by Anne Katz PhD, RN, FAAN
It is well known that overweight/obesity are linked to the development of certain cancers (breast, prostate, gynecologic, colorectal) but they also play a role in recurrence of cancer and are linked to poor outcomes including decreased functional and emotional quality of life and survival (Heo et al., 2015).
Many women gain weight during and after treatment for breast cancer (Sedjo et al., 2014) and women who are moderately obese experience less protection from recurrence from endocrine therapy (Ewertz et al., 2011). Obese women tend to have larger tumours at diagnosis and a 32% increased risk of recurrence (Majed et al., 2008).
Men with prostate cancer who are obese are 44% more likely to die of their disease (Cantarutti et al., 2015). Obesity increases the risk of recurrence for men treated with radiation (Wang et al., 2015) and surgery (Chalfin et al., 2014). Obesity also increases the incidence of urinary incontinence after surgery (Wolin, Luly, Sutcliffe, Andriole, & Kibel, 2010), a significant factor in poor quality of life after treatment.
Obesity is associated with a greater risk of death in women with endometrial cancer (Arem & Irwin, 2013), cervical cancer (Frumovitz et al., 2014), and ovarian cancer (Kumar, Bakkum-Gamez, Weaver, McGree, & Cliby, 2014).
For individuals with colorectal cancer, not only is obesity a risk factor for recurrence (Scarpa et al., 2014) but it is also associated with a significant increased risk for the development of secondary cancers (Gibson et al., 2014).
What can providers do?
Health care providers MUST talk to their patients about this topic, even though it is difficult for some. Using plain language is vitally important; words have meaning and the way the message is conveyed about the need for the patient to manage their weight influences whether the patient feels stigmatized or not. The words ‘weight’ and ‘unhealthy weight’ may be more acceptable (R. Puhl, Peterson, & Luedicke, 2013). Being told that their weight is affecting their health resulted in nine times more patients being aware of this as a problem (Durant, Bartman, Person, Collins, & Austin, 2009). Patients are more likely to lose weight if told that they need to do this (Pool et al., 2014) but there is a delicate balance between motivation and feeling judged (Gudzune, Beach, Roter, & Cooper, 2013).
Cancer may present a ‘teachable moment’ for patients and their families and health care providers may be more willing to talk about this when there is evidence about the association between overweight/obesity (Coa, Smith, Klassen, Thorpe, & Caulfield, 2015), such as in the case of breast, prostate, gynecologic and colorectal cancers. In one study, 80% of individuals diagnosed with cancer changed their dietary intake however only about 50% of their family members made more health food choices (Humpel, Magee, & Jones, 2007).
Barriers and facilitators
One of the most significant barriers to discussing obesity with patients is the weight status of the health care provider. For some patients, this may be seen as a common struggle and advice from an overweight or obese health care provider may be more acceptable (Bleich, Gudzune, Bennett, Jarlenski, & Cooper, 2013). On the other hand, patients may resist advice from an overweight or obese health care provider as they appear to not be taking their own advice (R. M. Puhl, Gold, Luedicke, & DePierre, 2013).
There are a number of tools available to help the health care provider start the discussion with patients. The 5 A model, used for tobacco cessation is a helpful one as many health care providers are familiar with it.
Ask – The health care provider asks the patient about how they feel about their weight, what their eating habits are, etc.
Assess – The health care provider assesses the patient’s readiness to make changes and/or what they have done in the past to manage their weight.
Advise – The health care provider gives the patient direct information about how their weight is affecting their health.
Assist – The health care provider gives information about what the patient can do to manage their weight.
Arrange – The health care provider refers the patient for specialist help from a nutritionist as necessary and/or follow up for the patient to monitor their progress.
Other useful techniques include motivational interviewing, the Brief Negotiation Interview (Pantalon et al., 2013), and the SPIKES model. It may take multiple conversations to motivate the patient to make the lifestyle changes necessary to lose weight including dietary change and increasing physical activity. There is no magic bullet for dietary change and a single approach will not work for all patients. There is no evidence about what method may work for individuals with cancer as the focus in patients with cancer has traditionally been on preventing weight loss during treatment and managing cachexia.
