Managing Obesity in Survivors of Gynecologic Cancer

Allison Staley, MD, MPH

Allison Staley, MD, MPH

Obesity influences the development and management of gynecologic cancer through several mechanisms, including hormonal, inflammatory, and metabolic pathways. Prospective data demonstrate a significantly increased risk of mortality from cancers of the breast, uterus, cervix, and ovary in women who are considered obese.¹ With nearly 40% of the adult population in the Unites States classified as obese (body mass index [BMI] ≥30kg/m²), gynecologic oncologists must be ready to address the specific needs and considerations for this population, including for patients who have entered survivorship.

Addressing modifiable risk factors for recurrence is the crux of survivorship goals following primary cancer treatment. Patients must be counseled regarding the known risks of obesity in the setting of a malignancy diagnosis. Nonobese women with endometrial cancer have better survival rates than obese women.² Therefore, interventions aimed at addressing risk factors for cardiovascular disease will likely have greatest potential to improve survival in women with endometrial cancer, particularly low-grade and early-stage disease.³

Patient education is key to successful survivorship. In a survey of 1500 healthy women, nearly 60% were not aware that obesity increased the risk of developing endometrial cancer.⁴ In another survey, only 53.5% of women with endometrial cancer were aware that obesity was a factor in the development of their disease.⁵

Further, only 37% of patients report that their healthcare provider discussed the relationship between their obesity and development of gynecologic malignancy.⁶ In a survey of 450 gynecologic oncology providers, 40% reported feeling that they had adequate preparation to counsel patients on weight loss strategies, but only 11% of responders reported receiving formal training in obesity management, most often from conference lectures or self-directed reading.⁷ Women’s health providers must be poised to advise and support women on obesity’s relationship to cancer development and recurrence. Within this dialogue must be a discussion of tangible strategies to attain sustainable weight loss, including lifestyle changes, pharmacologic interventions, and bariatric surgery.

The Physician’s Role in Patient Counseling

Clinical evidence consistently shows that patients who receive directed counseling from physicians are more likely to lose weight and use appropriate methods to do so.⁸ Many national cancer organizations promote obesity education and weight loss as a priority for effective cancer care. The American Society of Clinical Oncology has recommended the Assess, Advise, and Refer framework as an approach for providers to address obesity with their patients. Providers should take the following steps:

Assess the patient’s BMI at each office visit. Any BMI that is not within normal limits must be qualified and discussed with the patient.

Advise a patient considered obese on the associated reproductive health risks, such as malignancy, infertility, surgical complications, and high-risk pregnancy and preterm birth. Acknowledging these events as potential downstream effects of obesity can be a productive first step in increasing patient motivation and engagement in strategies for weight loss.

Refer the patient to weight loss management centers, community programs, or bariatric surgery consultation, particularly for the population classified as morbidly obese.⁹

Lifestyle Changes and Weight Loss Programs

Providing even a small amount of directed nutrition and lifestyle counseling leads to significant changes in patient diet and weight loss. Williams et al reported that 5 physician-directed counseling sessions over 1 year can successfully result in weight loss for women.¹⁰ Additionally, community-based programs offer the required consistency and affordability for patients who are uninsured, underinsured, or who lack financial support. YMCA organizations, for instance, provide nutrition consultations in addition to fitness education across the country. For cancer survivors, Livestrong provides 12-week, small-group programming to increase healthy nutrition and physical activity through the YMCA. More novel payment structures are required to support these community-based programs, but such structures may offer more financial availability to patients needing to meet out-of-pocket costs.^8,11

For patients who need pharmacologic intervention, there are 2 categories of anti-obesity drugs: central acting appetite suppressants, or satiety enhancers, and peripherally acting agents. The FDA has approved 5 pharmacologic agents for weight-loss management: orlistat, lorcaserin (Belviq), phentermine/topiramate, naltrexone/bupropion (Contrave), and liraglutide. These agents have been approved for use in patients with a BMI ≥30 or in patients with a BMI ≥27 with 1 obesity-related comorbidity. These medications are available as prescriptions, and orlistat can be purchased over the counter.

Common adverse effects of these drugs include nausea, vomiting, and constipation, and education regarding drug-specific effects is required for safe medication management. For providers, these agents may be used as safe adjuncts to lifestyle modifications and close counseling to achieve demonstrable weight loss.

