ORIGINAL ARTICLE
The Current State of Pancreatic Cancer in Canada
Incidence, Mortality, and Surgical Therapy
Scott Hurton, MD, Frank MacDonald, MD, Geoff Porter, MD, MSc, Mark Walsh, MD, MSc,
and Michele Molinari, MD, MSc
Objective: This study aimed to evaluate the trends in the incidence,
survival, and surgical therapy for Canadian patients affected by pancre-
atic cancer (PC).
Methods: The incidence, mortality, number of resections, and out-
comes of patients with PC stratified by year, sex, and province were
extracted from Canadian cancer databases.
Results: In 2012, PC was diagnosed in 4600 Canadians and it was
responsible for 4300 deaths. The age-standardized incidence was 9 to
10 new cases per 100,000 individuals. The mortality rate remained the
highest among all the solid tumors with a case-to-fatality ratio of 0.93.
The age-standardized 5-year relative survival was 9.1% (95% confi-
dence interval [CI], 8.3Y10). There were geographic variations among
provinces with the highest survival registered in Ontario (10.9%; 95%
CI, 9.9Y12) and the lowest survival reported in Nova Scotia (4.7%; 95%
CI, 2.8Y7.2). The percentage of patients who underwent surgery de-
creased from 19% (2006Y2007) to 17% (2009Y2010). Pancreatic resec-
tions were performed in high-volume centers in 74% of cases. In-hospital
mortality was 5%, 93% of patients were discharged home, and 36% of
patients required home support after discharge.
Conclusions: Long-term outcomes of Canadian patients affected by PC
remain unsatisfactory, with only 9% of the patients surviving at 5 years.
Surgical therapy was performed only in 17% to 19% of patients.
Key Words: pancreatic cancer, epidemiology, Canada, incidence,
therapy, survival
Abbreviations: ASMR - age-standardized mortality rate,
CCDPC - Centre for Chronic Disease Presenting and Control,
PC - pancreatic cancer, PHAC - Public Health Agency of Canada
(Pancreas 2014;43: 879Y885)
P ancreatic adenocarcinoma, represents the majoirity of pan-
creatic cancers (PC) and it is the fourth leading cause of
cancer-related deaths in North America, with a case-to-fatality
ratio of 0.91.1Y5 The adjusted incidence of PC in the United
States was 10.8 to 11.3 per 100,000 individuals during the pe-
riod between 1988 and 2002.6 Similar data were reported in
Canada where the age-standardized incidences were 9.8 for men
and 8.4 for women per 100,000.4 Progressive weight loss, an-
orexia, abdominal pain, and jaundice are the most common
clinical presentations.7,8 Contrary to many other cancers, the
From the Department of Surgery, Dalhousie University, Halifax, Nova
Scotia, Canada.
Received for publication October 25, 2013; accepted February 24, 2014.
Reprints: Michele Molinari, MD, MSc, Room 6-302 Victoria Bldg, 1276
South Park St, Halifax, Nova Scotia, Canada, B3H 2Y9
(e<mail: Michele.molinari@cdha.nshealth.ca).
The authors declare no conflict of interest.
Copyright * 2014 by Lippincott Williams & Wilkins
Pancreas & Volume 43, Number 6, August 2014
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outcomes for PC remain unsatisfactory. The median survival of
patients with PC is 4 months and in the presence of metastatic
disease is only 60 to 90 days.9 The poor prognosis has not
significantly improved over the last decades mostly because
available cytotoxic agents and radiation therapy have a negli-
gible impact on patients’ survival.10 Surgery remains the only
curative therapy but feasible only for 10% to 20% of patients
who present with localized disease.11
Tumor biology, poor response to chemoradiotherapy, and
early metastases contribute to the poor survival of patients with
PC.12 It also seems that the persistent lack of confidence in the
available therapies continues to hinder the long-term outcomes
of PC and many patients do not receive adequate care. Bilimoria
et al13 have shown that up to 38% of patients with early-stage
tumors and no identifiable contraindication to surgery did not
undergo resection because of failure of proper referral. Another
study showed that PC continues to have the lowest rate of cancer-
directed therapy among common tumors.14
This lack of confidence in the surgical and medical therapy
for PC was partially justified in past decades when the perioper-
ative mortality of pancreatic resections was significant.15 In more
recent times, there has been a considerable drop in perioperative
mortality to less than 3% in specialized centers16,17 with long-
term survival up to 30%.12,17
However, these outcomes may not reflect the reality at a
population level. In North America, most of the epidemiologi-
cal studies on PC are from the United States.6,18Y22 Except for
a few publications,4,23,24 there is a lack of population-based studies
on PC in Canada. Therefore, the main purpose of this review is to
report the Canadian statistics on the incidence, survival, and sur-
gical therapy for patients affected by PC.
DATA EXTRACTION
The data reported in the article were extracted from annual
reports provided by Statistics Canada, Public Health Agency of
Canada (PHAC), and Canadian Cancer Statistics. These agencies
collect data on the incidence, mortality, number of pancreatic re-
sections, outcomes after surgical therapy, and overall survival of
patients with PC at a national and provincial level in Canada.25
For the surgical care provided to Canadians diagnosed with PC,
the Hospital Morbidity Database at the Canadian Institute for
Health Information was used as the source of information be-
cause it is a national database that captures administrative, clini-
cal, and demographic information on inpatients from all acute
care hospitals in Canada.
The diagnosis of PC was made using the International
Classification of Diseases for Oncology,26 and causes of death
were classified according to the International Statistical Classifi-
cation of Diseases and Related Health Problems, 10th Revision.27
The incidence and mortality data were obtained from the PHAC at
Chronic Disease Infobase Data Cubes (http://66.240.150.17/
cubes/data-cubes-eng.html; last accessed October 22, 2013) and
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Hurton et al Pancreas & Volume 43, Number 6, August 2014

