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Obesity/Overweight and Cancer

Obesity2by 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




annekatzDr 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.”



The Power of Exercise for Cancer Survivors

CarolMichaelsby Carol Michaels MBA, ACE, ACSM owner of Carol Michaels Fitness and the creator of Recovery Fitness


“I am a four-year breast cancer survivor. Of course this has led to many challenges for me, especially with having to face physical limitations after surgeries. When I first came to the Recovery Fitness class I could not raise my right arm. It was difficult to walk because of extreme pain in my right leg. Any slight movement caused pain in my chest because my chest has been so tight as a result of my bilateral mastectomy. Due to these and other problems, I became very depressed and pretty much gave up on trying doing anything; only leaving home for doctor’s appointments. That changed when I took a chance and began to exercise. After coming to the class twice a week for five months, I can raise my arm straight up without pain. I can walk better and my chest isn’t as tight and sore as it was.  This has given me the confidence I was lacking and I feel good about myself again. There are still rough days, but my exercise class gives me the opportunity to work on my challenges with others that can relate to what I’m dealing with. The class has changed my life and has helped me physically and mentally.”


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Caregiver Tips to Stay Active

exercise-bedby Ann Fonfa, Survivor, Cancer Patient Advocate


When my mother was in the early stages of Alzheimer’s Disease, she lived with my sister.  I was only working part time for my husband’s business so I could fly out to spend time with her and give my sister a break.  I would spend two to three weeks with her at a time.  It wasn’t long before I realized my own health was suffering.  My mother didn’t want to walk about like she used to and I was growing uncomfortable with my own physical inactivity.

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Commentary: Cancer Related Fatigue

Fatigue2by Doris Howell, RN, PhD 

Read the article in the Current Oncology Journal:

A pan-Canadian practice guideline and algorithm: screening, assessment, and supportive care of adults with cancer-related fatigue

Cancer-related fatigue (CRF) is a universal side effect of most cancer treatments, particularly chemotherapy, radiotherapy, or immune therapies. 1-3 About a third of post-treatment survivors, will also experience persistent or chronic fatigue for years. 4-6 Fatigue is described by patients as one of the most distressing symptoms of cancer as it interferes with daily living, affects cognitive functioning, work performance, and negatively impacts quality of life (QoL).7-10 CRF has also been described as the most under-acknowledged and under-treated cancer symptom.11 It is often cited that there is no effective medical treatment for fatigue since its etiology is not yet fully explained.12 This is often reinforced in health care communication to patients and can lead to under-reporting of CRF as patients assume it is untreatable and must be tolerated.13 Yet, our review of the evidence in the pan-Canadian practice guideline for assessment and management of fatiguetargeted to health care practitioners shows there are effective interventions that can improve the patients’ subjective experience of fatigue.14 Moreover, emerging research suggests that many of these interventions (i.e. exercise) may also play a role in altering the biological mechanisms that are hypothesized to cause CRF and its persistence long after treatment ends.15,16 More recent reviews provide further compelling evidence of the efficacy of interventions, particularly activity or exercise-based interventions, on reducing fatigue.17,18 In spite of this evidence, patients may still not be receiving the best advice to manage fatigue.19

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Survivorship Series: More Studies Support Exercise During and After Cancer

exercise4 by Anne Katz, PhD, RN 

This Monthly Survivorship Series, written by CKN Survivorship Editor, Anne Katz, is provided by CKN with permission from ONS.  We hope this series will become a useful resource that will help to facilitate dialogue between cancer patients, their loved ones and their physicians with a view towards improving the quality of life for cancer survivors.  

I keep finding articles on the role of exercise in cancer survivorship. I think someone is trying to get a message to me – over the years I have personally fallen off that wagon and have finally conquered that demon and now love my daily time on the treadmill!

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Exercise in Cancer: Progressing Towards Integration

by Daniel Santa Mina, PhD; Andrew G. Matthew, PhD

Read the original paper in Current Oncology here.

Any comprehensive (and arguably introductive) discussion of strategies to optimize cancer survivorship considers the role of exercise.  Following a diagnosis, exercise has been shown to improve pre-, peri, and post-treatment physical and psychosocial outcomes in many cancers and their related treatments.  The breadth of the existent evidence that describes these benefits continues to grow at an unmatched rate in the field of complimentary therapies in oncology.  As such, reviews of the literature have been published multiple times per year over the past few years.  Certainly, one would assume that with this rapidly expanding volume of evidence, a movement towards clinical integration of exercise in oncology would follow in haste.  Unfortunately, this has not been the case as community-based or clinically-integrated cancer exercise programs remain the exception rather than the norm, even amongst larger tertiary care institutions.  However, there are signs that we are on the cusp of a new era in survivorship where exercise is considered an essential adjunct therapy and is recommended to a majority of patients with some facilitation of a safe and effective exercise prescription.

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