Obesity and Cancer: The Meaning of Patient Advocacy

| November 17, 2009

This is a CE-accredited article. The timeline for submitting the post-test for this article has expired.

ABSTRACT
According to a recent analysis by the American Institute for Cancer Research, about 100,500 new cases of cancer are thought to be caused by obesity every year. This study which is the most comprehensive attempt ever to estimate the cancers attributed to extra weight poses implications for clinicians who advocate for patients of size. Statistics pertaining to weight and cancer prevalence, screening, diagnostic testing, and strategies for patient advocacy are discussed.

INTRODUCTION
Excess weight is thought to be linked to nearly 100,000 cancer deaths in the United States each year.[1] Yet, researchers suggest that most Americans do not realize being overweight is a risk factor for many forms of cancer.[2] Perhaps providers overlook opportunities to discuss the relationship between obesity and malignancy with their patients with obesity because of the urgency presented by other health issues. For example, consider the significant comorbidities that pose everyday struggles, such as sleep apnea, diabetes mellitus, and dyslipidemia.

In 2007, the American Cancer Society published data that explained that among men in the United States, cancers of the prostate, lung and bronchus, and colon and rectum account for about 54 percent of all newly diagnosed cancers. Prostate cancer alone accounts for about 29 percent (218,890) of incident cases in men. The three most commonly diagnosed types of cancer among women in 2007 are thought to be cancers of the breast, lung and bronchus, and colon and rectum, accounting for about 52 percent of estimated cancer cases in women. Breast cancer alone is expected to account for 26 percent (178,480) of all new cancer cases among women.[3]

Based on 2002 data from the American Cancer Society, cancers linked to obesity comprise approximately 51 percent of all new cancers among women and 14 percent among men.[4] Further research from the American Cancer Society suggests that, at least in the United States, obesity is responsible for 20 percent of all cancer deaths in women and 14 percent in men.[2] The American Cancer Society further estimates that 90,000 people each year are dying from obesity-related cancers. Experts concluded that cancers of the colon, breast (postmenopausal), endometrium, kidney, and esophagus are associated with obesity.[5] Some studies have also reported links between obesity and cancers of the gallbladder, ovaries, and pancreas.[6] Obesity and physical inactivity may account for 25 to 30 percent of several major cancers: colon, breast (postmenopausal), endometrial, kidney, and cancer of the esophagus.[6] Obesity as a risk factor for a number of cancers is discussed in this article along with appropriate screening recommendations. Ideas for special diagnostic considerations are discussed. Strategies for providers to serve as patient advocates in awareness and access in helping patients meet these screening recommendations—acknowledging weight and size as realistic barriers—are described. Illustrative composite case vignettes are included.

CONCERNS OF OBESITY
The incidence and severity at diagnosis are especially problematic for larger, heavier individuals. For example, one study, which specifically examined the relationship between breast and cervical cancer and unrecognized barriers to screening among women with obesity, presents the threat of delays in preventive and early intervention.[7] Although the mechanism of incidence is debatable, the severity of cancer at initial diagnosis may be due to delays in diagnosis (See The Voice of Mary).[8] The severity of cancer on initial diagnosis may occur because either the examining physician is reluctant to perform proper examinations or because the patient is hesitant to allow a comprehensive assessment (See Refusal of Care). Early diagnosis is key and may impact survival rate.[8] For example, in terms of mortality, for women, obesity-related cancers are estimated to comprise 28 percent of cancer-related deaths in 2002: 15 percent breast cancers (39,600 deaths), two percent uterine cancers (6,600 deaths), and 11 percent colorectal cancers (28,800 deaths). Among men, obesity-related cancers are estimated to comprise 13 percent of cancer-related deaths in 2002: 10 percent colorectal cancers (27,800 deaths) and three percent kidney cancers (7,200 deaths).[4] Obesity may impact treatment as well. Intravenous (IV) drug administration can be challenging if clinicians have difficulty with IV access among larger, heavier patients whose veins may be hidden deep beneath the skin surface. Radiation therapy tables may not accommodate the weight of a larger person and radiation may not penetrate through extensive fatty tissue, thereby interfering with diagnostic studies.

