Body mass index has no impact on complications and mortality for patients with stage IV pancreatic ductal adenocarcinoma

Introduction

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy with a very poor prognosis. Currently PDAC is the fourth leading cause of cancer-related death in the United States (USA), with an overall survival (OS) rate of only 8% (1). Several risk factors for the occurrence of PDAC are known such as smoking and alcohol intake (2). Diabetes and obesity also play a crucial role in the development of PDAC.

Overweight and obesity are rising medical and socio-economic problems worldwide. The peak in the prevalence of obesity is recorded between 60–64 years of age in women and between 50–54 years of age in men (3). Obesity affects an estimated 42% of adults in the USA (4). Kentucky (KY) ranks seventh nationwide in obesity prevalence with 37% of the 1.3 million adults affected (5). By 2030, the adult obesity rate in Kentucky is projected to rise to 54% (6).

Obesity is a recognized risk factor for PDAC and may present additional challenges during palliative treatment. Excess body weight is linked to greater fat accumulation within the pancreas (pancreatic steatosis), which fosters an inflammatory microenvironment through heightened cytokine production, extracellular matrix deposition, and fibrotic changes (7). Obesity contributes to complications like metabolic diseases, such as type 2 diabetes and gout, cardiovascular diseases such as high blood pressure and coronary heart disease, and joint problems such as osteoarthritis and back pain (8). Obesity is also linked to development of sleep disorders and psychiatric illnesses. Overweight and obesity may limit the extent of surgery, systemic treatment and create obstacles to radiation. Overall, overweight and obesity can impact life expectancy with and without cancer. While some research data (9,10) found no link between high body mass index (BMI), PDAC and poor survival, suggesting BMI may not impact outcome directly, other significant studies reveal a more complex picture, showing high BMI linked to worse survival (11-13). In essence, early-life weight gain or high visceral fat can negatively affect PDAC development, but it remains controversial whether patients with stage IV PDAC and overweight/obesity should be managed differently and whether this group experiences higher rates of risks and complications compared to patients with a low BMI. Therefore, we retrospectively investigated stage IV PDAC patients from the University of Kentucky (UK) and grouped them accordingly to their BMI into two groups: low BMI (BMI <25 kg/m²) vs. high BMI (BMI ≥25 kg/m²). The objective of this study is to examine the significance of BMI on outcome and complications in patients with diagnosis of stage IV PDAC. We did not directly measure sarcopenia or visceral adiposity in our analysis, but we included Pre-BMI (6–12 month before PDAC diagnosis) as an additional parameter. Although a longer period of weight analysis before the PDAC diagnosis would be desirable, the data could not be reliably obtained weight changes from Pre-BMI to BMI at the time of PDAC diagnosis were taken into account. We hypothesize that overweight or obese patients have a higher risk of developing complications related to PDAC. We present this article in accordance with the STROBE reporting checklist (available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-160/rc).

Methods

Study design and data collection

This research was a single-cohort study conducted retrospectively. Between January 1^st, 2017, and October 10^th, 2024, data were collected from adult patients; 18 years or older (n=162) with a stage IV histologically proven PDAC diagnosed at the UK, Lexington, USA. The collected data included BMI, demographic information, smoking status, alcohol status, chemotherapy information, medical history variables, albumin, total protein & carbohydrate-antigen 19-9 (CA19-9) test results, medical complications [endoscopic retrograde cholangiopancreatography (ERCP): biliary and/or pancreatic stenting or exchanges, thrombosis: blot clots (vein occlusion) occurring anywhere in the body, infections: any type of bacterial, viral, or fungal infections recorded, gastrointestinal (GI) bleedings: any type of upper or lower GI bleeding], days in hospital, admission numbers to hospice and mortality. Data set was collected at start of PDAC treatment, except Pre-BMI. Evaluation of follow up visits as well as entries in the electronic health record, including presentations at outside hospital facilities, were used for analysis of complications and chemotherapy treatments only. The study was conducted in accordance with the International Guidelines for Ethical Review of Epidemiological Studies, and the Declaration of Helsinki and its subsequent amendments. The study was approved by University of Kentucky, Office of Research Integrity (No. 99650). Individual consent for this analysis was waived due to the retrospective nature.

Patient classification

Patients were divided into two groups according to their BMI. BMI was calculated as the ratio of weight in kilograms, to height in meters squared. The World Health Organization (WHO) divides body weight into four groups: underweight (BMI <18.5 kg/m²), normal weight (BMI 18.5–24.9 kg/m²), overweight (BMI 25–29.9 kg/m²) and obesity (BMI >30 kg/m²) (14). Due to our group size, the patients were divided into only two groups: low BMI (BMI <25 kg/m²) n=76 vs. high BMI (BMI ≥25 kg/m²) n=86.

