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

Discussion

In general, the studies reviewed here suggest that the negative impact of obesity on routine screening is most relevant to cervical cancer rather than breast cancer screening and to white, as opposed to African American, women. It should be noted that a small number of studies used the same databases for their analyses; for example, both Ferrante et al.[19] and Wee et al.[34] based their data on the 2000 NHIS and both reported similar findings. The present review may therefore overemphasize these results. However, even when factoring in the redundancy of these studies, there remains compelling evidence that obese women, particularly white women, tend to have lower rates of cervical cancer screening.

It has been suggested that the mammogram referral (handled by phone or fax), rather than a scheduled office visit for a Pap test (in which the women is typically weighed and required to disrobe) may lessen the impact of obesity on breast cancer screening.[21] With respect to the impact of race, teasing out racial distinctions in the literature is challenging given the variations in sample populations, methodology, covariates, and the historically low numbers of minority women included in this research. The majority of data are based on regression analyses that control for a number of variables, and factors that might account for racial differences in screening rates as a function of BMI are not readily apparent. In addition, where studies analyzed data separately by race, authors generally report results only for white and African American women.[15,24,26–28] Wee et al.[34] studied the impact of BMI on cervical cancer screening among white, African American, and Latina women, finding that obesity negatively influenced screening only for severely obese white women. Interestingly, a higher percentage of both white and Latina women cited discomfort and embarrassment as the primary reason for not obtaining Pap tests, while African American women were more likely to cite lack of physician recommendation.[34] Among Latinas, overweight and obese women were more likely than their healthy weight counterparts to cite the cost of screening as a deterring factor.[34]

Significant differences may exist between white and African American women with respect to weight consciousness and the avoidance of gynecologic examinations. Several authors have speculated that racial differences in body image and a tendency for African American women to define a larger ideal body size compared to white women account for the trends observed in studies to date.[20,36,51,52] More specifically, while African American women have the highest obesity rates in the United States, they may not experience the degree of body dissatisfaction and stigma that appears to deter white women from obtaining pelvic examinations. Wee et al.[27] examined the impact of obesity on mammography use among a racially diverse sample of women and found that low self-esteem (defined in this study as feelings of worthlessness, sadness, or hopelessness in the preceding 30 days) did not affect the relationship between BMI and breast cancer screening in the multivariate model. However, obese white women were more likely than their African American counterparts to report feelings of "worthlessness" in the last 30 days.[27] This finding appears to support the concept of racial differences in body satisfaction, which has been reported previously.[51]

Psychosocial factors related to weight stigma in health care, which may be especially relevant to the gynecologic examination, clearly warrant further study. Simply put, overweight and obese women often face disdainful and disrespectful treatment by health care providers.[13] Studies reviewed in this article suggest that while obesity does not significantly affect clinicians' likelihood of recommending routine screening, the nature of the visit and patient/provider attitudes may be discouraging obese women from obtaining routine gynecologic cancer screening and other types of preventive care. Given the current prevalence of obesity in the United States, increasing provider education on caring for obese patients in a sensitive and effective manner and reducing weight bias in the clinical setting is greatly needed. A number of concrete measures may improve obese women's comfort during clinical visits, including having armless chairs in waiting rooms, larger blood pressure cuffs, and appropriately sized examination tables, gowns, and speculums; offering women the option to refuse being weighed at each visit, and ensuring that weights are taken in a private setting, may also increase patients' comfort.[13] Research on whether such measures do in fact increase obese women's likelihood of obtaining breast and cervical cancer screening is needed.

Importantly, a number of authors cited the perceived potential for decreased accuracy of gynecologic cancer screening among severely obese women.[13,53,54] Studies suggest an association between obesity and decreased breast mass palpability[53,55] as well as decreased mammogram specificity.[56,57] However, it is unlikely that obesity directly influences the accuracy of the Pap test—although extra adipose tissue may make the speculum examination more challenging and/or decrease the palpability of ovarian and adnexal masses. Whether current large (Graves) speculums are adequate for visualization and endocervical sample collection in severely obese women may require further evaluation. In addition, self-sampling for human papillomavirus (HPV) DNA has been shown to have high accuracy when compared with conventional Pap testing,[58,59] and this may be a future option for cervical cancer screening among populations that face barriers to care. De Alba et al.,[58] who reported 90% sensitivity and 88% specificity of unsupervised self-collection, also found high satisfaction for this method among Latinas. HPV self-sampling may be one important strategy for obese and other women with documented low rates of cervical cancer screening.

Finally, the available literature suggests a critical need to improve patient–provider communication related to body weight during routine visits, such as the well-woman examination. Obesity can increase women's risk for irregular menses, dysfunctional uterine bleeding, and other gynecologic problems, making the annual examination an opportune time to discuss healthy weight strategies for women across the lifespan. One challenge is effectively offering and integrating weight loss counseling into the visit while recognizing that women may be deterred by an overemphasis on weight during a routine Pap test. Simply being told to "lose weight" is clearly ineffective and even counterproductive for many women. Not wanting to receive this type of unhelpful and perhaps condescending advice was cited by nearly one-third of participants (n = 22) in a study by Drury et al.,[41] in which BMI >27.5 kg/m2 directly correlated with delays or avoidance of health care in the past year (r = 0.33; P < .01). The need for a more holistic approach to combating obesity, focusing on overall health rather than simply weight loss, and the development of concrete weight loss strategies and goals together with the patient have been proposed.[41,60] Importantly, studies have shown that minority women are less likely than their white counterparts to receive information about the health consequences of obesity[60]—highlighting once again the need to integrate weight loss counseling into routine gynecologic care for all patients regardless of race.

Obesity is now one of the most important public health challenges in the United States and worldwide.[61] There is compelling evidence of lower rates of breast and cervical cancer screening for obese compared to healthy weight women, particularly among white women. This trend is concerning given both the epidemic proportions of obesity in the United States and the heightened risk for certain gynecologic cancers associated with obesity. Despite the large number of studies examining barriers and facilitators among women relating to gynecologic examinations and mammography, studies seldom ask specifically about body weight as a factor that may discourage women from seeking care. Research on this topic is greatly needed to inform interventions aimed at improving access to and quality of care for obese women.

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