TABLE 1. Estimated New Cases of All Cancers and PC by Sex and Geographic Region (2012)

New Cases (Males)

Canada* BC AB SK MB ON QC* NB NS PEI NL*
All cancers 97,600 12,500 8800 2900 3100 37,300 24,500 2700 3200 510 1750
Pancreas 2200 300 200 65 70 810 610 60 70 10 25
New Cases (Females)
All cancers 88,800 10,800 7400 2600 3000 35,000 23,100 2200 2800 370 1400
Pancreas 2300 280 210 75 75 780 720 70 75 10 20
New cases for all cancers excluded nonYmelanoma skin cancer (basal and squamous).
*The actual data used to calculate the projected overall 2012 estimates were underestimated for this province.
Analysis by the Chronic Disease Surveillance and Monitoring Division, CCDPC, and Public Agency of Canada.
Data source by Canadian Cancer Registry database at Statistics Canada.
AB indicates Alberta; BC, British Columbia; MB, Manitoba; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia; ON,
Ontario; PEI, Prince Edward Island; QC, Quebec; SK, Saskatchewan.

from the Canadian Cancer Statistics 2012.28 Relative survival was
estimated as the ratio of observed survival in a population to the
expected or background survival rate.
All comparisons and data analysis reported in the article
had been conducted by the Chronic Disease Surveillance and
Monitoring Division of the Centre for Chronic Disease Present-
ing and Control (CCDPC), part of the PHAC.
INCIDENCE OF PC IN CANADA
In 2012, PC was diagnosed in 4600 Canadians, represent-
ing 2.3% and 2.6% of all newly diagnosed malignancies for men
and women, respectively (Table 1). The age-standardized inci-
dence of PC was equivalent for the 2 sexes, with 10 new cases for
men and 9 new cases for women per 100,000 individuals per year.
The estimated incidence rates differed by geographic areas, with
the highest values for both sexes recorded in the Atlantic Prov-
inces (Newfoundland and Labrador, Prince Edward Island, Nova
Scotia, New Brunswick; Table 2). Similarly to other solid tumors,
the incidence of PC depended on the age of the population be-
cause it ranged from 0.4 new cases for Canadians younger than
35 years up to 92 per 100,000 individuals for Canadians older
than 85 years (Fig. 1). During the period between 1992 and 2007,
the age-standardized incidence of PC in Canada ranged between
10 and 12 for men and 9.8 to 11.8 for women per 100,000 in-
dividuals (Fig. 2). Over the period from 1998 to 2007, annual per-
cent change in age-standardized incidence of PC decreased by
0.3% for men and increased by 0.4% for women.
LIFETIME PROBABILITY OF DEVELOPING
PC IN CANADA
In 2011, PC represented the 14th most frequent cancer for
both sexes, with a lifetime probability of 1.3% (1 individual in
76 Canadians).
MORTALITY OF PC IN CANADA
In 2012, PC represented the fourth cause of cancer-related
mortality in Canada with 4300 deaths. The mortality rate re-
mained the highest among all the solid tumors with a case-to-
fatality ratio of 0.93. Pancreatic cancer was responsible for 5.4%
of all cancer-related deaths, with an age-standardized mortality
rate (ASMR) of 10 for men and 8 for women for 100,000 in-
dividuals (Table 3). When stratified by Canadian provinces, mor-
tality rates ranged between 9 and 12 for men and 6 and 9 for
women with the highest values recorded in the Atlantic Provinces
for both sexes. From 1983 to 2012, the ASMRs for men