Statistical analysis

Statistical analyses were performed using R, version 4.4.1. All P values are two-sided and tested at significance α=0.05. Table 1 includes a summary of demographic variables and risk factors. All continuous variables were summarized by mean, standard error (SE), median, and interquartile range (Q25, Q75). Categorical variables were summarized by frequency and proportion. Percent missingness are also listed for all variables. Associations between high BMI/low BMI patients’ attributes were analyzed using Chi-Square tests for categorical and t-tests for continuous variables when parametric assumptions held. If parametric assumptions were violated, associations were analyzed using Fisher exact tests for categorical and Kruskal-Wallis tests for continuous variables.

Binary outcomes were analyzed using multivariable logistic regressions and continuous outcomes were analyzed using multivariable linear regression. BMI group (high vs. low BMI), gender, age, race, smoking status, alcohol, albumin, total-protein, CA 19-9, and an indicator for each chemotherapy agent were included as variables in the model. Any chemotherapy agent that had less than 5 patients were dropped from the model. Race was reclassified as White and non-White (Black, Black or African American, other Asian American, Spanish American) due to the small sample size of some categories. Because this analysis required multiple statistical tests, the Benjamini & Hochberg procedure was used to adjust the P values of the BMI group coefficients.

Results

Patient characteristics

A total of 162 patients with PDAC were included in this analysis (Figure S1). 380 patients were excluded due to our exclusion criteria (age younger 18 years, neuroendocrine tumors of the pancreas, patients with PDAC recurrence after surgery and missing significant incomplete data sets). The detailed demographic characteristics are outlined in Table 1. A total of 86 (53%) patients had a high BMI (BMI ≥25 kg/m²). The median Pre-BMI in the high BMI group was 32.0 kg/m² and in the low BMI group 24.1 kg/m² (Table 1, Figures 1,2). The Pre-BMI was significantly different between the groups (P<0.001). And 55 (64%) patients of the high BMI group had a Pre-BMI >30 kg/m². At PDAC diagnosis 36 (42%) patients of the high BMI group had a BMI >30 kg/m². In total, 19 high BMI patients lost so much weight that they changed their category from Pre-BMI >30 kg/m² to BMI >25 kg/m². Only 5 (7%) patients in the low BMI group had a Pre-BMI >25 kg/m². 14 (16%) of the high BMI and 17 (22%) of the low BMI patients experienced weight gain, going from their Pre-BMI to BMI at PDAC diagnosis. Four (5%) patients of the low BMI group were considered underweight before PDAC diagnosis. Four (5%) additional patients changed from normal weight to underweight after PDAC diagnosis.

Figure 1 Weight changes of PDAC patients with high BMI group. X-axis: patient index number. Blue color: Pre-BMI. Red color: BMI at PDAC diagnosis. BMI, body mass index; PDAC, pancreatic ductal adenocarcinoma.

Figure 2 Weight changes of PDAC patients with low BMI group. X-axis: patient index number. Blue color: Pre-BMI. Red color: BMI at PDAC diagnosis. BMI, body mass index; PDAC, pancreatic ductal adenocarcinoma.

In total, 90 (56%) patients were male, and 149 (92%) patients were white. The median age at diagnosis was 67 years. Twenty-two patients (14%) had undergone two-line chemotherapies. FOLFIRINOX (fluorouracil, leucovorin, irinotecan, oxaliplatin) treatment was given in 64 (40%) patients. Other chemotherapy regimens were: capecitabine, gemcitabine, gemcitabine + nab-paclitaxel, FOLFIRI (fluorouracil, leucovorin, irinotecan), FOLFOX (fluorouracil, leucovorin, oxaliplatin), NALIRIFOX (liposomal irinotecan, 5-fluorouracil, leucovorin, oxaliplatin), and pembrolizumab + carboplatin. Smoking status (current and former) was positive in 99 (61%) of patients. Alcohol status was positive in 49 (30%) of patients. The median for albumin was 3.8 g/dL, for total protein 6.8 g/d and CA19-9 467.5 U/mL. Comorbidities were as follows: hypertension, 101 (62%) patients; type 2 diabetes, 77 (48%) patients; hyperlipidemia, 63 (39%) patients; gastroesophageal reflux disease, 46 (28%) patients and coronary artery disease, 26 (16%) patients.

