Objective
Obesity is associated with the development and risk of death from several women’s cancers. The study objective was to describe and compare oncologic providers’ attitudes and practices as they relate to obesity counseling and management in cancer survivors.
Study Design
Society of Gynecologic Oncology members (n = 924) were surveyed with the use of a web-based, electronic questionnaire. χ 2 and Fisher exact tests were used to analyze responses.
Results
Of the 240 respondents (30%), 92.9% were practicing gynecologic oncologists or fellows, and 5.1% were allied health professionals. Median age was 42 years; 50.8% of the respondents were female. Of the respondents, 42.7% reported that they themselves were overweight/obese and that ≥50% of their survivor patients were overweight/obese. Additionaly, 82% of the respondents believed that discussing weight would not harm the doctor-patient relationship. Most of the respondents (95%) agreed that addressing lifestyle modifications with survivors is important. Respondents believed that gynecologic oncologists (85.1%) and primary care providers (84.5%) were responsible for addressing obesity. More providers who were ≤42 years old reported undergoing obesity management training ( P < .001) and were more likely to believe that survivors would benefit from obesity education than providers who were >42 years old ( P = .017). After initial counseling, 81.5% of the respondents referred survivors to other providers for obesity interventions.
Conclusion
Oncology provider respondents believe that addressing obesity with cancer survivors is important. Providers believed themselves to be responsible for initial counseling but believed that obesity interventions should be directed by other specialists. Further research is needed to identify barriers to care for obese cancer survivors and to improve physician engagement with obesity counseling in the “teachable moment” that is provided by a new cancer diagnosis.
Obesity is the second leading cause of death in the United States. The US Centers for Disease Control and Prevention report that more than two-thirds of US adults are obese or over weight and that obesity has become the leading public health problem facing industrialized nations. Increasing body mass index (BMI) is a risk factor for all-cause and cancer-related death; in women, it is a major risk factor for the development of several female cancers, which include endometrial, breast and ovarian cancers. Over one-half of breast and ovarian cancer survivors and approximately 80% of endometrial cancer survivors are obese. Many studies have shown that obese women with and without cancer have poorer health outcomes and quality of life than their nonobese counterparts. Furthermore, obesity is a significant risk factor for progression of and death from cancer.
See related editorial, page 341
For Editors’ Commentary, see Contents
In May 2012, the Institute of Medicine released an urgent report calling for American citizens to take swift action to prevent obesity by stating that, if current trends continue, nearly one-half of the population would be obese by the year 2030 and that obesity-related health care expenditures would rise to >$200 billion annually in the United States. Yet, recent reports suggest that physician assessment and behavioral management of obesity in adults is at a low level relative to the magnitude of the problem. The Institute of Medicine, STOP Obesity Alliance, and other leading organizations have outlined the scope of the obesity epidemic and stated that physicians must take an aggressive lead in fighting obesity by asking patients about their weight and recommending exercise.
Although many cohorts have a favorable cancer prognosis with the potential for long-term survival, obese cancer survivors are at risk for significant morbidity and death. Unfortunately, compared with other overweight survivor cohorts, obese gynecologic cancer survivors are not losing weight or making healthy lifestyle modifications after a cancer diagnosis. Providers who care for these women are positioned uniquely to impact the general and cancer-related health outcomes of their patients by counseling them on the risks that are associated with excess weight and initiating obesity interventions during the “teachable moment” that is provided by a new cancer diagnosis. However, there are no data regarding the educational background and approach of these providers with regards to the management of obesity in the survivorship period. The study purpose was to describe the backgrounds, attitudes, and practices of providers who care for women with gynecologic malignancies regarding lifestyle counseling and obesity management in this cohort.
Materials and Methods
The institutional review board at the Greater Baltimore Medical Center in Baltimore, MD, approved this study. After further approval by the Society of Gynecologic Oncology to conduct the study, an email invitation to participate was sent to all actively practicing North American Society of Gynecologic Oncology members in September and October 2011. Those members who did not complete the survey immediately were sent 2 additional invitations to participate. Participation was voluntary; there was no incentive or compensation offered, and the email invitation provided an “opt-out” option.