TABLE 2. Age-Standardized Incidence Rates for All Types of Cancer and PC by Sex and Geographic Region in Canada in 2012

Males
Canada* BC AB SK MB ON QC* NB NS PEI NL*
All cancers 456 413 442 449 425 459 474 523 498 528 485
Pancreas 10 0 10 10 10 10 12 12 10 12 7
Females
All cancers 368 324 335 354 354 382 383 379 383 337 359
Pancreas 9 8 9 9 8 8 11 10 9 8 4
New cases for all cancers exclude nonYmelanoma skin cancer (basal and squamous).
*The actual data used to calculate the projected overall 2012 estimates were underestimated for this province.
Analysis by the Chronic Disease Surveillance and Monitoring Division, CCDPC, and Public Agency of Canada.
Data source by Canadian Cancer Registry database at Statistics Canada.
AB indicates Alberta; BC, British Columbia; MB, Manitoba; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia; ON,
Ontario; PEI, Prince Edward Island; QC, Quebec; SK, Saskatchewan.

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Pancreas & Volume 43, Number 6, August 2014 Pancreatic Cancer in Canada

FIGURE 1. Incidence of PC stratified by age groups in Canada. Most cases of PC in Canada affect individuals older than 60 years
(data reported by Statistics Canada for the year 2007).

FIGURE 2. National trend of the age-standardized incidence of PC in Canada during the period 1992 to 2012 stratified by sex.

TABLE 3. Age-Standardized Mortality Rates for All Types of Cancer and PC by Sex and Geographic Region (2012)

Males
Canada* BC AB SK MB ON QC* NB NS PEI NL*
All cancers 184 167 174 187 197 177 198 193 223 195 230
Pancreas 10 10 9 10 10 9 10 12 12 10 9
Females
All cancers 368 324 335 354 354 382 383 379 383 337 359
Pancreas 8 8 9 7 7 7 9 9 9 6 6
New cases for all cancers exclude nonYmelanoma skin cancer (basal and squamous).
*The actual data used to calculate the projected overall 2012 estimates were underestimated for this province.
Analysis by the Chronic Disease Surveillance and Monitoring Division, CCDPC, and Public Agency of Canada.
Data source by Canadian Cancer Registry database at Statistics Canada.
AB indicates Alberta; BC, British Columbia; MB, Manitoba; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia; ON,
Ontario; PEI, Prince Edward Island; QC, Quebec; SK, Saskatchewan.

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Hurton et al Pancreas & Volume 43, Number 6, August 2014

FIGURE 3. National trend of the ASMR of PC in Canada during the period 1983 to 2012 stratified by sex.

