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Obesity-Related Cancer in Women

A Clinical Review

Katz, Anne PhD, RN, FAAN

AJN The American Journal of Nursing: August 2019 - Volume 119 - Issue 8 - p 34–40
doi: 10.1097/01.NAJ.0000577332.56265.51
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There is mounting evidence that obesity is linked to numerous types of cancer that affect both sexes. But the incidence of obesity-related cancers is particularly high among women. Obesity is implicated not only in the development of cancer, but also in cancer recurrence, treatment complications, and poor patient outcomes. Nurses, particularly those caring for women, should be aware of these associations so they may provide effective patient teaching about preventing cancer and mitigating its adverse effects. The author discusses the role of obesity in the development and recurrence of cancer in women; describes weight loss interventions that may reduce cancer risk in overweight or obese patients; and suggests interviewing techniques to help nurses sensitively address the topic of overweight and obesity with their female patients.

The author discusses the role of obesity in the development and recurrence of breast, gynecologic, and colorectal cancers in women; describes weight loss interventions that may help overweight or obese patients reduce their cancer risk; and explains interviewing techniques to address the often-sensitive topic of overweight and obesity.

Anne Katz is a clinical nurse specialist at CancerCare Manitoba, Winnipeg, Canada. Contact author: anne.katz@cancercare.mb.ca. The author and planners have disclosed no potential conflicts of interest, financial or otherwise.

Figure 1.

Figure 1.

Obesity rates have reached an all-time high in the United States, with the latest National Center for Health Statistics prevalence data showing that 39.8% of U.S. adults are obese—38% of American men and 41.5% of American women.1 Over the past decade, the role that overweight and obesity play in cancer development, recurrence, and related mortality, particularly among women, has become increasingly clear. A population-based study that examined the relationship between body mass index (BMI) and cancer incidence estimated that, in 2012 in North America, of the cancers newly diagnosed in women, 78,984 (9.4%) were attributable to overweight or obesity, compared with 31,792 (3.5%) of the cancers newly diagnosed in men.2 Furthermore, gynecologic cancers are among those with the strongest evidence for the association with obesity. (For a depiction of overweight-and-obesity–related cancers, see Figure 1.)

When Han and colleagues conducted an analysis of the Atherosclerosis Risk in Communities cohort study, which included nearly 16,000 American men and women ages 45 through 64, they found that being overweight or obese in young adulthood (ages 18 to 29) and weight gain from young to older adulthood increases cancer risk. Specifically, they determined that a woman's BMI at age 25 appears to raise her risk of developing cancer (particularly endometrial cancer) at a later point, regardless of subsequent weight change, and both BMI at age 25 and weight gain from that point forward are associated with an increased risk of postmenopausal breast cancer.3 The longer a woman is overweight or obese, the greater her risk of developing an obesity-related cancer, with incidence of postmenopausal breast cancer and endometrial cancer rising (after adjustment for degree of overweight) by 8% and 37%, respectively, for every 10 years in which BMI is 10 units above normal weight.4 From 1997 to 2014, obesity rates rose more rapidly among adult cancer survivors than among the general population, with the annual increase in obesity prevalence among breast cancer survivors and female colorectal cancer survivors estimated to be 3% and 3.1% higher, respectively, than that of adults without a cancer history.5 Nurses caring for women of all ages need to be aware of the association between obesity and cancer in order to provide appropriate patient teaching and support.

This article discusses the role of obesity in the development and recurrence of breast, gynecologic, and colorectal cancers in women; describes weight loss interventions that may help overweight or obese patients reduce their cancer risk; and explains interviewing techniques that can help nurses better communicate with female patients about the often sensitive topic of overweight and obesity.

