The Worst Person in the World (2021)

Julie is in her late twenties in Oslo. She drifts between medicine, psychology, photography and writing while trying to work out who she is. She spends years with Aksel, an underground comics artist fifteen years older, who wants children. Then she leaves him for Eivind, a barista she meets after wandering into a stranger's party. The story runs in twelve chapters, with a prologue and an epilogue.

Late on, Aksel's brother finds Julie at work. He tells her Aksel has pancreatic cancer that cannot be cured. Julie goes back. She visits the hospital, photographs him, and walks the streets they used to share.

Thinner and frightened, Aksel talks about a life measured in the records and objects that will outlive him. He talks about the life he wanted with her. His brother leaves a voicemail saying he is unlikely to survive the night. Julie walks through Oslo until sunrise.

The ending is discussed here in full, because the illness is the ending.

The film skips the part most cancer stories are built around. There is no lump, no test, no waiting room, no moment of being told. The news is simply already bad.

That is the truest thing in it. NCI is direct about why. Early on, pancreatic cancer may cause no signs or symptoms at all. The symptoms it does cause look like many other illnesses. And the pancreas sits hidden behind the stomach, small intestine, liver, gallbladder, spleen and bile ducts, so nothing is visible or easy to feel.

Put those three together and you get Aksel's situation. The conversation opens at how long, because whether was settled before anyone knew to ask.

Trier is unusually sharp on the parts nobody warns you about.

The news reaches an ex-partner second-hand, through a brother. Nobody has decided who is entitled to be told, or in what order. Then there is the question of who is entitled to grieve, which the film leaves open and which real families argue about for years.

Visitors run out of things to say. Aksel does some of the work of putting them at ease. And his long monologue is not about fearing death in the abstract. It is about mourning small ordinary things, which is what most people describe when they are asked.

Aksel stays lucid, funny and largely comfortable almost to the end. That is the film's major liberty.

Advanced pancreatic cancer commonly brings severe pain, jaundice, digestive failure and deep weakness. Weight loss is often extreme. Symptom control usually requires a lot of medication, and often heavy sedation in the last weeks.

There is also no staging conversation, no chemotherapy, and almost no sign of the palliative care team who would in practice be central. Aksel's illness is a shape in Julie's life rather than a course of treatment.

That is a defensible choice. The film is about her. But the smoothness of his dying should not be read as typical.

Most pancreatic cancers are found once they are already advanced, and that is not a story about people ignoring symptoms.

There is nothing to notice at the start. When something finally shows, the earliest signs are things that thousands of harmless conditions also cause: pain in the upper or middle abdomen that can go through to the back, weight loss with no explanation, loss of appetite, and fatigue.

One symptom behaves differently. Jaundice, meaning yellowing of the skin and the whites of the eyes, is hard to explain away. It often comes with pale stools and dark urine. Painless jaundice in an adult is the sign that most reliably gets someone assessed quickly, and it should be.

There is no pancreatic cancer screening for adults at average risk. In August 2019 the US Preventive Services Task Force gave it a grade D, which means it recommends against the test in adults without symptoms. The available tests are not good enough to do more good than harm.

Surveillance is a different thing, and the words get mixed up. Surveillance means repeated MRI or endoscopic ultrasound, run through specialist programmes, for a small group with strong inherited risk.

NCI lists the risk factors that matter here: a family history of pancreatic cancer or pancreatitis, and certain inherited conditions, including Lynch syndrome, Peutz-Jeghers syndrome, hereditary breast and ovarian cancer syndrome, familial atypical multiple mole melanoma syndrome, and ataxia-telangiectasia. Smoking, excess body weight, diabetes and chronic pancreatitis also raise risk.

If several close relatives have had pancreatic cancer, that is a reason to ask about genetic assessment. For everyone else, asking for a scan is not the answer.

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This is a film about indecision, and about the fear of having chosen wrong. Aksel's cancer is the device that closes the door on one of the choices.

As a portrait of pancreatic cancer it is honest about the timing and dishonest about the body. Take the first and leave the second.

If you are here because your skin or your eyes have turned yellow, do not wait to see whether it passes. Ask to be seen. For more, see screening and possible warning signs.

• NCI — Pancreatic Cancer Treatment (PDQ®), Patient Version
• US Preventive Services Task Force — Pancreatic Cancer: Screening (2019)

This page discusses The Worst Person in the World for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care. Spotted an error? Please email [email protected].