Introduction Patients with pancreatic cancer manifest with advanced stage at diagnosis, have limited effective treatment options, and poor overall survival. Routine use of invasive diagnostic procedures with a view to commencing palliative chemotherapy may subject patients to overtreatment without substantive benefit, which may be further exacerbated in regional centres due to limitations in access to tertiary services. Methods A retrospective cohort analysis of all patients presenting emergently to a provincial hospital in Aotearoa New Zealand with a new diagnosis of pancreatic cancer between 1 July 2018 - 1 July 2023 inclusive was performed. Patients were identified from discharge diagnosis coding data, with data describing patient and pancreatic cancer disease factors collated from the electronic health record. Results A total of 75 patients were included. The median age at diagnosis was 72 years, with 56% male. Of the 48% referred for chemotherapy, 33% died prior to oncology assessment or commencing treatment. 28% were assessed as not candidate for chemotherapy. 62% of patients receiving ERCP returned nondiagnostic brushings, with 77% referred to a tertiary centre for EUS. Patients receiving palliative chemotherapy had an absolute median survival benefit of 9 months with an additional median 46 days to first treatment compared to those receiving best supportive care. Conclusion Our study highlights the need to rationalise diagnostic and treatment referral pathways that minimise patient harm. Careful selection of patients candidate for palliative chemotherapy may facilitate a reduction in unwarranted invasive diagnostic procedures and treatment complications that may enhance patient care.