Genome-wide association studies (GWAS) are a powerful tool for detecting variants associated with complex traits and can help risk stratification and prevention strategies against pancreatic ductal adenocarcinoma (PDAC). However, the strict significance threshold commonly used makes it likely that many true risk loci are missed. Functional annotation of GWAS polymorphisms is a proven strategy to identify additional risk loci. We aimed to investigate single-nucleotide polymorphisms (SNP) in regulatory regions [transcription factor binding sites (TFBSs) and enhancers] that could change the expression profile of multiple genes they act upon and thereby modify PDAC risk. We analyzed a total of 12,636 PDAC cases and 43,443 controls from PanScan/PanC4 and the East Asian GWAS (discovery populations), and the PANDoRA consortium (replication population). We identified four associations that reached study-wide statistical significance in the overall meta-analysis: rs2472632(A) (enhancer variant, OR 1.10, 95%CI 1.06,1.13, p = 5.5 × 10-8), rs17358295(G) (enhancer variant, OR 1.16, 95%CI 1.10,1.22, p = 6.1 × 10-7), rs2232079(T) (TFBS variant, OR 0.88, 95%CI 0.83,0.93, p = 6.4 × 10-6) and rs10025845(A) (TFBS variant, OR 1.88, 95%CI 1.50,1.12, p = 1.32 × 10-5). The SNP with the most significant association, rs2472632, is located in an enhancer predicted to target the coiled-coil domain containing 34 oncogene. Our results provide new insights into genetic risk factors for PDAC by a focused analysis of polymorphisms in regulatory regions and demonstrating the usefulness of functional prioritization to identify loci associated with PDAC risk.

1st Propaedeutic University Surgery Clinic Hippocratio General Hospital Medical School National and Kapodistrian University of Athens Athens Greece

Biomedical Center Faculty of Medicine in Pilsen Charles University Plzeň Czech Republic

Blood Transfusion Service Meyer Children's Hospital Florence Italy

Cancer Center Amsterdam Imaging and Biomarkers Amsterdam the Netherlands

Carol Davila University of Medicine and Pharmacy Bucharest Romania

Center for Translational Medicine Semmelweis University Budapest Hungary

Department for Determinants of Chronic Diseases National Institute for Public Health and the Environment Bilthoven The Netherlands

Department of Biology University of Pisa Pisa Italy

Department of Biomedical Sciences Humanitas University Milan Italy

Department of Diagnostics and Public Health ARC Net Centre for Applied Research on Cancer University of Verona Verona Italy

Department of Digestive Tract Diseases Medical University of Lodz Lodz Poland

Department of Gastroenterology San Carlo Hospital Potenza Italy

Department of General Visceral and Thoracic Surgery University of Hamburg Medical Institutions Hamburg Germany

Department of General Visceral and Transplant Surgery Heidelberg University Hospital Heidelberg Germany

Department of Medicine Laboratory Medicine University of Padova Padua Italy

Department of Molecular Biology of Cancer Institute of Experimental Medicine of the Czech Academy of Sciences Prague Czech Republic

Department of Oncology Faculty of Medicine and Dentistry Palacky University Olomouc Czech Republic

Department of Oncology Fondazione IRCCS Casa Sollievo della Sofferenza Hospital San Giovanni Rotondo FG Italy

Department of Pathology Cancer Center Amsterdam Amsterdam UMC University of Amsterdam Amsterdam the Netherlands

Department of Radiology and Oncology Institute of Cancer of São Paulo São Paulo Brazil

Department of Surgery Erasmus MC University Medical Center Rotterdam The Netherlands

Department of Surgery Fondazione IRCCS Casa Sollievo della Sofferenza Hospital San Giovanni Rotondo FG Italy

Department of Surgery Oncology and Gastroenterology University of Padova Padua Italy

Department of Surgery University Hospital Kralovske Vinohrady 3rd Faculty of Medicine Charles University Prague Czech Republic

Digestive and Liver Disease Unit S Andrea Hospital Rome Italy

Division of Clinical Epidemiology and Aging Research German Cancer Research Center Heidelberg Germany

Division of Gastroenterology and Research Laboratory Fondazione IRCCS Casa Sollievo della Sofferenza Hospital San Giovanni Rotondo FG Italy

Division of General and Transplant Surgery Pisa University Hospital Pisa Italy

Division of Pancreatic Diseases Heart and Vascular Center Semmelweis University Budapest Hungary

Division of Preventive Oncology German Cancer Research Center and National Center for Tumor Diseases Heidelberg Germany

Endoscopic Unit Department of Gastroenterology IRCCS Humanitas Research Hospital Milan Italy

Gastroenterology and Gastrointestinal Endoscopy Unit IRCCS San Raffaele Scientific Institute Vita Salute San Raffaele University Milan Italy

Gastroenterology Department and Institute for Digestive Research Lithuanian University of Health Sciences Kaunas Lithuania

General Surgery Unit Department of Translational Research and New Technologies in Medicine and Surgery University of Pisa Pisa Italy

Genomic Epidemiology Group German Cancer Research Center In Neuenheimer Feld 280 69120 Heidelberg Germany

German Cancer Consortium German Cancer Research Center Heidelberg Germany

Institute for Translational Medicine Medical School University of Pécs Pécs Hungary

Institute of Biology and Medical Genetics Institute of Physiology 1st Faculty of Medicine Charles University Prague Czech Republic

János Szentágothai Research Center University of Pécs Pécs Hungary

Laboratory for Applied Science and Technology in Health Carlos Chagas Institute Curitiba PR Brazil

Laboratory for Experimental Oncology and Radiobiology Center of Experimental Molecular Medicine Amsterdam UMC Location University of Amsterdam Amsterdam the Netherlands

Laboratory of Biology Medical School National and Kapodistrian University of Athens Athens Greece

Network Aging Research Heidelberg University Heidelberg Germany

Pancreatic Unit IRCCS Humanitas Research Hospital Milan Italy

PancreatoBiliary Endoscopy and Endosonography Division Pancreas Translational and Clinical Research Center San Raffaele Scientific Institute Milan Italy

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