The online, 47-item survey assessed provider demographics and health information, practice characteristics, availability of obesity education resources, provider knowledge of obesity and its relationship to cancer, and opinions and practices regarding approaching obesity counseling and treatment in obese gynecologic cancer survivors. Most questions were formatted in a multiple-choice fashion. To measure the extent to which respondents agreed or disagreed with questions, many questions used a Likert Scale. Many questions were based on previous, similar survey studies in the literature. The survey also included a needs assessment to identify the scope of the obesity problem among gynecologic cancer survivors as perceived by provider respondents and to determine the preparedness of cancer providers to address obesity counseling and treatment with their patients.
Descriptive statistics were calculated with the number of responses as the denominator. Fisher exact test and the χ 2 test were used to detect differences in responses among groups with the use of Stata statistical software (version 11.1; StataCorp, College Station, TX).
Results
Two hundred forty oncology providers (30%) responded to the survey. Provider demographics are listed in Table 1 . Most respondents were gynecologist oncologists or fellows (92.9%) who reported practicing in an urban setting (66.8%) and at a university hospital (52.7%). The median respondent age was 42 years (range, 29-77 years), and 80.7% of respondents were white. Respondents were well distributed by gender, number of years in practice, and region of the country. Respondent self-reported health information is also detailed in Table 1 . Approximately 42% of respondents reported a BMI in the overweight or obese range (≥25 kg/m 2 ). Most under- and normal-weight respondents were <42 years old (53.8%); the majority of overweight or obese respondents (61.6%) were ≥42 years old ( P = .020). Male respondents were more commonly overweight or obese than female respondents (65.9% vs 20.69%; P < .001).
| Characteristic | n | % |
|---|---|---|
| Job | ||
| Gynecologic oncologist | 191 | 80.2 |
| Gynecologic Oncology fellow | 30 | 12.7 |
| Medical Oncologist | 1 | 0.4 |
| Radiation Oncologist | 3 | 1.3 |
| Allied health professional | 12 | 5.1 |
| Other | 1 | 0.4 |
| Region | ||
| New England | 24 | 10.1 |
| Mid Atlantic | 42 | 17.7 |
| Midwest | 54 | 22.7 |
| Southeast | 55 | 23.1 |
| Southwest | 28 | 11.8 |
| West | 35 | 14.7 |
| Practice setting | ||
| Urban | 159 | 66.8 |
| Suburban | 65 | 27.3 |
| Rural | 14 | 5.9 |
| Practice type | ||
| Federal government | 4 | 1.7 |
| University hospital | 125 | 52.7 |
| Community hospital | 22 | 9.3 |
| Hybrid | 44 | 18.6 |
| Solo private practice | 7 | 3.0 |
| Group private practice | 29 | 12.2 |
| Other | 6 | 2.5 |
| Years in practice | ||
| ≤3 | 74 | 31.6 |
| 4-15 | 83 | 35.5 |
| ≥16 | 77 | 32.9 |
| Age, y | ||
| <42 | 110 | 46.4 |
| ≥42 | 127 | 53.6 |
| Sex | ||
| Female | 121 | 50.8 |
| Male | 117 | 49.2 |
| Race | ||
| White | 191 | 80.6 |
| Black | 10 | 4.2 |
| Hispanic | 7 | 3.0 |
| Asian | 22 | 9.3 |
| Other | 7 | 3.0 |
| Body mass index | ||
| Underweight | 4 | 1.7 |
| Normal weight | 130 | 55.6 |
| Overweight | 71 | 30.3 |
| Obese | 29 | 12.4 |
| Adhere to American Cancer Society dietary guidelines | ||
| Not very often | 13 | 5.5 |
| Sometimes | 61 | 25.9 |
| Most of the time | 134 | 56.8 |
| Always | 28 | 11.9 |
| Exercise habits, d/wk | ||
| None | 25 | 10.6 |
| 1-2 | 78 | 32.9 |
| 3-5 | 112 | 47.3 |
| 6-7 | 22 | 9.3 |
When asked about previous training in obesity management, 54.6% reported self-directed learning; the less popularly reported modes of education included posttraining continuing medical education classes (18.3%), informal training with colleagues (17.9%), formal didactics (15.0%), and continuing medical education classes while in training (6.3%). Twenty-nine providers (12.1%) reported no training on the subject. Compared with older providers, more providers who were <42 years old reported having attended a formal course regarding obesity management during residency or fellowship training (23.6% vs 7.9%; P = .001) or informal training with colleagues (25.8% vs 11.8%; P = .007). Participation in continuing medical education courses after residency training was reported more commonly by providers who were >42 years old (26.8% vs 9.1%; P = .000) and providers who had been in practice longer (4.1%, 21.7%, and 29.9% of those respondents with <3, 4-15, and ≥16 years of experience, respectively; P < .001).