REDUCING RISKS
Research suggests that preventing weight gain could reduce the risk of developing many cancers.[6] However, a survey conducted in 2002 showed that only one percent of the respondents knew that maintaining a healthy weight was an effective way to reduce their risk of cancer.2 Experts recommend that people establish habits of healthy eating and physical activity early in life to prevent overweight and obesity.[6] Those who are already overweight or obese are advised to avoid additional weight gain and to lose weight through a low-calorie diet and additional exercise.[9] Even a weight loss of 5 to 10 percent of total weight can provide health benefits.[10] People of size must recognize the relationship between weight and health. Trusted providers are in the best position to discuss this relationship with the patient and set realistic health goals, which include healthy eating and activity objectives.

Sufficient evidence exists to support recommendations that adults and children maintain reasonable weight for their height and ages for multiple health benefits, including decreasing their risk of cancer.[11] However, with the difficulty in losing and maintaining weight, this is not always possible. Providers are encouraged to reach out to resources, such as the American Cancer Society, an organization that is doing its part to help individuals control risks by publishing guidelines for healthy eating and activity. American Cancer Society recommends balancing calorie intake with physical activity by eating at least five servings of fruit and vegetables every day, choosing whole grains over processed grains, and limiting red meat.[12] Adults should engage in at least 30 minutes of moderate physical activity five days a week or more.[13] Patients who have limited physical mobility or strength may benefit from a physical therapist or other expert who understands the unique needs of a larger person who may have an unusual body habitus with a weight maldistribution that makes physical activity difficult. Keep in mind, there is an increased risk of falls among larger, heavier individuals because of impaired postural balance.[14] Patients with morbid obesity often report joint pain, instability, decreased mobility, functional limitations, peripheral neuropathy, and other conditions that interfere with activity.[15] Obesity is an independent risk factor for falls.[16] Recent research suggests excess weight and weight maldistribution impact balance and postural sway. For example, an extreme anterior or posterior position of the body’s center of mass relative to the ankle joint and potential health-related factors, such as muscular atrophy, are likely to exacerbate the risk of falling in an individual who is obese.[17] Each of these factors are thought to increase the risk of functional limitations that lead to falls. Increased obesity correlates with impaired postural balance and falls even in younger individuals aged 40 and below.[15] A specific plan of action for activity that addresses these risks protects the patient who is attempting to make healthy lifestyle changes.

CANCER SCREENING
A recent report suggests that screening for breast, cervical, and colon cancer saves lives,[18] but too few Americans are getting the recommended screens or getting them regularly enough. Robert Smith at the American Cancer Society explains that the rate of screening for breast and cervical cancers has stayed about the same since 2000, while the rate of colorectal cancer screening has increased—but not as fast as experts had hoped.[19] For example, only 50.6 percent of men and women age 50 to 64, and 57.6 percent of those older than 65, have regular colonoscopies. In addition, only about 19 percent of adults have regular fecal occult blood tests. Among women, 60.7 percent of those age 40 to 64 have mammograms; that number slips to 59.8 percent for women age 65 and over.

The best way for consumers to make sure screening is accomplished according to the American Cancer Society recommendations is for consumers to remind doctors when it is time to have a screening test. Patients such as Mary (See The Voice of Mary) not only fail to remind their providers when a mammogram is due, but will often find reasons to delay the exam. Perhaps as a healthcare professional in the field of bariatrics, you can work with the clinic or out-patient center where the mammogram will take place and asking the following questions: Will the technician understand that a larger woman is scheduled for mammography? Is additional time allotted? Are special provisions in place such as an oversized gown or chairs?

The American Cancer Society publishes guidelines for cancer screening screening.20 For cervical cancer, women should access regular Papanicolaou (Pap) smears, starting at age 20. For breast cancer, women should start receiving regular breast examinations at age 20 and annual mammograms at age 40. For colorectal cancer, both men and women should start regular screening at age 50. Many surgeons who perform weight loss surgery (WLS) require preoperative cancer screening based on American Cancer Society guidelines.