Arem, H., & Irwin, M. L. (2013). Obesity and endometrial cancer survival: a systematic review. Int J Obes (Lond), 37(5), 634-639. doi:10.1038/ijo.2012.94
Bleich, S. N., Gudzune, K. A., Bennett, W. L., Jarlenski, M. P., & Cooper, L. A. (2013). How does physician BMI impact patient trust and perceived stigma? Prev Med, 57(2), 120-124. doi:10.1016/j.ypmed.2013.05.005
Cantarutti, A., Bonn, S. E., Adami, H. O., Gronberg, H., Bellocco, R., & Balter, K. (2015). Body mass index and mortality in men with prostate cancer. Prostate, 75(11), 1129-1136. doi:10.1002/pros.23001
Chalfin, H. J., Lee, S. B., Jeong, B. C., Freedland, S. J., Alai, H., Feng, Z., . . . Han, M. (2014). Obesity and long-term survival after radical prostatectomy. J Urol, 192(4), 1100-1104. doi:10.1016/j.juro.2014.04.086
Coa, K. I., Smith, K. C., Klassen, A. C., Thorpe, R. J., Jr., & Caulfield, L. E. (2015). Exploring important influences on the healthfulness of prostate cancer survivors’ diets. Qual Health Res, 25(6), 857-870. doi:10.1177/1049732315580108
Durant, N. H., Bartman, B., Person, S. D., Collins, F., & Austin, S. B. (2009). Patient provider communication about the health effects of obesity. Patient Educ Couns, 75(1), 53-57. doi:10.1016/j.pec.2008.09.021
Ewertz, M., Jensen, M. B., Gunnarsdottir, K. A., Hojris, I., Jakobsen, E. H., Nielsen, D., . . . Cold, S. (2011). Effect of obesity on prognosis after early-stage breast cancer. J Clin Oncol, 29(1), 25-31. doi:10.1200/jco.2010.29.7614
Frumovitz, M., Jhingran, A., Soliman, P. T., Klopp, A. H., Schmeler, K. M., & Eifel, P. J. (2014). Morbid obesity as an independent risk factor for disease-specific mortality in women with cervical cancer. Obstet Gynecol, 124(6), 1098-1104. doi:10.1097/aog.0000000000000558
Gibson, T. M., Park, Y., Robien, K., Shiels, M. S., Black, A., Sampson, J. N., . . . Morton, L. M. (2014). Body mass index and risk of second obesity-associated cancers after colorectal cancer: a pooled analysis of prospective cohort studies. J Clin Oncol, 32(35), 4004-4011. doi:10.1200/jco.2014.56.8444
Gudzune, K. A., Beach, M. C., Roter, D. L., & Cooper, L. A. (2013). Physicians build less rapport with obese patients. Obesity (Silver Spring, Md.), 21(10), 2146-2152. doi:10.1002/oby.20384 [doi]
Heo, M., Kabat, G. C., Strickler, H. D., Lin, J., Hou, L., Stefanick, M. L., . . . Rohan, T. E. (2015). Optimal cutoffs of obesity measures in relation to cancer risk in postmenopausal women in the Women’s Health Initiative Study. J Womens Health (Larchmt), 24(3), 218-227. doi:10.1089/jwh.2014.4977
Humpel, N., Magee, C., & Jones, S. C. (2007). The impact of a cancer diagnosis on the health behaviors of cancer survivors and their family and friends. Supportive Care in Cancer, 15(6), 621-630. doi:10.1007/s00520-006-0207-6
Kumar, A., Bakkum-Gamez, J. N., Weaver, A. L., McGree, M. E., & Cliby, W. A. (2014). Impact of obesity on surgical and oncologic outcomes in ovarian cancer. Gynecol Oncol, 135(1), 19-24. doi:10.1016/j.ygyno.2014.07.103
Majed, B., Moreau, T., Senouci, K., Salmon, R. J., Fourquet, A., & Asselain, B. (2008). Is obesity an independent prognosis factor in woman breast cancer? Breast Cancer Res Treat, 111(2), 329-342. doi:10.1007/s10549-007-9785-3
Pantalon, M. V., Sledge, W. H., Bauer, S. F., Brodsky, B., Giannandrea, S., Kay, J., . . . Rockland, L. H. (2013). Important medical decisions: Using brief motivational interviewing to enhance patients’ autonomous decision-making. J Psychiatr Pract, 19(2), 98-108. doi:10.1097/01.pra.0000428556.48588.22