Ninety-nine percent of respondents reported that ≥50% of their patients were overweight or obese. Most providers “agreed” or “strongly agreed” that they had adequate training regarding the association of obesity with surgical complication rates (88.6%), cancer development and prognosis (66.1%), adjuvant treatment outcomes (59.1%), and physical activity recommendations (52.3%).
Approximately one-half of the respondents reported that overweight and obese gynecologic cancer survivors did not have a good understanding of the general and cancer-related implications of body weight (50%), eating habits (47.1%), or physical activity (47.7%). Most of the respondents believed that it was beneficial to educate survivors regarding the health risks of obesity (93%), healthy eating habits (96.6%), goal weight (96%), physical activity guidelines (96%), and the association of obesity with general health (96%) and gynecologic cancer prognosis (94.8%).
Table 2 stratifies provider beliefs regarding obesity interventions by provider age, sex, and BMI. An overwhelming majority of respondents (94.9%) “agreed” or “strongly agreed” that addressing weight and lifestyle modifications in women with obesity-associated gynecologic cancers is important. However, less than one-half of them (48.6%) believed that actually discussing weight goals alone was likely to help obese survivors lose weight. Female respondents ( P = .042) and providers with a BMI of <25 kg/m 2 ( P = .045) were more likely to “strongly agree” with the importance and benefit of intervention and patient education on obesity than male and overweight providers. Furthermore, provider respondents who were <42 years old were more likely than their older counterparts to “strongly agree” that survivors benefitted from education on obesity in relationship to their cancer prognosis ( P = .017).
| Variable | Provider age, % | Provider sex, % | Provider body mass index, % | ||||||
|---|---|---|---|---|---|---|---|---|---|
| <42 y | ≥42 y | P value | Female | Male | P value | <25 kg/m 2 | ≥25 kg/m 2 | P value | |
| It is important to address weight and lifestyle modifications. | .863 | .043 | .045 | ||||||
| Strongly agree | 64.4 | 60.0 | 70.1 | 53.5 | 79.8 | 51.3 | |||
| Agree | 29.9 | 35.3 | 27.6 | 38.4 | 25.0 | 42.1 | |||
| It is necessary to educate gynecologic cancer survivors on the health risks of obesity. | .179 | .003 | .313 | ||||||
| Strongly agree | 45.3 | 32.1 | 51.1 | 26.5 | 44.2 | 32.4 | |||
| Agree | 47.7 | 60.7 | 42.0 | 66.3 | 49.5 | 60.8 | |||
| Discussing weight goals with overweight and obese cancer survivor can help them lose weight. | .037 | .055 | .105 | ||||||
| Strongly agree | 11.6 | 9.4 | 13.6 | 7.1 | 11.6 | 9.3 | |||
| Agree | 46.5 | 29.4 | 45.5 | 31.0 | 34.7 | 42.7 | |||
| Patients benefit from education on | |||||||||
| Goal weight | .441 | .000 | .002 | ||||||
| Strongly agree | 67.4 | 55.8 | 75.0 | 48.2 | 70.8 | 50.7 | |||
| Agree | 29.1 | 39.5 | 21.6 | 47.1 | 29.2 | 40.0 | |||
| Healthy eating habits | .714 | .005 | .006 | ||||||
| Strongly agree | 72.0 | 66.3 | 80.7 | 57.6 | 77.1 | 60.0 | |||
| Agree | 25.6 | 29.1 | 18.2 | 36.5 | 22.9 | 32.0 | |||
| Physical activity | .885 | .008 | .030 | ||||||
| Strongly agree | 72.1 | 68.6 | 80.7 | 60.0 | 77.1 | 62.7 | |||
| Agree | 23.3 | 27.9 | 18.2 | 36.9 | 21.9 | 29.3 | |||
| Obesity and cancer prognosis | .017 | .000 | .038 | ||||||
| Strongly agree | 72.1 | 53.5 | 78.4 | 47.1 | 70.8 | 53.3 | |||
| Agree | 22.1 | 41.9 | 19.3 | 45.9 | 27.1 | 37.3 | |||
| Obesity and general health | .099 | .001 | |||||||
| Strongly agree | 74.4 | 59.3 | 79.5 | 54.1 | 74.0 | 58.7 | .097 | ||
| Agree | 22.1 | 36.0 | 18.2 | 40.0 | 24.0 | 34.7 | |||
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