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Objectives To report estimates of cancer incidence (1982–2016) and mortality (1980–2020) in the Health Watch cohort after four decades of follow-up.Methods Health Watch is a prospective cohort study of 18 040 (16 666 men, 1374 women) employees recruited between 1981 and 2000.Personal data were linked to national and state cancer and death registries. Standardised mortality ratios (SMRs) and standardised incidence ratios were calculated using national population rates adjusted for age, sex and calendar period.Results All-cause mortality was reduced compared with Australian population rates (men: SMR 0.79, 95% CI 0.77 to 0.82; women: SMR 0.70, 95% CI 0.59 to 0.83).Conclusions Lower mortality likely reflects the healthy worker effect. Persistent excesses of mesothelioma, melanoma and prostate cancer may reflect ongoing occupational risks warranting targeted prevention and surveillance. In particular, melanoma risk underscores the need to minimise both occupational and recreational ultraviolet exposure.