The trends in treatment and outcome of 13560 patients with pancreatic cancer, and in incidence of the disease, in the West Midlands health region were determined between 1957 and 1986 using data from the West Midlands Region Cancer Registry. Patients were divided into those diagnosed in the first 20 years (19570–1976, n = 7888) and the most recent 10 years (1977–1986, n = 5672). The disease was more common in men and the incidence increased up to 1970 after which it levelled off. In the 1977–1986 period a lower proportion of patients had laparotomy alone (825 (14·5 per cent) versus 1552 (19·7 per cent)), a similar proportion had bypass surgery (2010 (35·4 per cent) versus 2760 (35·0 per cent)), while a greater proportion had supportive care (2710 (47·8 per cent) versus 3368 (42·7 per cent)) but the resection rates were the same (145 (2·6 per cent) versus 208 (2·6 per cent)). The 30-day mortality rates between the two periods unproved for resection (40 (27·6 per cent) versus 94 (45·2 per cent)), bypass surgery (436 (21·7 percent) versus 691 (25·0 per cent)) and laparotomy (372 (45·1 per cent) versus 873 (56·3 per cent)). The 12-month survival rate for bypass did not significantly differ during the study (14·9 per cent versus 12·4 per cent) but there was a significant improvement in the 5-year survival for resection (9·7 per cent versus 2·6 per cent, P < 0·015). The resection rates were low and 30-day mortality rates for surgery were high compared with those of other published series.