There was a significant difference between groups regarding to smoking status. There were less current and former smokers in the high BMI group. There was a trend for more type 2 diabetes in the high BMI group (55.8% vs. 38.2%). FOLFIRINOX therapy was more frequent in the high BMI group (44.2% vs. 34.2%). There was no statistically significant difference between the other characteristics and parameters.

Complications, mortality, hospice and days in hospital

The detailed data are outlined in Tables 2,3. The leading complication was infection which occurred in 89 (55%) patients. Additional procedures/complications included, biliary and/or pancreatic stenting or exchanges (ERCP) in 73 (45%) patients, thrombosis in 58 (36%) patients, and GI bleedings in 32 (20%) patients. There was no statistically significant difference between the groups.

Hospice admissions were more frequent in the low BMI with 31 (41%) patients, but the difference was not significant [odds ratio 0.46, 95% confidence interval (CI): 0.22 to 0.95]. A total of n=93 (57%) patients died. No significant difference between both BMI groups. The median number of hospital days was 9.0 without significant differences between the groups.

Discussion

PDAC is a worldwide health burden. It is the 12^th most common malignancy globally, with the highest incidence in North America, Europe, East Asia and Australia (15-17). Incidence rates are higher in men, and the majority of pancreatic cancers are PDAC (12). Different risk factors for the development of PDAC are known such as cigarette smoking, alcohol consumption, diabetes, and obesity (18-26). In KY, obesity represents a significant public health concern, impacting approximately 1.3 million adults across the state (5). This high prevalence underscores the widespread nature of the condition and highlights a special need to focus on this overweight population in KY state.

Systemic chemotherapy is the preferred treatment approach for patients with stage IV PDAC. FOLFIRINOX, nab-paclitaxel plus gemcitabine, or NALIRIFOX are the choices of first line therapy (27-29). However, the management of these patients is dependent on age, comorbidities, and patient preference. Overweight and obesity are linked to numerous health conditions, such as cardiovascular disease, chronic kidney disease, sleep disorders, and type 2 diabetes (8). Overweight and obesity are overall recognized as a negative predictor of outcomes in cancers (30,31).

It was demonstrated that in patients with PDAC visceral obesity correlates with poorer OS and progression-free survival (PFS), along with a higher incidence of regional lymph node metastases (32). Additionally, obesity has an impact on patient’s candidacy for surgical intervention, higher risk for complications from an anaesthesia perspective and higher risk of complications (33). Historic epidemiological studies from MD Anderson Cancer Center, Memorial Sloan Kettering Cancer Center, and Mayo clinic reported that obesity was associated with decreased OS in PDAC (11-13). Kasenda et al. from the Swiss cancer group demonstrated that obese PDAC patients have a worse prognosis compared to non-obese patients (34). Majumder et al. evaluated different PDAC studies and showed statistically higher mortality in patients with High premorbid BMI in 5 of the studies (35). Next, a multivariable analysis showed increased risk of PDAC-related death in patients with obesity (36). In contrast, a meta-analysis by Shi et al. found that high BMI at diagnosis is not associated with survival (9). A study by Gaujoux et al. found no correlation between high BMI, visceral fat, and OS of PDAC patients (10).

Studies about the influence of BMI on the treatment of established PDAC are inconsistent. Given the conflicting data and the obesity burden in KY, the aim of the present study was to analyze the impact of BMI on complications and mortality in patients with stage IV PDAC undergoing systemic treatment. We studied 162 patients with confirmed stage IV PDAC and divided them into two groups: low BMI (BMI <25 kg/m²) and high BMI (BMI ≥25 kg/m²). The overall characteristics of the patients were largely comparable between the two groups, but the distribution of smoking status was significantly different between groups. This contrasts with Jiang et al., who described the opposite finding with a positive smoking history in their obesity group (37). The patients with a combination of smoking and low BMI did not show less or more complications compared to the high BMI group. There was also no significant difference in mortality between both groups.

Obesity is widely recognized as one of the primary risk factors contributing to the onset and progression of type 2 diabetes, with numerous studies demonstrating a strong association between excess body weight and impaired glucose metabolism (9). Obesity and diabetes are closely linked through the shared mechanism of insulin resistance, a metabolic abnormality characterized by impaired cellular responsiveness to insulin (38). High circulating insulin and insulin-like growth-factor 1 (IGF-1) have been involved in tumor progression and may impact OS (9,39). Adipose tissue in obese individual functions as an active endocrine organ, secreting a wide range of adipokines and inflammatory mediators. Elevated levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and related cytokines contribute to systemic inflammation, induction of oxidative stress, and disruption of normal immune surveillance. This inflammatory environment creates a condition that promotes tumor progression (40,41). Our analysis revealed that individuals classified within the higher BMI group also showed a significant higher prevalence of type 2 diabetes compared to those with low BMI categories.

