69.54, 71.94) | 14 624 (33.61) | 69.02 (67.85, 70.19) | −2.4 (−4.7, −0.1)§ | 15 407 (33.96) | 71.3 (70.13, 72.48) | 3.3 (0.9, 5.8)§ | 15 967 (34.91) | 69.68 (68.57, 70.81) | −2.3 (−4.5, 0.0) |
| Rural-urban continuum || | |||||||||||
| Metro counties | 36 501 (84.04) | 10.70 (10.59, 10.81) | 36 403 (84.18) | 10.44 (10.33, 10.55) | −2.4(−3.9, −1.0)§ | 38 126 (84.56) | 10.76 (10.65, 10.87) | 3.0 (1.5, 4.5)§ | 38 394 (84.49) | 10.57 (10.46, 10.68) | −1.7 (−3.1, −0.3)§ |
| Non-metro counties | 6847 (15.96) | 10.45 (10.20, 10.71) | 6748 (15.81) | 10.12 (9.87, 10.37) | −3.1 (−6.4, 0.3) | 6885 (15.43) | 10.26 (10.01, 10.52) | 1.1 (−2.3, 4.7) | 6968 (15.49) | 10.25 (10.00, 10.50) | 0.0 (−3.4, 3.5) |
| County economic status^ | |||||||||||
| Lower 25% | 3989 (9.12) | 10.54 (10.21, 10.88) | 3638 (8.36) | 9.79 (9.47, 10.12) | −7.1 (−11.3, −2.7)§ | 3851 (8.49) | 10.32 (9.99, 10.67) | 5.4 (0.6, 10.5)§ | 4164 (9.11) | 10.15 (9.84, 10.47) | −1.7 (−6.0, 2.9) |
| Middle 25%-75% | 24 899 (56.93) | 10.62 (10.49, 10.76) | 24 455 (56.20) | 10.51 (10.38, 10.65) | −1.1 (−2.8, 0.7) | 24 896 (54.87) | 10.76 (10.62, 10.90) | 2.4 (0.5, 4.2)§ | 24 511 (53.60) | 10.67 (10.53, 10.81) | −0.8 (−2.6, 1.0) |
| Highest 25% | 14 359 (32.83) | 10.73 (10.55, 10.91) | 14 961 (34.38) | 10.35 (10.19, 10.53) | −3.5 (−5.7, −1.2)§ | 16 162 (35.62) | 10.64 (10.47, 10.81) | 2.8 (0.4, 5.1)§ | 16 602 (36.30) | 10.39 (10.23, 10.55) | −2.4 (−4.5, −0.2)§ |
Abbreviations: PNET = pancreatic neuroendocrine tumor, CI = confidence interval, NH = non-Hispanic
Rates represent the number of cases per 100,000 persons and are age-adjusted to the 2000 U.S. standard population (19 age groups—US Census P25-1130).
Incidence data are compiled from central cancer registries supported by the Centers for Disease Control and Prevention's National Program of Cancer Registries or the National Cancer Institute's Surveillance, and Epidemiology and End Results (SEER) Program and have met high-quality data criteria for all years, 2019–2022. The incidence data cover 100% of the U.S. population.
Characteristic values with other, missing, or blank results are not included in this table. Total counts may not match.
Differences in rates were significant at P<.05.
Defined based on U.S. Department of Agriculture Economic Research Service 2013 Rural-Urban Continuum Codes. Rural-urban Continuum data for Kansas are not available.
This variable is based on the Appalachian Regional Commission's County economic classification. The variable is defined as: lower 25%-at risk and distressed, Middle 25%-75%-transitional; Highest 25%-attainment and competitive. Due to incomplete county information, data from Kansas was excluded from this analysis.
Men had a larger decline in incidence from 2019–2020 (−2.7%; 95% CI: −4.6, −0.9) and from 2021–2022 (non-significant, −1.8; 95% CI: −3.6, 0.0) than women, whereas women experienced a larger increase from 2020–2021 (3.0; 95% CI: 1.0, 5.0) than men.
Statistically significant declines from 2019–2020 were seen among Hispanic persons −6.6% (95% CI: −10.9%, −2.2%) and non-Hispanic White persons −2.1% (95% CI: −3.6, −0.5). By 2021, incidence increased by 4.7% (95% CI: 0.0, 9.6) among Hispanic persons and by 1.8% (95% CI: 0.2, 3.5) among non-Hispanic White persons.
By age, statistically significant declines from 2019–2020 were seen among most age groups, except among those aged 0–44 and 65–74 years. Among those aged 0–44 years, incidence was stable at 2.1% (95% CI: −7.5, 12.8) from 2019–2020, increased by 15.0% (95% CI: 4.6, 26.5) from 2020–2021, and remained stable (0.6%; 95% CI: −8.2, 10.2) from 2021–2022. For economic status, counties categorized as at-risk and distressed experienced the largest changes in incidence.
On average, the distribution of cases by stage at diagnosis was relatively stable, with approximately 15% diagnosed at the localized stage, 31% at the regional stage, and 50% at the distant stage. However, the percentage of localized cases increased by 4.7% from 2020–2021 and was slightly higher in 2022 (15.6%) than in 2019 (14.7%) (Figure 2).
Figure 2.
Distribution of Pancreatic Exocrine Cancer by Stage at Diagnosis and Year of Diagnosis, United States, 2019–2022
Source: US Cancer Statistics. Stage at diagnosis was categorized as localized, regional, or distant based on directly coded SEER summary stage. The percentage of cases diagnosed at unknown stage was 4.2% in 2019, 3.4% in 2020, 3.2% in 2021, and 3.0% in 2022. Bars represent the percentage of cases diagnosed at each stage. The numbers between bars represent one-year percentage change in these percentages, with arrows representing increase or decrease.
