The incidentally identified pancreatic cyst is an increasing burden for both physicians and patients alike. Although we recognize that most of these lesions are benign and may not progress, a subset of these lesions are premalignant, may have frank cancer, and may progress over time. Most occur in older patients who have associated comorbidity. Recent studies highlight neoplastic features of these cysts that when present may warrant surgery or close long-term follow-up; however, there has been little study on the natural history factoring in patient comorbidity and pancreatic cancer-free survival. This retrospective cohort study underscores the importance of patient comorbidity in our management algorithm, and these data should prompt subsequent guidelines to factor in such comorbidity.