Cancer screening guidelines are recommended for those people at average risk for cancer and without any specific symptoms.[18] People who are at increased risk for certain cancers may need to follow a different screening schedule, such as starting at an earlier age or being screened more often. For example, research suggests postmenopausal women with abdominal adiposity appear to be at higher risk for breast cancer than women whose fat is distributed over the hips, legs and buttocks. Therefore, the distribution of body fat serves as a measure to predict a woman’s risk of developing breast cancer, and screening recommendations ought to be considered based on these unique variations in individuals. Because women with overweight and obesity have higher mortality rates for cervical and breast cancer, they should be targeted for increased screening.[7] Those with symptoms that could be related to cancer should see their provider right away. For individuals aged 20 or older having periodic health exams, a cancer-related checkup should include health counseling, and depending on a person’s age and gender, might include exams for cancers of the thyroid, oral cavity, skin, lymph nodes, testes, and ovaries, as well as for some noncancerous conditions.[18] This screening is best accomplished as part of a comprehensive health exam.[21]

A clinical breast exam performed by a healthcare provider should be part of a physical exam about every three years for women in their 20s and 30s and every year for women 40 and over.[9] In addition to the hormonal effects of being overweight, excess fat deposits in the breasts make it more difficult to detect small lumps during a clinical breast exam, which can delay early detection of the disease. Women should know how their breasts normally feel and report any breast change promptly to their provider. As advocates, providers must encourage woman in clinical breast exam starting in their 20s. Women at risk should be followed more closely by their provider, who will decide what further action might be necessary—this could include an annual mammogram and or magnetic resonance imaging (MRI) every year.

Beginning at age 50, both men and women at average risk for developing colorectal cancer should undergo screening designed to find both early cancer and polyps.[22] The choice as to the screening test for an individual is best decided on by the patient and his or her provider.

All women should begin cervical cancer screening about three years after they begin having vaginal intercourse, but no later than when they are 21 years old. Screening should be done every year with the regular Pap test or every two years using the newer liquid-based Pap test. Beginning at age 30, women who have had three normal Pap test results in a row may get screened every 2 to 3 years. Another reasonable option for women over 30 is to get screened every three years (but not more frequently) with either the conventional or liquid-based Pap test, plus the human papillomavirus (HPV) deoxyribonucleic acid (DNA) test. Women who have certain risk factors such as diethylstilbestrol (DES) exposure before birth, human immunodeficiency virus (HIV) infection, or a weakened immune system due to organ transplant, chemotherapy, or chronic steroid use should continue to be screened annually.[9]

Both the prostate-specific antigen (PSA) blood test and digital rectal examination should be offered annually, beginning at age 50, to men who have at least another 10-year life expectancy. Men need to speak with their provider to determine if they fall into a high-risk category based on ethnicity, family tendencies, or other factors that might indicate the need for screening at an earlier age. Information should be provided to all men about what is known and what is uncertain about the benefits, limitations, and harms of early detection and treatment of prostate cancer so that they can make an informed decision.[19]

SPECIAL DIAGNOSTIC CHALLENGES
Staging and diagnostic studies can be challenging in the presence of obesity. Selecting the proper advanced diagnostic tool will depend not only on the clinical situation but also the patient’s weight and body configuration.[23] Although a brain MRI may be the most appropriate technique for evaluating a low-grade glioma, if the patient cannot fit into the MRI scanner, this is not a reasonable diagnostic option. Therefore, before scheduling a patient with obesity for a diagnostic imaging procedure, it is important to know the patient’s weight and circumference, at the largest point, to assess whether the patient will fit properly. Table weight limits and aperture diameters for fluoroscopy differ from those for computed tomography (CT) and for MRI. Currently, industry standards exist for table weight limits and aperture diameters for each of the imaging techniques. In increasing order of cross-sectional diameter, according to current industry standards, the imaging techniques are fluoroscopy, CT, cylindric bore MRI, and vertical bore open MRI. Patients who exceed the manufacturer’s suggested weight limits of the diagnostic table might not only damage the mechanics of the table, but injure the caregiver or themselves. The equipment carries a warranty insured to a specific weight. The cost to repair damage caused by a heavier patient is not likely covered under the manufacturer’s warranty. In some cases, patients may meet the weight limit of a table but may exceed the gantry or bore diameter because of their girth. Typically, the industry-standard aperture in fluoroscopy is 18 inches; the gantry diameter in CT, including multidetector-row computed tomography (MDCT), is nearly 28 inches; and the bore aperture in MRI is 24 inches. Although the aperture diameters are accurate in the horizontal plane on CT and MRI, they do not account for the table thickness entering the gantry or bore and therefore overestimate the vertical distance. Typically, in the vertical plane, 6 to 7 inches must be subtracted from the gantry or bore diameter to account for the table thickness. Patients and caregivers should be spared the embarrassment of unsuccessful attempts to perform diagnostic examinations with inappropriately sized equipment.