decreased from 12.9 per 100,000 individuals to 9.8 per 100,000
individuals (Fig. 3). On the other hand, the ASMR for women
remained nearly unchanged with 8.5 deaths per 100,000 in-
dividuals in 1983 and 7.8 deaths per 100,000 individuals in
2012 (Fig. 3).
LIFETIME PROBABILITY OF DYING
OF PC IN CANADA
In 2011, the lifetime probability of dying of PC in Canada
was 1.4% (1 individual over 77).
SURVIVAL
From 2005 to 2007, the age-standardized 5-year relative
survival of Canadians affected by PC was 9.1% (95% confi-
dence interval [CI]; 8.3Y10). There were geographic variations
among the Canadian provinces, with the highest survival reg-
istered in Ontario (10.9%; 95% CI, 9.9Y12) and the lowest sur-
vival reported in Nova Scotia (4.7%; 95% CI, 2.8Y7.2; Fig. 4).
From the data collected up to 2006, the predicted relative
survival ratio of Canadians diagnosed with PC (age, 15Y99
years) was 21% (95% CI, 21Y22) at 1 year, 8% (95% CI, 8Y9)
at 3 years, and 6% (95% CI, 6Y7) at 5 years. When the age-
specific 5-year survival was analyzed comparing different age
groups at 2 separate periods (1992Y1994 vs 2005Y2007), younger
patients (age, 15Y44 years) had considerable better outcomes
than older patients (age, 65Y74 years; Fig. 5). Despite some
progress in the 5-year survival, PC continues to have the lowest
5-year relative survival for both men (5.4%) and women (5.9%)
among other common tumors in Canada.
SURGICAL THERAPY
During the years 2006 to 2010, the number of patients
undergoing surgical resection remained unchanged despite the
increasing number of Canadians diagnosed with PC (Fig. 6).
The percentage of patients who underwent surgery decreased
from 19% during the period 2006 to 2007 to 17% during the

FIGURE 4. During the period from 2005 to 2007, the age-standardized 5-year relative survival of Canadians affected by PC was 9.1%
(95% CI, 8.3Y10). There were geographic variations of the age-standardized 5-year survival among the Canadian provinces with the
highest survival registered in Ontario (10.9%; 95% CI, 9.9Y12) and the lowest survival reported in Nova Scotia (4.7%; 95% CI, 2.8Y7.2).

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Pancreas & Volume 43, Number 6, August 2014 Pancreatic Cancer in Canada

FIGURE 5. Age-specific 5-year survival stratified by age at 2 separate periods in the Canadian population (1992Y1994 vs 2005Y2007).

period 2009 to 2010. Most pancreatic resections (74%) occurred
in hospitals where more than 20 resections were performed
per year.29 Among all the resected patients, 93% were discharged
home, 36% of patients required some support for their care or
housing after their discharge, and 5% died while still in hospital
from perioperative complications.
DISCUSSION
Canada is one of the few nations in the world with a cancer
registry system that can be used to analyze trends and patterns
and compare outcomes across the nation. It is estimated that in
2012, 1 in 3 to 4 Canadians died of cancer.30
Age is a significant risk factor for many common tumors,4
and it is expected that Canada will experience a significant in-
crease of the number of patients with malignancies and sub-
sequent health care costs in the near future because of the
increased life expectancy observed during the last decades.31 As
an example, the life expectancy of the Canadian population is
currently 77 years for men and 82 years for women in comparison
with 59 and 61 years, respectively in 1920.32 Canadians older than
65 years will represent 25% of the entire population by 2031.33
Similarly to other developed countries, gastrointestinal ma-
lignancies represent one of the most common tumors affecting
Canadians.34 Among all the gastrointestinal tumors, PC is the
second most frequent malignancy after colorectal cancer.28,34
When compared with colorectal cancer where 40% of all pa-
tients die of the disease, the mortality rate of PC is still more
than double (93%).
One of the interesting findings of the current Canadian
Cancer Statistics is that the age-standardized mortality of PC has
decreased. This trend was more significant for men than for women.
The age-standardized mortality for men dropped from 12.9 per
100,000 in 1983 to 9.8 per 100,000 in 2012. On the other hand,
the mortality for women has remained unchanged with 8.5 deaths
per 100,000 in 1983 and 7.8 deaths per 100,000 in 2012. One of
the possible explanations is the fact that cigarette smoking during
the same period has become less prevalent in men. For example,
during the years 1994 to 1995, 8.7% of Canadians were smokers
in comparison with 3.7% in 2010 to 2011.35

FIGURE 6. During the years 2006 to 2010, the number of patients undergoing surgical resection in Canada remained stable despite
the increasing number of Canadians diagnosed with PC. The percentage of patients who underwent surgery with curative intent
decreased from 19% during the period 2006 to 2007 to 17% during the period 2009 to 2010.

