The Impact of Obesity on Gynecologic Cancer Screening: An Integrative Literature Review

Tess Aldrich, MSc, APRN; Barbara Hackley, CNM, MS

Disclosures

J Midwifery Womens Health. 2010;55(4):344-356. 

In This Article

Abstract and Introduction

Abstract

Introduction: Evidence indicates lower rates of breast and cervical cancer screening among obese compared to nonobese women. This integrative review examines the association between gynecologic cancer screening and body weight, as well as potential barriers to screening.
Methods: A literature search of standard computerized databases was conducted for peer-reviewed articles published between 1950 and January 2009.
Results: Twenty-three studies met the criteria for review. Of the 17 studies that evaluated rates of cervical cancer screening, 13 found obese women significantly less likely than their nonobese counterparts to have had a recent Papanicolaou test, a trend that was stronger in white women when compared to African American women. Eight of the 15 studies examining routine mammography found an inverse association between increasing body weight and recent screening, although findings generally pertained only to women who were white and/or severely obese. Possible barriers to care included embarrassment and perceived weight stigma in the clinical setting, lack of appropriately sized examination equipment, and poor patient–provider communication.
Discussion: Further research is needed to clarify the challenges that obese women face in accessing care and to evaluate strategies such as ensuring the availability of appropriate equipment and supplies, the use of alternative screening methodologies, and more culturally sensitive counseling approaches that may improve screening rates in obese women.

Introduction

The prevalence of obesity, defined as body mass index (BMI) >30 kg/m2, has increased markedly among adults in the United States in the last decade, from an estimated 23% between 1988 and 1994 to 32% in 2004.[1,2] The highest rate of obesity is among African American women, of whom 49.7% were obese in 1999 and 2000, compared to 39.7% of Mexican American women and 30% of white women.[1]

Obesity is associated with many well-documented health risks, including an increased incidence of endometrial and postmenopausal breast cancer[3–5] and later-stage breast cancer diagnosis.[6,7] Importantly, mortality from both cervical and breast cancer is also higher among obese compared to nonobese women.[4,8]

Several reasons exist for these trends. The hormonal milieu associated with obesity—namely, high levels of unopposed estrogen resulting from increased aromatization of androgen precursors in adipocytes and decreased levels of sex hormone–binding globulin—may favor the development of hormone-dependent tumors.[4] While this hormonal phenomenon is less consistently associated with cervical cancer, a number of large, population-based studies have found increasing cervical cancer mortality risk with higher BMI values, particularly with adenocarcinomas of the cervix.[4,8–10]

Despite their heightened risk for certain gynecologic cancers, a growing body of literature is documenting decreased rates of routine breast and cervical cancer screening among obese compared with nonobese women.[11–28] Obesity in the United States has historically been overrepresented among minority and lower socioeconomic groups and is perhaps associated with lower rates of health insurance[29,30]—factors that can negatively affect women's access to and use of preventive care services. However, body weight is increasingly recognized as an independent predictor of gynecologic cancer screening, with a number of large, retrospective studies finding significantly lower Papanicolau (Pap) test and mammography rates among obese women, after controlling for factors such as age, race, health insurance, socioeconomic group, and comorbidity. These findings raise questions about the implications obesity itself has on women's receipt of gynecologic care.

Primary care clinicians are uniquely positioned to increase cancer screening rates, reduce disparities in access to health care, and improve quality of care for all women. Accomplishing these goals will require better insight into high-risk groups and the specific challenges they face in the health care system. This article examines the impact of obesity on breast and cervical cancer screening, first comparing screening rates among obese and nonobese women as presented in the published literature, and secondly reviewing the articles obtained and other relevant research to identify barriers faced by overweight and obese women in obtaining recommended cancer screening tests.

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