Weight and aperture limit data should be posted and be made easily available within the department and on patient care units. Despite these industry standard limits, some imaging vendors are now recognizing the issue of obesity and have increased the table weights and aperture dimensions of their newest imaging equipment.

Physical limitations on equipment are not the only diagnostic challenges. The exams themselves may differ in larger, heavier patients with a high degree of adiposity. For example, radiographs are limited by X-ray beam attenuation that results in lower image contrast. Also, the increased body thickness through which the X-ray beam must travel results in increased exposure time and introduces motion artifact. The typical setting to obtain a chest radiograph is a kVp of 90 to 95 and mAs of 2 to 2.5. However, in patients with obesity these settings can result in inadequate penetration of the X-ray beams through the patient’s body, along with more background scatter.24 Care needs to be taken when performing and relying on diagnostic exams performed on patients with obesity.

In the event a staging or other diagnostic procedure needs to be accomplished in the operating room, a standard table operating room may not accommodate the patient properly. Hospitals and outpatient surgical centers need to factor in the accommodation of patients with severe obesity patients as part of their surgical table purchase decisions. Suppliers and manufacturers have responded to the need for tables that hold higher capacity weight and some operating room tables will accommodate 1,200 pounds. Manufacturers are also responding to the need for adjustable heights of operating room tables. When performing procedures on certain patients with morbid obesity, the incision site could be very high because the abdomen is so large. In this case, surgeons have expressed the need for the operating room table to be as low as possible so that staff members are able to ergonomically reach the patient. Tables are available to support, raise, and lower patients as heavy as 1,100 pounds. Patients as heavy as 600 pounds can be fully positioned into various surgical postures and can also be moved along the longitudinal slide of the table top. Complementing the tables are a complete line of table accessories including table-width extensions that expand from 20 to 28 inches and split-leg sections. Modular designs and accessories mean existing tables can be upgraded with bariatric capabilities. Bariatric restraints available with some tables help assure secure positioning of the heaviest patients, while bariatric power-lift stirrups utilize gas-spring assistive technology to help users easily lift the legs of patients with obesity into lithotomy postures. Consider a pressure redistribution surface on the operating room table to counter the stress of pressure on the soft tissue. Talk with vendors and seek resources as these products continue to evolve based on consumer need.[25]

ADVOCATING FOR AWARENESS AND ACCESS
Patients should be encouraged to ask providers about access to cancer screening procedures. Staff members scheduling procedures should be advised of the patient’s body weight to ensure providers or technicians have the opportunity to pre-plan for procedures. When scheduling procedures, patients should be encouraged to ask if the facility is able to accommodate their weight and body configuration. Patients should also be encouraged to ask about appropriately fitting gowns. If the facility does not have provisions for larger patients, individuals should feel encouraged to bring a clean, properly fitted gown. Healthcare professionals referring patients who are obese for diagnsotic examinations should determine before the appointment if the exam table or diagnostic equipment of the facility will accommodate the patient width and weight.

CONCLUSION
Trends in cancer incidence and mortality include stabilization of incidence rates for all cancer sites combined in men from 1995 through 2004 and in women from 1999 through 2004 and a continued decrease in the cancer death rate since 1990 in men and since 1991 in women. Overall, cancer death rates in 2004 compared with 1990 in men and 1991 in women have decreased by 18.4 percent and 10.5 percent, respectively, resulting in the avoidance of over a half million deaths from cancer during this time interval. This suggests that both cancer incidence and mortality in the United States have decreased in the past two decades.26 Although this study reflects all cancers, the drop in cancer rates is attributed mostly to fewer cases of prostate and colorectal cancer among men and fewer cases of breast and colorectal cancer among women. Lung cancer continues to increase, especially among women.[27]

Health is ultimately the responsibility of the patient. Understanding the risks of obesity is the first step. Recognizing the value of cancer screening procedures is the next. However, a challenge for patients is access to procedures at facilities able to accommodate the larger, heavier patient. If reasonable accommodation cannot be accomplished, patients as well as referring physicians should discuss and investigate alternative options. Members of the healthcare team are in the best position to advocate for patients seeking health-promoting activities irrespective of weight.

REFERENCES
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25.    Akridge J. Maximum capacity: facilities, manufacturers respond to soaring obesity rates with bariatric products and equipment for the continuum of care. Healthcare Purchasing News. January 2007.
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