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

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


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

In This Article


Gynecologic Cancer Screening in Obese and Nonobese Women

Twenty-six studies were identified that explored differences in breast and/or cervical cancer screening based on obesity status. Of these, 23 studies met the criteria for review.[11–28,31–35] Seven of the 23 studies pertain to Pap tests, six to mammography, and 10 to both cervical and breast cancer screening. The majority of the studies are cross-sectional, retrospective analyses of population-based surveys, such as the National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS), or chart reviews. Two studies used a prospective design,[11,13] which allowed for more detailed questions about women's and providers' perspectives. In general, studies examining cervical cancer screening included women 18 years of age and older, while those specific to mammography limited analyses to women ≥40 years of age to correspond to mammography screening guidelines.

The majority of studies determined the proportion of women having obtained a Pap test and/or mammogram within the previous 1 to 3 years. Most authors calculated BMI from participants' self-reported weight and height and used the following World Health Organization (WHO) categories: normal weight (BMI 19–24.9 kg/m2), overweight (BMI 25–29.9 kg/m2), class I obesity (BMI 30–34.9 kg/m2), class II obesity (BMI 35–39.9 kg/m2), and class III obesity (BMI ≥40 kg/m2). Five studies[12,14,16,17,25] examined overall predictors of gynecologic cancer screening, of which obesity and/or BMI was one; in these cases, obesity was usually examined as a binary variable.

Seventeen studies examined the association between cervical cancer screening and obesity,[11–13,17–26,32–35] with all but two[18,22] finding a significant inverse association between obesity and recent Pap testing and one[25] reporting a borderline significant association (Table 1). Where analyses were conducted separately based on race, results are included in Table 1. In general, large, retrospective studies of national survey data found a trend of less cervical cancer screening with increasing BMI, although this finding pertains only to white women in several of the studies.[20,24,26,34] A number of studies also found a significant inverse association between high BMI and up-to-date cervical cancer screening only for severely obese women.[13,32,17] Datta et al.[17] were the only authors to study African American women exclusively in a large, national survey, and these authors found that women who were either underweight (BMI <20) or severely obese (BMI ≥30) were significantly more likely to have delayed Pap testing than their healthy weight counterparts.

Of the two studies that found no association between obesity and cancer screening,[18,22] the Lubitz et al.[22] study was based on a very low overall cervical cancer screening rate of roughly 20% in a sample of primarily low-income, minority women at an urban teaching hospital. The most common reason cited for not performing a Pap test regardless of patients' weight was lack of physician time, followed by terminal illness and advanced age. However, physicians were significantly more likely to cite acute illness, vaginitis, or menstruation as reasons for delayed Pap tests among obese compared to nonobese women (odds ratio [OR] = 4.59; 95% confidence interval [CI], 1.67–12.5). Ferrante et al.[18] found obese women significantly less likely than healthy weight women to have had a recent Pap test in crude analyses; however, their results were not significant in the adjusted model.

Fifteen studies examined routine mammography rates by body weight, with eight reporting significant differences in screening between obese and nonobese women (Table 2).[14,16,19,20,24,27,32] In general, the association between BMI and breast cancer screening was not as consistent as that between obesity and cervical cancer screening. Several large, retrospective studies of national data observed a significant association, although it generally pertained only to women in the most extreme category of obesity.[19,27,32] Cohen et al.,[15] who surveyed a large sample of women in the Southern Community Cohort Study, the majority of whom were African American, also found that only black women with BMI ≥40 kg/m2 were significantly less likely than their nonobese counterparts to have had a mammogram in the past 2 years, an association that was not significant for obese and nonobese women of other ethnicities. Interestingly, Wee et al.[27] analyzed 1998 NHIS data and observed that while white women with class III obesity had lower rates of recent mammography than their nonobese counterparts, obesity was associated with increased screening among African American women.

Several studies that reported significantly lower rates of cervical cancer screening with increasing BMI failed to observe a similar trend for mammography in multivariate analyses.[18,21,26,33] In addition, a recent study of 100,197 New Hampshire women ≥40 years of age found that while underweight women were less likely than their healthy weight counterparts to have had a mammogram in the previous 2 years (OR = 0.57; 95% CI, 0.48–0.68), women who were in the overweight and obesity class I and II categories were slightly more likely to adhere to regular screening.[31] The authors point to major public education campaigns and recent advances to reduce the physical discomfort of mammography as possible reasons for discrepancies between this and earlier studies that observed a reverse trend.[14,20] Colbert et al.[16] was the only study identified that examined age of initiation of screening mammography based on body weight, and these authors found that obese women began screening 1.6 years later than healthy weight women (P < .001) in a large, predominantly white population. Here, the effect of obesity on age of first mammogram was greater than that of race or ethnicity.[16]

Understanding Barriers to Care

A recent review by Cohen et al.[36] examining the association between obesity and breast, cervical, and colorectal cancer screening also found an inverse relationship between increasing BMI and rates of both Pap tests and mammograms, with the latter applying only to white women. This review included many of the same studies as those detailed in this article. However, Cohen et al.[36] highlighted many of the methodologic differences among studies. In this article, we include studies published since the Cohen et al.[36] article and also explore some reasons for observed differences in screening rates for the purpose of identifying areas for future study and intervention.

Given the consistency of these findings in the literature, it is imperative to understand why obese women tend to receive less screening. Despite the number of published reports on the negative impact of obesity on gynecologic cancer screening, limited qualitative data exist to explain the observed trends. However, findings from studies reviewed in this article suggest several possible explanations that are both patient- and provider-driven. These factors may act as barriers to breast and cervical cancer screening for obese women, thereby placing them at greater risk for disease.