The tumor marker CA19-9 is a commonly used biomarker for diagnosis and management of PDAC (42). CA19-9 effectiveness is limited by low sensitivity and specificity. Based on our data, body weight has no impact on the CA 19-9 levels and no statistical significance different between the investigated BMI groups. It is important to note that patients with high BMI tend to receive more FOLFIRINOX therapy compared to low BMI patients. This suggests that chemotherapy intolerance is likely not significantly elevated in this group and patients with a high BMI should not be treated differently. Cachexia is generally prevalent in diverse cancer diseases and not solely found in PDAC. Cachexia is caused by a multifactorial process, including tissue wasting, poor appetite, and fatigue. Cachectic patients have a higher risk for complications and shorter survival (43).

Our group of BMI ≥25 kg/m², contained overweight and obese patients and was labelled as high BMI group. Due to our smaller patient size, we refrained from dividing the patients into further individual BMI groups. The Pre-BMI and BMI at PDAC diagnosis was for the low BMI group quite similar. Only 7% of the low BMI patients were overweight before PDAC diagnosis and none were classified as obese. 23% of the high BMI patients experienced weight loss from Pre-BMI to BMI and changed their WHO BMI category from obese to overweight. Patients from both groups (20%) experienced weight gain going from their Pre-BMI and BMI measurements, but this did not significantly impact the BMI category of the patients. However, the reasons for weight gain are not entirely clear. Changes in diet, exercise, medication side effects, and dental hygiene could be contributing factors. Closer monitoring of this subgroup patients would be useful for further investigation. Our data of weight gain within both groups is particularly interesting, as PDAC patients typically lose rapidly a lot of weight.

The Global Leadership Initiative on Malnutrition (GLIM) is an approach to check for malnutrition and is using three phenotypic criteria (weight loss, low BMI, low muscle mass) and two etiology criteria (reduced food intake/assimilation and inflammation/disease burden) (44). Here, we were only able to find the BMI data retrospectively, and the single weights in kilograms needed for using the GLIM criteria are missing. However, 131 (81%) of our patients experienced a non-volitional weight loss. For these patients, a diagnosis of malnutrition appears very likely, but precise grading according to GLIM is not possible. Unfortunately, we were unable to monitor long-term weight changes after PDAC diagnosis, as the records were incomplete. Thus, further assessments of weight changes were not possible. To combat malnutrition, all patients received access to nutritional shakes and drinks after being diagnosed with PDAC. In addition, patients received nutritional counselling if interested.

Only 2% of all patients had an underweight/cachexia before PDAC diagnosis and 5% after PDAC diagnosis. We determined that patient in the low BMI group are more frequently admitted to hospice but there was no difference in the mortality. The albumin levels and the total protein of the groups were similar; thus, high BMI does not equate optimal nutrition status. Obese patients who experience significant weight loss may still appear nutritionally adequate, which can lead to hospice admission being considered less often. The number of overweight patients with weight loss is an important group that should perhaps receive more attention. However, the weight loss occurred mainly before the PDAC diagnosis, so early intervention with dietary changes was not possible to prevent further weight loss. Unfortunately, the CRP level was not recorded, and the assessment of albumin and total protein are only of limited value in evaluating the malnutrition status.

Due to the retrospective design of our study, the limited number of patients and the single center setting, our analysis has limitations. We were unable to differentiate between visceral fat vs. overall BMI and did not measure sarcopenia. However, this is to our knowledge the first publication with a focus on BMI for stage IV PDAC in the state of KY, a region affected by overweight and obesity. Our data may not be transferable to all other US states and other western countries.

Conclusions

We concluded that patients in both investigated groups had even complication rates and mortality, and all patients can be treated similarly with systemic chemotherapy. The incidence of type 2 diabetes and smoking differed between the groups but had no influence on complications or overall patient outcomes. Future, prospective studies might be of interest to confirm our results.

Acknowledgments

The abstract of this article has been presented in https://journals.lww.com/ajg/fulltext/2025/10002/s207_no_impact_of_body_mass_index_on_complications.208.aspx. ACG Annual scientific meeting, Phoenix, USA, October 2025. We are thankful to the patients and physicians of the Markey Center.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-160/rc

Data Sharing Statement: Available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-160/dss

Peer Review File: Available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-160/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-160/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the International Guidelines for Ethical Review of Epidemiological Studies, and the Declaration of Helsinki and its subsequent amendments. The study was approved by University of Kentucky, Office of Research Integrity (No. 99650). Individual consent for this analysis was waived due to the retrospective nature.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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