Discussion
Using the most recent U.S. cancer statistics data, we found that PNETs and PDACs followed similar incidence patterns in the years before and after the COVID-19 pandemic with incidence decreasing from 2019–2020 and increasing from 2020–2021. These changes correspond to disruptions in health care due to the COVID-19 pandemic and are similar to patterns observed for other cancer sites, including female breast cancer, which in 2021 showed evidence of making up for previous missed cases.9 While our study also confirms past evidence that pancreatic incidence has rebounded to pre-pandemic levels,17,18 our study further expands on how the COVID-19 pandemic impacted the different histological subtypes of pancreatic cancer.
PNET incidence decreased from 2019–2020, increased from 2020–2021, and stabilized from 2021–2022. The increase in PNET incidence from 2020–2021 was higher than the observed decrease from 2019–2020. Because some PNETs produce symptoms and are identified during diagnostic or incidental imaging,19,20 disruptions in routine care during the onset of the COVID-19 pandemic may have resulted in missed PNET diagnoses in 2020.21 Results from our study showed that PNET incidence rebounded to pre-pandemic levels in 2021 and 2022; one explanation may be that as restrictions lifted, vaccinations became available, and safety measures were adopted, routine care resumed and patients who could not access care at the onset of the pandemic may have been able to get the care they needed.
Similar to PNETs, PDAC incidence decreased in 2020 and increased in 2021. However, the clinical context between PNETs and PDACs differs. While PNETs are less aggressive and can produce symptoms at earlier stages,19,20 PDAC is extremely aggressive and typically remains asymptomatic until advanced stages.22,23 This, together with the absence of recommended universal screening guidelines for pancreatic cancer, makes early detection less likely.24,25 One exception is the management of high-risk individuals, including those with a strong family history of pancreatic cancer and specific hereditary cancer syndromes/germline mutations, such as hereditary gastrointestinal cancer syndromes.24,25 The American College of Gastroenterology recommends surveillance for these patients to minimize the risk of developing pancreatic cancer or to enable earlier detection.25 Although stay-at-home orders in 2020 may have disrupted services for these high-risk patients and other pancreatic cancer patients, we observed a 4.7% increase in localized-stage diagnoses from 2020–2021, suggesting that as restrictions lifted, resumption of surveillance and healthcare use captured more cases at earlier stages.
We observed differences by sex for PNET and PDAC. Although males had higher rates than females, from 2020–2021, rates among females increased more than among males. Previous time trend research also revealed that incidence rates of pancreatic cancer increased slightly faster among females (6% per year) compared to males (4% per year).26
Although pancreatic cancer is diagnosed predominantly in older adults, accumulating evidence suggests rising incidence among younger individuals.26–30 An analysis of data covering 55% of the U.S. population showed that pancreatic cancer is increasing faster among younger female patients, with the steepest rate increase in the younger age groups.28 Several studies suggest that obesity-related health conditions, cigarette smoking, and alcohol use may be the reasons for this upward trend among younger patients.27,30,31,32 We also observed age-related differences from 2020–2021, with the highest change in incidence among those aged 0–44 years for both cancer types. Among those aged <45 years, the increase in PNET incidence exceeded the observed decrease during the COVID-19 pandemic, and PDAC rates did not drop during any of the years as they did for other age groups.
Stage distribution for PNETs and PDACs followed similar patterns: Distant-stage cases increased from 2019–2020 and localized-stage cases increased from 2020–2021. The pattern change in stage distribution could reflect the stay-at-home orders during the COVID-19 pandemic followed by the subsequent resumption of healthcare services during the following years. These results suggest that despite the stay-at-home orders during the pandemic, patients with more advanced disease continued to seek and receive care, and as restrictions lifted and routine care resumed, the detection of earlier stage pancreatic cancers rebounded. This pattern is particularly important for pancreatic exocrine cancer, given its aggressiveness, the projected rise in future cases, and the small percentage of patients being diagnosed at localized stages. Continued surveillance of pancreatic cancer incidence and stage distribution may result in improved health outcomes.
Limitations
This study has at least three limitations. First, the most recent national data include cases diagnosed only through 2022. This brief period following the initial onset of the COVID-19 pandemic is too short to draw a complete picture of pancreatic incidence during the COVID-19 pandemic. As more data becomes available, we will gain a better understanding of how cancer incidence changed. Second, the delayed reporting of pancreatic cancer cases—specifically, the time between diagnosis and reporting to cancer registries—may have resulted in under-ascertainment of cases during this time. Changes to the case count could lead to variations in our analysis. Additional years of data will help us further understand the effect of the COVID-19 pandemic on pancreatic cancer incidence. Lastly, there may be some reporting delays which would affect the pancreatic cancer incidence counts.33
Conclusion
Disruption of healthcare delivery systems and the postponement of medical services during the COVID-19 pandemic resulted in a decrease in incidence for many cancers.21,34 A study of SEER data found that for some cancer sites, the number of diagnoses reported has begun to rebound.9 Our data suggest that by 2022, PNET and PDAC incidence had returned to pre-COVID-19 pandemic levels. Furthermore, the increase in the percentage of localized pancreatic cancers in the year following the COVID-19 pandemic highlights the importance of returning to routine medical care. Continued surveillance of pancreatic cancer may improve health outcomes.
Acknowledgments
We acknowledge state and regional cancer registry and health department personnel.
Footnotes
The findings and conclusions are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
This research was supported in part by an appointment (S Bock) to the Research Participation Program at CDC administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the U.S. Department of Energy and CDC.
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