Obese Women's Attitudes and Perceptions towards Gynecologic Cancer Screening

Several studies have documented pervasive weight bias and stigma—both subtle and overt—among health care professionals, which can manifest in various forms.[37–39] In a small study of obese, predominantly white men and women, participants cited friends, spouses, family members, and health care professionals among the most common sources of weight stigma.[40] Amy et al.[13] conducted one of a small number of studies to explore both women's and providers' views regarding the impact of obesity on gynecologic cancer screening. In this study, which employed focus groups and structured interviews to elicit respondents' views on receiving breast and cervical cancer screening, overweight women reported discourteous treatment by clinic staff, being told they were "too heavy" for a Pap test, and being examined using medical equipment, gowns, and examination tables that were too small, making the visit awkward or even painful.[13] Importantly, women also cited a tendency for clinicians to ascribe patients' diverse health complaints to their obesity alone and to give unwanted counsel on weight loss.[13] Such practice implies a trend among providers to overemphasize a patient's weight in setting the visit's agenda, which may not correspond to a woman's own needs. These types of provider attitudes, whether real or perceived, may undermine overall quality of care received by obese women.

The available literature also suggests that attitudes of embarrassment, stress, and fear among obese women regarding gynecologic cancer screening play an important role in deterring them from seeking care. In a recent study by Mitchell et al.,[33] which found a decreased likelihood of recent Pap testing for overweight and obese women, severely obese women were twice as likely as normal weight controls to cite "fear" as a deterring factor, in reference to the pain of the examination, shame and embarrassment, and concern that the test would detect a malignancy or pathology.

A related theme common to several studies on avoidance of preventive health care visits among obese women is reluctance to be weighed at each visit and to receive what is perceived as unhelpful advice about weight loss.[13,23,41] Olson et al.[23] studied 310 female nursing staff at a Wisconsin community hospital and found that appointment cancellation—including appointments for Pap testing—was significantly associated with higher BMI but was unaffected by participants' age, education, occupation, or reason for last visit. Among the roughly 13% of women who cancelled visits for weight-related reasons, the most common motives were shame and reluctance to be "lectured" about their weight, as reported by 25% of obese and 55% of extremely obese women (P < .001).[23] Similar results were reported by Drury et al.,[41] who documented greater avoidance of health care with increasing BMI because of women's shame at having gained weight since their last visit.

Provider Perceptions Regarding Gynecologic Examinations in Obese Women

Health care provider attitudes and practices regarding the gynecologic examination and obese women likely play a critical role in influencing care-seeking behavior. This concept could apply to subtle negative attitudes providers convey to heavier women during the examination as well as to more overt actions, such as the lack of recommendations or referrals for obese women to be screened. In a survey of 1316 physicians and 291 women, Adams et al.[11] found that patients' likelihood of receiving routine Pap tests decreased as BMI increased; importantly, 17% of providers expressed a disinclination to perform the pelvic examination in obese women and 83% of providers were reluctant to examine women who themselves appeared reluctant. Providers' specific reasons for reluctance to perform Pap tests in larger women were not reported, though aversion was greater among younger physicians.[11] In a more recent prospective study with primary care providers, including nurse practitioners and other nursing professionals, 85% of respondents stated that the gynecologic examination was more challenging in obese women.[13] More than half of respondents also stated they had received no specific training on providing gynecologic care to severely obese patients and expressed a desire for such training. In response to an open-ended question on what would aid them the most in caring for large women, providers listed general information on health care for the very obese and more accessible supplies that are sized appropriately for obese patients, including larger speculums, gowns, and blood pressure cuffs.[13] Respondents also cited the challenge of providing adequate counseling and health education in the very short visit.

Research on provider recommendations for breast and cervical cancer screening in obese women is limited, although in general, studies do not suggest strong disparities in provider referrals based on body weight.[19,22,27] Using patient data obtained from a computerized medical record system, Lubitz et al.[22] analyzed physician and resident reports of Pap testing—and reasons for not testing—eligible women. The likelihood of performing the test for obese and nonobese women did not differ significantly after controlling for patient age and race. The authors point out, however, that this was a secondary analysis of data, and overall cervical cancer screening rates were very low, at roughly 20%. In a much larger study that included white, African American, and Latina women responding to the 2000 NHIS, Wee et al.[27] also found that, among women who had not had a Pap test in the 3 years preceding the survey, both obese and nonobese women were equally likely to have received a physician recommendation to be screened. Ferrante et al.[19] reported similar findings.

Increased Illness Burden in Obese Women

Several authors suggest that overall poor health status among obese women may also deter them from obtaining routine cancer screening and other preventive care, often in spite of seeing multiple providers and spending significant amounts of money on health care.[18,19,21,33,42–44] Obesity increases the risk for cardiovascular disease, osteoarthritis, obstructive sleep apnea, pregnancy complications, and menstrual irregularities, and is associated with other endocrine pathologies, such as polycystic ovarian syndrome.[45,46] In a retrospective study with women 50 to 75 years of age, Beckman et al.[47] observed that women with diabetes had significantly lower rates of screening mammography than matched controls, adjusting for race and insurance status, despite averaging a higher number of office visits. Similar findings were reported by Fontana et al.,[48] who observed that having diabetes reduced women's odds of recent mammography by roughly one-half (OR = 0.53; 95% CI, 0.29–0.97); women with heart disease were also less likely than those without to have had a recent Pap test (OR = 0.32; 95% CI, 0.19–0.54). An inverse association between increasing comorbidity and the likelihood of recent cervical cancer screening[49] and mammography acceptance[50] has also been shown. In addition to the impact of competing health care priorities on routine cancer screening, obese women may tend to see multiple providers/specialists but lack a primary "gatekeeper" who ensures that they receive routine screenings. No studies were identified that specifically support this concept, which deserves further exploration.


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