Weight Loss Still a Challenge in Endometrial Cancer Setting

Pam Harrison

March 27, 2019

HONOLULU — Efforts to help women with endometrial cancer lose weight and improve their prognosis continue to disappoint with long-term follow-up. Among women who lose weight initially with a short-term intervention, the best that seems to be achievable is a stable weight, research presented here shows.

The disappointing findings were discussed here during a plenary session at the Society of Gynecologic Oncology (SGO) Annual Meeting 2019.

In reaction, experts involved in weight loss interventions suggest a more militaristic approach to weight loss for all women with endometrial cancer. For these women, obesity increases the risk of all-cause mortality by up to ninefold compared with non-obese patients, they point out.

"When a patient has a myocardial infarction, they go right into cardiac rehabilitation; you don't ask them if they want to do it, they just have to go," study lead author Andrea Hagemann, MD, Washington University School of Medicine in St. Louis, Missouri, told Medscape Medical News.

"So I think we owe it to our patients that once they are diagnosed and treated, we put them into an intervention of their choice. They can choose what they prefer to do, but they have to do something; they just have to participate," she emphasized.

Shannon Armbruster, MD, from the University of Texas MD Anderson Cancer Center in Houston, agreed, but she cautioned that physicians must stop assuming that everyone is going to respond to the same type of weight loss intervention, as that is simply not the case.

"Some people would rather work out with a partner, others would rather work out by themselves. So if we can create effective interventions — maybe 3 different ones — and allow patients to choose which one they feel most comfortable with, I think patients would be much more successful," Armbruster told Medscape Medical News.

She also emphasized that interventions must offer patients a combination of diet and physical activity because without the diet component, "patients are not going to lose weight," she emphasized.

Here, the medical community might take a page out of a program such as Weight Watchers, where dietary control remains a cornerstone of their approach to successful weight loss. This could be leveraged to improve outcomes for patients with endometrial cancer who need to lose weight, Armbruster suggested.

Furthermore, all the experts at the meeting interviewed by Medscape Medical News strongly felt that women are largely unaware that obesity contributes both to their risk of developing endometrial cancer and, if they have it, their risk of dying from this cancer.

"There are data from our institution, among others, that show that only about one third of patients understand this," session co-chair Leslie Clark, MD, from the University of North Carolina in Chapel Hill, told Medscape Medical News.

"So this is where we are failing our patients, but there is room for improvement and that is where we are trying to go," she said.

Weight Loss Intervention

Results from a weight loss intervention offered to patients with endometrial cancer in Hagemann's own clinic, presented here at the meeting, are relatively typical of the field, she said.

No more than 30% of patients who were eligible to participate in the study agreed to do so, she pointed out.

This left researchers with approximately 80 patients for study enrollment, half of whom were randomly assigned to the intervention and the other usual care.

The mean body mass index (BMI) of the group was 41kg/m2 on study enrollment, as Hagemann noted. (A BMI >40 is considered severely obese).

Initially, the intervention relied on a technology called Scaledown, a "smart" scale that automatically gives patients positive reinforcement if — upon weighing themselves — the scale shows patients have lost weight.

Unfortunately, the manufacturer of this smart scale was bought out shortly after researchers initiated the study, so they resorted to a "home-grown" approach referred to as the interactive obesity treatment approach (IOTA). In this scheme, patients were partnered with "health coaches" to motivate them to stick to goals for the rest of the study.

Regardless, neither approach incentivized patients to lose much weight, with 48% of participants in the intervention group actually gaining weight over the 6-month study interval. Another 30% either lost less than 2.5% of their body mass or had a stable weight over the study interval.

"I think we need to do better," Hagemann told delegates.

While the intervention was able to stave off weight gain in some of their patients, "we conclude that weight loss interventions are feasible but insufficient to be able to address the scale of obesity we are seeing today," she concluded.

Steps to Health Program

Armbruster reached much the same conclusion following her review of what happened to endometrial cancer survivors 10 years after they participated in a 6-month "Steps to Health" weight-loss intervention program.

One hundred women completed the Steps to Health program and, after 10 years, researchers identified some 30 patients who agreed to participate in a subsequent survey.

Ten years after they participated in the program, the median age was 70 years and the median BMI was 29.4 kg/m2 — very little difference from the median BMI of 30.4 kg/m2 on study entry, Armbruster noted. (A BMI of 30 to 35 is considered moderately obese.)

The physical and mental components of patients' functional status also remained unchanged after 10 years, she added.

However, self-efficacy, meaning participants' confidence in their ability to exercise, was significantly lower at 10 years than it was during the intervention. Median self-efficacy was 2.9 at 10 years compared with a median of 4.8 at 6 months (P < .001).

Conversely, Armbruster noted that the time spent engaging in all physical activity remained relatively stable across the years, at 720 minutes (12 hours) per week after the study intervention to 655 minutes (10.9 hours) per week at 10 years.

"We also found that women who lost 3% of their body weight during the intervention period weighed less 10 years later," she added.

Specifically, women who reported a decrease in physical activity at 10 years had a median BMI of 41.9 kg/mg2, whereas those who reported an increase in physical activity at 10 years had a median BMI of 29.1 kg/m2.  (This is the upper limit of what is considered overweight, rather than obese.)

About half of the original participants in the Steps to Health program indicated that they also participated in additional lifestyle interventions after completing the program.

"This represents an opportunity for us to intervene further to try to help patients reach their health goals," Armbruster suggested.

Nevertheless, she acknowledged that having conversations about weight and cancer can be very challenging for physicians.

"I think sometimes people can be very put off by these kinds of those conversations, so we need to look at how we present this to our patients — to let them hear what you are saying without them feeling insulted or that we are telling them that they are fat," Armbruster emphasized.

"Patients need to understand that we are coming from a place of concern and care for them," she reiterated.

Obesity and Cancer Mortality

Another presentation at the meeting highlighted the increased risk of cancer (in general) with obesity and lack of physical exercise.

This presentation reported data from the third US National Health and Nutrition Examination Survey (NHANES III), from an analysis of 3380 women, median age 55 years.

Obesity was associated with a 58% higher cancer mortality risk, whereas lower levels of physical activity increased the risk of cancer mortality by 67% compared with the non-obese and more active women in the survey.

"We also looked at survival at the time of follow-up and stratified cancer-related deaths by obesity status," Karen Levy, MD, fellow in training, Stanford University in California, told delegates.

Among non-obese women, "we found that participants who were more physically active demonstrated significantly improved survival compared to the less active group," she reported.

In contrast, more physical activity in the obese cohort did not result in a survival advantage, Levy noted.

"In fact, there was a twofold increased risk of cancer death in those who were both obese and who had less physical activity," Levy said.

"And neither race, income, or education level or number of chronic illnesses affected these outcomes," she observed.

Hagemann, Armbruster, Clark, and Levy have disclosed no relevant financial relationships.

Society of Gynecologic Oncology (SGO) Annual Meeting 2019. Abstracts 39, 40, 41. Presented March 19, 2019.

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