More than two-thirds of endometrial cancer survivors are obese. Despite excellent cancer-specific outcomes, survivors of early-stage endometrial cancer experience poor general health outcomes and high mortality rates because of obesity-related comorbidities. Over time, these women are more likely to die of cardiovascular disease than any other cause, including cancer. Gynecologic oncologists desire to address obesity but report having received insufficient training. Cancer survivors confirm that gynecologic oncologists rarely and inadequately address the issue.

The Society of Gynecologic Oncology has joined ranks with other large medical organizations in calling on providers to address obesity actively with cancer survivors. With aggressive nutritional and medical treatment obese endometrial cancer survivors can lose weight. Bariatric surgery is associated with dramatic weight loss outcomes but is under-studied in this population. Gynecologic oncologists express interest in offering medical and surgical bariatric referrals to obese cancer survivors. However, the acceptability of and compliance with these referrals has not been described in this setting.

Gynecologic oncologists are poised uniquely to harness the ‘teachable moment’ provided by a cancer diagnosis and have liberal access to women during the survivorship period, which is a time when women are motivated but experience distinct challenges to healthy weight loss. In this prospective cohort study, we offered medical and surgical bariatric referrals to women with complex atypical hyperplasia or stage I or II endometrioid endometrial cancers. We describe the acceptability of and compliance with these referrals and detail weight loss attempts that are initiated within 3 months after the bariatric referral is offered. Additionally, we explore factors that are associated with the acceptability of and compliance with referrals and the initiation of weight loss attempts.

Materials and Methods

Institutional review board approval was obtained through the Cleveland Clinic (protocol # 13-1528) for this prospective intervention cohort study. Women were approached between December 2013 and September 2014 during gynecologic oncology clinic visits at Cleveland Clinic Main Campus, Hillcrest and Fairview Hospitals. Inclusion criteria were a history of complex atypical hyperplasia or a stage I or II endometrioid adenocarcinoma of the endometrium, 18-65 years old, a body mass index (BMI) ≥30 kg/m ² , and agreement of their gynecologic oncologist that they could be approached for enrollment. Exclusion criteria included stage III or IV, recurrent or progressive cancer, nonendometrioid histologic condition, poorly controlled psychiatric or medical conditions that contraindicate weight loss interventions, or an active second primary malignancy.

One of the authors (A.J.) identified potential subjects for recruitment in advance based on the inclusion and exclusion criteria that were mentioned earlier to minimize bias. The author and, occasionally research nurses at the remote sites, obtained consent and coordinated bariatric referrals, administered surveys, and collected data. Women who were already in the care of a bariatric specialist were surveyed but were not offered a referral. All other women were offered a medical referral with a bariatrician who specializes in medically supervised weight loss. Otherwise, women were offered a surgical referral if they met National Institutes of Health criteria for a bariatric surgery referral: BMI ≥40 kg/m ² or ≥35 kg/m ² with an obesity-related comorbidity.

After informed consent was obtained, women were asked to fill out a questionnaire. Three items asked women to rate their baseline beliefs regarding the acceptability of a bariatric referral, the health benefits of modest weight loss, and their relationship with their gynecologic oncologist on a Likert scale ( Figure 1 ). Baseline quality-of-life, function and symptoms were assessed with the validated European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires, both the 30-item questionnaire (EORTC QLQ-30, version 3) and the endometrial cancer module. These questionnaires were administered and scored in accordance with published guidelines. Women who declined a referral were asked to provide reasons. A priori, it was decided that these reasons would be categorized as fear of surgery, financial or insurance coverage concerns, distance from hospital, wanting to attempt weight loss independently, or not desiring weight loss.

Baseline beliefs of obese women with complex atypical hyperplasia and early endometrial cancer

The 106 women who consented for participation believed that it was appropriate for gynecologic oncologists to address obesity and believed that a loss of 10% of their body weight would be beneficial.

Jernigan. Bariatric referrals and endometrial cancer. Am J Obstet Gynecol 2015 .

A chart review was performed to collect baseline demographics that included age and race. Distance from the hospital in minutes without traffic and in miles was calculated between their home address and the hospital with the use of google-maps. Median household income was estimated with the use of their residential zip code and 2010 US Census Data. Height and weight were collected, and medical comorbidities were recorded with the use of the data from their clinic visit; BMI and Charlson Comorbidity Index (CCI) score were calculated subsequently. Tumor histologic condition, stage, treatment, and postoperative complications were recorded. Timing between intervention and diagnosis, surgery, and last treatment (surgery, chemotherapy, hormonal therapy, or radiation therapy) was calculated in days to the date the referral was offered; if treatment was ongoing, zero days were considered to have lapsed.

Three months after referral, women were contacted with an email or phone survey. Women who did not initiate a weight loss attempt were asked to identify barriers to the initiation of changes. A chart review verified compliance with bariatric referrals, defined as attending a visit with the bariatric specialist. Women who did not respond to the 3-month follow-up survey or did not have any record of compliance with a referral or initiation of weight loss attempts on chart review were considered to have not initiated a weight loss attempt.

We planned to describe our findings after 100 women were offered referrals. Study data were collected and managed with the REDCap electronic data capture tools (Vanderbilt, Nashville, TN). Statistical analysis was performed using JMP (version 10.0.2d1; SAS Institute Inc, Cary NC). Univariate analysis was performed for a relationship between demographic, treatment variables, and EORTC scores with acceptance of a referral, compliance with a referral, and initiation of a weight loss attempt. Associations between categoric covariates were assessed with χ ² tests. Group differences in means of continuous measures were evaluated with Student t tests. In addition, outcomes that were associated with continuous independent variables were compared with the use of outcomes for 1st and 4th quartiles with χ ² tests. Multivariate logistic regression models were used to assess for an association between demographic, treatment variables, and EORTC scores with acceptance of a referral, compliance with a referral, and initiation of a weight loss attempt. Confounders that were associated significantly with an outcome in the univariate model ( P < .05) were identified and included in the multivariate model. All tests were 2-tailed and were considered significant at a probability value of < .05.