Background <p>Epidemiologic data on mesothelioma in China remain limited, particularly with respect to long-term, province-level characterization of demographic features and survival outcomes.</p> Methods <p>We conducted a 16-year retrospective cohort study of mesothelioma patients diagnosed at a major provincial tertiary referral center in China between 2009 and 2025. Among 128 identified cases, 93 met strict pathological criteria and were included for analysis. We evaluated sex distribution, anatomic site, age at diagnosis, and survival outcomes, and compared these features with representative cohorts from the United States, Europe, and Japan.</p> Results <p>Our 16-year provincial cohort showed a nearly equal male-to-female ratio that markedly distinct from the male predominance reported in Western populations. Peritoneal mesothelioma accounted for 33.3% of cases, a proportion higher than that typically reported in global cohorts. The higher proportion of female patients was observed across both pleural and peritoneal mesothelioma. The median age at diagnosis was significantly younger than that observed in the United States. The median progression-free survival (PFS) and overall survival (OS) were 10&#xa0;months and 16&#xa0;months, with a notable survival advantage for females with peritoneal mesothelioma. Notably, only 7.5% of patients had documented asbestos exposure, indicating additional environmental and/or genetic contributors maybe relevant in this setting.</p> Conclusions <p>This long-term provincial cohort delineates mesothelioma epidemiology at the province level in China, marked by a near-equal sex distribution with substantial female representation across disease subtypes, a high proportion of peritoneal cases, younger age at diagnosis and a low prevalence of documented asbestos exposure. These findings show clear region-specific evidence, underscoring potential geographic heterogeneity in mesothelioma epidemiology.</p>