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Hurton et al
Several epidemiological studies have confirmed that ciga-
rette smoking is one of the well-known risk factor for PC.9,18,36
Other risk factors are poor nutrition,21,36Y38 obesity,36Y38 poor
fitness level,22,39 sedentary lifestyle,19,21,40 and genetic predis-
position.21,23,41 Conversely, eating fruits and vegetables seems
to have a protective effect.19,21,39,40 Our study has shown that in
the 4 Atlantic Canadian provinces (Newfoundland and Labrador,
Prince Edward Island, Nova Scotia, and New Brunswick), not
only was the incidence of patients with PC the highest in Canada
but also the age-standardized 5-year survival was the lowest. This
might be due to several factors. In Atlantic Canada, there is the
highest proportion of cigarette smokers than the rest of the
country (16.9%Y18.8% vs 12.4%Y17.2%), who are physically
inactive (47.2%Y52% vs 40.2%Y50%), who are affected by obe-
sity (21.7%Y28.2% vs 13.5%Y18.2%), and who consume less
than 5 servings of fruit or vegetables per day (61.5%Y70.3% vs
46.8%Y56.5%).28 Other possible explanations are differences in
socioeconomic status. For example, individuals living in Atlantic
Canada were older (median population age, 42.8Y44.2 years vs
36.5Y41.9 years in other provinces)42 and with lower personal
annual income (Can $25,620Y27,430 vs $28,120Y35,770 in 2010
Canadian dollars).34,43 From the available data, it seems that
access to primary medical care was not different across prov-
inces, and only 19% to 21% of Canadians reported that they
did not have any contact with their general practitioners during
a period of 12 months.28 However, it is possible that Canadians
living in the Atlantic Provinces had more challenges in accessing
tertiary medical centers because the proportion of people living
in rural areas was significantly higher than the rest of the coun-
try except for the Northwest Territories, Yukon, and Nunavut
(41%Y53% vs 14%-33%). It is also possible that patients living
in Atlantic Canada were diagnosed with more advanced stages
of their disease or that they were more likely unfit to undergo
surgical treatment or chemotherapy because of medical condi-
tions associated with obesity, sedentary lifestyle, and cigarette
smoking.
Our results confirmed that surgical resection is an option
only for 17% to 19% of patients with PC in Canada. This is in
keeping with other large epidemiological studies from the
United States where surgical therapy was performed in 9% to
20% of patients because of the presence of locally advanced
disease, metastases, or comorbidities that excluded patients from
surgery.5,20 When surgery was feasible, most of the patients (74%)
were referred to high-volume Canadian centers with perioperative
mortality of 5% and comparable with reports from high-volume
centers in other countries.9,16,24,44Y46
This study has several limitations. The completeness of
registration of new cancer cases in Canada is generally very
good but there are exceptions. For example, death certificate
information has not been available for registry purposes in
Newfoundland and Labrador until very recently. Although the
Canadian Council of Cancer Registries and its standing com-
mittee on data quality make every effort to achieve uniformity
in defining and classifying new cancer cases, reporting pro-
cedures and completeness still vary across different provinces
and territories. This has led to underestimates of the incidence
of some cancers in some areas. Another shortcoming is that data
on adjuvant and palliative therapies received by Canadian pa-
tients with PC are not available. Therefore, it is still unclear if
the significant variations in 5-year survival of patients living in
different provinces are due to different risk factors, availability
of diagnostic services leading to differences in tumor stages at
the time of diagnosis, or differences in treatments received
during the temporal course of their disease. The degree to which
death certificate information is checked against hospital records
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Pancreas & Volume 43, Number 6, August 2014
also varies across provinces and territories, and this affects the
accuracy of incidence on hospital data.
On the other hand, this report represents the most com-
prehensive population-based assessment of the current and his-
torical epidemiological data on PC in Canada.
In conclusion, the overall prognosis of PC in Canada re-
mains poor. Although perioperative mortality is low, only 17%
to 19% of patients are candidates to surgical resection. The over-
all 5-year survival of Canadian patients with PC is 9%, but there
are geographic areas where overall survival is lower than expected.
Although the mortality rate of PC remains the highest among all
tumors diagnosed in Canada in 2012, further studies are warranted
to identify potential modifiable risk factors, more effective strate-
gies for early detection, and treatment modalities.
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