The study team, led by Charlotte Goodrose-Flores of Danderyd Hospital and colleagues including Kathrin Wode, set out to answer a question that has received surprisingly little attention in palliative care research: how do perceptions of the body change as terminal illness advances, and do women and men experience those changes differently? Body image, broadly defined as the perceptions, thoughts, and feelings a person holds about their own body, is shaped by cultural context, and women and men typically report different concerns within the same culture. Previous research has shown that men are generally more satisfied with their bodies than women even at higher body mass index levels, and that women report smaller ideal female body silhouettes than men do.

Cancer places body image at the intersection between cultural body ideals and the patient’s pre-diagnosis sense of self, a collision that can complicate both understanding and management of distress during serious illness. Among people with rectal or colon cancer, women have reported greater body image distress than men, yet in studies of advanced cancer of any type, men reported a more negative perception of weight loss compared with women. How such perceptions evolve over time in advanced pancreatic cancer, a disease marked by some of the most severe wasting seen in oncology, had not previously been tracked.

Unintentional weight loss is a hallmark of pancreatic cancer, with roughly 80 percent of patients experiencing persistent loss. Cancer-related weight loss is not simply starvation-type malnutrition but a complex metabolic condition involving systemic inflammation and other abnormalities. Because maintaining body weight, regardless of pre-diagnosis weight, is linked to extended survival, nutritional interventions remain a key priority in cancer care. For pancreatic cancer patients these include pancreatic enzyme replacement therapy to reduce malabsorption, pharmacological treatments for nausea and vomiting, dietary supplements to raise energy and nutrient intake, and corticosteroids often prescribed as appetite stimulants. The research group had previously been unable to demonstrate any beneficial effect of corticosteroid treatment on appetite or weight change during long-term follow-up in this patient group.

The new analysis exploited the infrastructure of the MISTRAL trial, a Swedish multicentre, double-blind, randomised, placebo-controlled study that recruited 290 patients with advanced pancreatic cancer between June 2016 and December 2021. Participants were randomised one to one to receive either mistletoe extract or placebo in addition to comprehensive oncological treatment and palliative care. Because the trial found no differences in overall survival or quality of life between the treatment arms, mistletoe extract was not considered a confounder in the present post-hoc study. Assessments took place at randomisation, after five to six weeks, and at two, three, four, six, and nine months, with participants weighing themselves at home weekly and recording the values in a study diary.

To qualify for the post-hoc analysis, participants must have died during the study period or within 180 days after its end and must have completed at least two assessments of body image and weight worries. Of the original 290 trial participants, 19 lacked a recorded date of death within the study window and 146 had fewer than two assessments in the final six months of life, leaving 125 participants, of whom 64, or 51.2 percent, were women. Mean age was 68.4 years, mean body mass index was 23.5 kilograms per square metre, and the median time from diagnosis to randomisation was 37 days. Median survival from trial inclusion was six months, with men surviving significantly shorter than women, five versus seven months, and men being ineligible for palliative chemotherapy more often than women at inclusion.

Body image distress and weight worries were captured by three questions in the European Organisation for Research and Treatment of Cancer QLQ-PAN-26 questionnaire, which is specifically designed for pancreatic cancer. Patients rated whether they had felt physically less attractive as a result of their disease and treatment, whether they had been dissatisfied with their body, and whether they had worried about their weight being too low, using a four-point scale from not at all to very much. The two body image items formed a multi-item scale scored from 0 to 100, while weight worries were scored as a single item on the same scale, with higher scores indicating worse symptoms. The researchers constructed variables at 30, 60, 90, 120, 150, and 180 days before death, counting questionnaire responses within two weeks of each time point, and calculated body mass index at each of those months using weights recorded within 14 days.

Statistical modelling with mixed-effects linear regression, including random intercepts for each individual and adjustment for age, revealed a steady increase in body image distress of 3.54 points per month closer to death, with a 95 percent confidence interval of 1.67 to 5.41, in both sexes combined. Weight worries rose by 2.98 points per month, with a confidence interval of 0.53 to 5.44. Body mass index declined by an average of 0.23 units per month, with a confidence interval of minus 0.36 to minus 0.09. There were no statistically significant differences between women and men in the rate of change for any of the three outcomes, although the pattern of predicted means suggested that women tended to report higher body image distress closer to death while men reported higher weight worries across all time points, with the gap in weight worries narrowing as death approached.

The authors interpret these trajectories against a cultural backdrop that places greater pressure on women than on men to maintain a thin body to be perceived as attractive, which may explain why women’s body image distress appeared to accelerate more in the final months. At the same time, the results contrast with the group’s earlier finding in patients with advanced cancer of all types, where men reported significantly increased body image distress after weight loss while women did not. One possible explanation offered is that pancreatic cancer progression is associated with more rapid weight loss than most other cancer types, and that this rapid decline may be perceived as a more pronounced signal that death is approaching, potentially outweighing cultural ideals of female thinness for both sexes.

The researchers emphasise that their findings highlight an underexplored dimension of living with pancreatic cancer in the palliative phase: physical decline reflected in body image distress, weight worries, and falling body mass index extends beyond the direct effects of chemotherapy, surgery, or radiation, and deserves explicit recognition from healthcare professionals because it may significantly affect quality of life. They also caution that the analysis was post-hoc and exploratory rather than pre-specified, that the sample size may have limited statistical power to detect sex differences, and that unmeasured confounding cannot be excluded. Participants in the original trial may represent a selected group of patients robust enough to enrol in a study during palliative care, and the findings may not generalise to patients with other cancer types. A prospective longitudinal cohort of individuals with advanced cancer is suggested as a more suitable design for future work, and the authors argue that future studies of body image and weight perception in advanced cancer should explicitly consider potential gender differences.

Subject of Research: Body image distress and weight worries in men and women with advanced pancreatic cancer during the final six months of life

Article Title: Body image distress in women and men with advanced pancreatic cancer approaching death – post-hoc analyses from the MISTRAL-trial

Article References: Goodrose-Flores, C., Bonn, S. E., Björkhem-Bergman, L., & Wode, K. (2026). Body image distress in women and men with advanced pancreatic cancer approaching death – post-hoc analyses from the MISTRAL-trial. Supportive Care in Cancer, 34(11), 1157. https://doi.org/10.1007/s00520-026-11420-4

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11420-4

Keywords: pancreatic cancer, body image, palliative care, weight loss, cancer cachexia, EORTC QLQ-PAN-26, MISTRAL trial, gender differences, end of life, quality of life, post-hoc analysis, supportive care