Pancreatic cancer: a haystack of needles

The 5-year overall survival rate for pancreatic adenocarcinoma is 11%, largely due to 75–90% of patients presenting with advanced-stage disease (1,2). In this study, Tan et al. used the US Centers for Disease Control and Prevention’s Wide-ranging ONline Data for Epidemiologic Research (CDC WONDER) database, containing national death certificate data, to assess temporal pancreatic cancer mortality trends from 1999 to 2024 (3,4). That period encompassed many major advances in pancreas cancer therapies, including FOLFIRINOX (5), immunotherapy (6), and PARP inhibitors (7). They found that overall age-adjusted mortality rates increased and that Black males had significantly and consistently higher age-adjusted mortality than other patient groups (3). This study corroborates the upward trend of pancreatic cancer mortality in other studies and reinforces the urgency of better understanding and reducing cancer care and outcomes disparities (8-11).

In using data derived from death certificates, Tan et al. take a different approach to assessing pancreas cancer outcomes than other authors. While their two main observations are generally consistent with other large cohort studies, several aspects of the work warrant consideration. The first is how accurately CDC WONDER data reflect cause-specific mortality, arguably the best cancer treatment efficacy indicator. Contrary to the generally held belief that all people with pancreatic cancer eventually die from their cancer, autopsy studies and detailed chart reviews show up to 1 in 7 of patients with pancreatic cancer died from other causes than cancer or its treatment (12,13). Aside from concerns over death certificates’ accuracy (14), at best, these data show us only the numerator of pancreas cancer-related deaths without a clear denominator.

Second, is how to view these findings in light of rising pancreatic cancer incidence (8-11). Suppose one cancer treatment aim is to extend life and its quality even with the disease. In that case, a growing gap between incidence and mortality may reflect more effective treatment and progress despite the minimal change in the ‘bottom line’. Tan et al.’s study is not designed to address this question. This gap, particularly across patient subgroups, warrants further high-quality epidemiological investigation with treatment data and cause-specific mortality.

Third, we must move beyond summative descriptions of pancreatic cancer care disparities and address the underpinnings of unequal healthcare. Tan et al.’s results echo others in showing consistent outcome gaps across racial groups (11); they hypothesize about but cannot empirically evaluate any disparity drivers. A nascent and growing body of research addressing the social, environmental, and political underpinnings of racial disparities across the care continuum will hopefully lead to more equity in cancer outcomes. It is tempting to hope that the gap between pancreas cancer incidence and mortality rates seen in this and other studies represents progress in caring for this disease. However, hope will not fix care inequity; we must understand the disease’s biology and its interplay with social and political cancer care determinants better and then intervene if we are to move any needles.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Gastrointestinal Oncology. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-24-697/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy of integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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