Pool, A. C., Kraschnewski, J. L., Cover, L. A., Lehman, E. B., Stuckey, H. L., Hwang, K. O., . . . Sciamanna, C. N. (2014). The impact of physician weight discussion on weight loss in US adults. Obesity research & clinical practice, 8(2), e131-139. doi:10.1016/j.orcp.2013.03.003 [doi]
Puhl, R., Peterson, J. L., & Luedicke, J. (2013). Motivating or stigmatizing? Public perceptions of weight-related language used by health providers. International journal of obesity (2005), 37(4), 612-619. doi:10.1038/ijo.2012.110 [doi]
Puhl, R. M., Gold, J. A., Luedicke, J., & DePierre, J. A. (2013). The effect of physicians’ body weight on patient attitudes: implications for physician selection, trust and adherence to medical advice. Int J Obes (Lond), 37(11), 1415-1421. doi:10.1038/ijo.2013.33
Scarpa, M., Ruffolo, C., Erroi, F., Fiorot, A., Basato, S., Pozza, A., . . . Castoro, C. (2014). Obesity is a risk factor for multifocal disease and recurrence after colorectal cancer surgery: a case-control study. Anticancer Res, 34(10), 5735-5741.
Sedjo, R. L., Byers, T., Ganz, P. A., Colditz, G. A., Demark-Wahnefried, W., Wolin, K. Y., . . . Rock, C. L. (2014). Weight gain prior to entry into a weight-loss intervention study among overweight and obese breast cancer survivors. J Cancer Surviv, 8(3), 410-418. doi:10.1007/s11764-014-0351-9
Wang, L. S., Murphy, C. T., Ruth, K., Zaorsky, N. G., Smaldone, M. C., Sobczak, M. L., . . . Horwitz, E. M. (2015). Impact of obesity on outcomes after definitive dose-escalated intensity-modulated radiotherapy for localized prostate cancer. Cancer, 121(17), 3010-3017. doi:10.1002/cncr.29472
Wolin, K. Y., Luly, J., Sutcliffe, S., Andriole, G. L., & Kibel, A. S. (2010). Risk of urinary incontinence following prostatectomy: the role of physical activity and obesity. J Urol, 183(2), 629-633. doi:10.1016/j.juro.2009.09.082
Dr Anne Katz is a clinical nurse specialist and AASECT-certified sexuality counsellor at CancerCare Manitoba. She has written 2 books on the topic of cancer survivorship (After You Ring the Bell: Ten Challenges for the Cancer Survivor [Hygeia Media] and Surviving after Cancer: Living the New Normal [Rowman & Littlefield]) and 3 on cancer and sexuality.
“I am thrilled to be taking on this new role as editor of the Survivorship Section for CKN. Initially you will see regular commentary from me on key aspects of the survivorship experience that I hope will lead you to think about, talk about with your patients and care providers, and then explore further in your own reading and research. Coupled with this will be key references to new research findings in this exciting growth area of cancer care.”
Dr. Katz’ professional life is focused on providing information, education and counselling to people with cancer and their partners about sexual changes that can occur during and after treatment. But there is another important aspect to this work; Dr. Katz wants every cancer patient to be able to have a discussion about sexuality with their health care providers. And so she travels across North America (as well as Europe and the Caribbean!) teaching health care providers to ask their patients about this important part of quality of life.
If you’d like to know more about Dr. Katz and the work she does, or if you’d like her to come to your city or town, health care facility or doctor’s office, you can contact her by email.
“I am always eager to spread the word and break the silence.”