Bariatric surgery, which commonly includes Roux-en-Y gastric bypass, adjustable gastric banding, and sleeve gastrectomy, has been shown effective in both short-term and long-term patient outcomes. This surgery lowers all-cause mortality and reduces the cardiovascular and diabetic effects of obesity.¹² A US retrospective cohort demonstrated a 60% decrease in cancer-related deaths following bariatric surgery, providing evidence of the correlation between obesity and cancer.¹³ Depending on the procedure type, weight loss typically ranges from 15% to 32% within the first 2 years following surgery and stable loss of 15% to 25% at 10 years.¹⁴

Patients may qualify for bariatric surgery if they have BMI ≥40 without comorbidity or BMI ≥35 with one or more severe obesity-related diseases.¹⁵ In spite of these well-documented benefits to health and quality of life, fewer than 1% of qualified patients undergo bariatric surgery. For patients with gynecologic cancer, systematic reviews show that patients favorably view a weight loss discussion with their cancer care provider, and patients are more likely to consider or receive bariatric surgery if a physician referred them for consultation.^16,17

A coordinated multidisciplinary and systematic effort is required to address the prevention and treatment of obesity, as the sequela of this disease is a clear risk factor for the development of gynecologic malignancy and other comorbidities. Support for weight loss interventions and transparent patient education are paramount. This worldwide health problem is ever growing, and women’s healthcare providers must be ready to address the specific needs and considerations for this population.

References

1. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of US adults. N Engl J Med. 2003;348(17):1625-1638. doi: 10.1056/NEJMoa021423.
2. Arem H, Irwin ML. Obesity and endometrial cancer survival: a systematic review. Int J Obes (Lond). 2013;37(5):634-639. doi: 10.1038/ijo.2012.94.
3. Ward K, Shah NR, Saenz CC, McHale MT, Alvarez EA, Plaxe SC. Cardiovascular disease is the leading cause of death among endometrial cancer patients. Gynecol Oncol. 2012;126(2):176-179. doi: 10.1016/j.ygyno.2012.04.013.
4. Soliman PT, Bassett RL, Jr, Wilson EB, et al. Limited public knowledge of obesity and endometrial cancer risk: what women know. Obstet Gynecol. 2008;112(4):835-842. doi: 10.1097/AOG.0b013e318187d022.
5. Beavis AL, Cheema S, Holschneider CH, Duffy EL, Amneus MW. Almost half of women with endometrial cancer or hyperplasia do not know that obesity affects their cancer risk. Gynecol Oncol Rep. 2015;13:71-75. doi: 10.1016/j. gore.2015.07.002.
6. Clark LH, Ko EM, Kernodle A, et al. Endometrial cancer survivors’ perceptions of provider obesity counseling and attempted behavior change: Are we seizing the moment? Int J Gynecol Cancer. 2016;26(2):318-324. doi: 10.1097/ IGC.0000000000000596.
7. Neff R, McCann GA, Carpenter KM, et al. Is bariatric surgery an option for women with gynecologic cancer? Examining weight loss counseling practices and training among gynecologic oncology providers. Gynecol Oncol. 2014;134(3):540-545. doi: 10.1016/j.ygyno.2014.06.006.
8. Nawaz H, Adams M, Katz D. Weight loss counseling by health care providers. Am J Public Health. 1999;89(5):764-767. doi: 10.2105/AJPH.89.5.764.
9. Liu L, Segura A, Hagemann A. Obesity education strategies for cancer prevention in women’s health. Curr Obstet Gynecol Rep. 2015;4(4):249-258. doi: 10.1007/ s13669-015-0129-8.
10. Williams LT, Hollis JL, Collins CE, Morgan PJ. Can a relatively low-intensity intervention by health professionals prevent weight gain in mid-age women? 12-month outcomes of the 40-Something randomized controlled trial. Nutr Diabetes. 2014;4:e116. doi: 10.1038/nutd.2014.12.
11. Vojta D, Koehler TB, Longjohn M, Lever JA, Caputo NF. A coordinated national model for diabetes prevention: linking health systems to an evidence-based community program. Am J Prev Med. 2013;44(suppl 4[4]):S301-S306. doi: 10.1016/j. amepre.2012.12.018.
12. Schauer PR, Bhatt DL, Kirwan JP, et al; STAMPEDE Investigators. Bariatric surgery versus intensive medical therapy for diabetes—3-year outcomes. N Engl J Med. 2014;370(21):2002-2013. doi: 10.1056/NEJMoa1401329.
13. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753-761. doi: 10.1056/NEJMoa066603.
14. Sjostrom L, , Narbro K, Sjöström CD, et al; Swedish Obese Subjects Study. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741-752.
15. Mechanick JI, Youdim A, Jones DB, et al; American Society for Metabolic & Bariatric Surgery. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient — 2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery. Obesity. 2013;21(suppl 1):S1-S27. doi: 10.1002/oby.20461.
16. Jernigan AM, Mauer KA, Cooper K, et al. Referring survivors of endometrial cancer and complex atypical hyperplasia to bariatric specialists: a prospective cohort study. Am J Obstet Gynecol. 2015;213(3):350.e1-10. doi: 10.1016/j. ajog.2015.05.015.
17. Funk LM, Jolles S, Fischer LE, Voils CI. Patient and referring practitioner characteristics associated with likelihood of undergoing bariatric surgery: a systematic review. JAMA Surg. 2015;150(10):999-1005. doi: 10.1001/jamasurg.2015.1250.