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BREAST CANCER

Pathophysiologic links between obesity and breast cancer. Epidemiological data demonstrate a strong, positive correlation between high levels of circulating estrogen and breast cancer in postmenopausal women who do not use postmenopausal hormone therapy. Obese postmenopausal women tend to develop hyperandrogenism and to have increased conversion of androgens to estrogen in adipose tissues. By increasing levels of circulating estrogen, obesity increases cell proliferation, reduces apoptosis, and raises the risk of developing breast cancer.6 Obesity is also associated with higher levels of circulating and local proinflammatory cytokines, which promote tumor angiogenesis.7 In addition, the development of breast cancer has been significantly associated with the presence of metabolic syndrome,8, 9 which is defined as the presence of at least three of the following features:

  • central obesity
  • hypertension
  • low levels of high-density lipoprotein cholesterol
  • high levels of low-density lipoprotein cholesterol
  • high blood glucose levels
  • high triglyceride levels

Behavioral factors linking obesity and breast cancer. A Danish study of more than 5,000 women from the Diet, Cancer, and Health Cohort found that obese postmenopausal women were significantly less likely to undergo mammographic screening than women of normal weight, though screening was free of charge.10 Nonparticipation in such screening could potentially delay breast cancer diagnosis until the disease is advanced and less responsive to treatment. The investigators suggest that this lower rate of participation may be attributable to poorer general health or greater disease burden than that seen in women of normal weight.10

Effects of weight on breast cancer prognosis. Central obesity is specifically associated with triple-negative breast cancer (characterized by estrogen receptor–negative, progesterone receptor–negative, and human epidermal growth factor receptor 2–negative tumors), which has a poorer outcome than other types of breast cancer and is more commonly found in African American women.11

Women who met the criteria for grade 2 obesity (BMI of 35 to 39 kg/m2) and grade 3 obesity (BMI of 40 kg/m2 or higher) were at greater risk for invasive breast cancer (hazard ratio [HR], 1.58; 95% CI, 1.40–1.79), larger tumor size (HR, 2.12; 95% CI, 1.67–2.69), and lymph node involvement (HR, 1.89; 95% CI, 1.46–2.45) in a secondary analysis of the Women's Health Initiative clinical trials.12 All are indicators of poor prognosis. But even a weight gain of 15 lbs. in four years has been shown to significantly increase the risk of breast cancer in otherwise healthy premenopausal women.13

Risk of breast cancer recurrence and death. A meta-analysis by Chan and colleagues identified 82 studies with a total of 213,075 breast cancer survivors that provided data on BMI before and after diagnosis, as well as total and cause-specific mortality. Their analysis found that, compared with women of normal weight, women who were obese (with a BMI of more than 30 kg/m2) before diagnosis, within 12 months of diagnosis, and 12 or more months after diagnosis had a 41%, 23%, and 21% higher risk of total mortality and a 35%, 25%, and 68% higher risk of breast cancer mortality, respectively.14 In a meta-analysis of data from 12 studies with a total of 23,832 women, a weight gain of 5% or more of body weight after breast cancer diagnosis increased risk of death from any cause (HR, 1.12; 95% CI, 1.03–1.22; P = 0.01), and risk was greater when weight gain exceeded 10% of body weight.15

Obesity is also associated with breast cancer recurrence after five years, a period of time after which risk of recurrence is generally considered to be substantially reduced.16 The link between obesity and risk of breast cancer recurrence and death is most clearly established for women with estrogen receptor–positive disease,17 which suggests that obesity may be so significant to overall health that the harm it causes negates the benefits of many medications, such as endocrine blockers, used to treat women with hormone-sensitive breast cancer.

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GYNECOLOGIC CANCERS

Endometrial cancer. Obesity and overweight increase both a woman's lifetime risk of developing endometrial cancer and her risk of developing it earlier in life.18 The increased risk is associated not only with adult obesity but also with childhood and adolescent obesity.19 High BMI at age 18 is associated with a nearly 30% increased risk of developing endometrial cancer (hazard rate ratio [HRR], 1.29; 95% CI, 1.12–1.49) for each five-unit increase in BMI, and adult weight gain raises the risk by more than 80% (HRR, 1.81; 95% CI, 1.66–1.98) per five-unit increase in BMI.20

Treatment for endometrial cancer is often effective, especially if the cancer is diagnosed early; the most common cause of death in endometrial cancer survivors is cardiovascular disease.21 Weight loss, an intervention that nurses can encourage in overweight or obese patients, is well known to help reduce the risk of cardiovascular disease. In addition, weight loss has been shown to reduce the risk of developing endometrial cancer by as much as 44%.22

The risk of cervical cancer is also increased in overweight (odds ratio [OR], 1.25; 95% CI, 0.79–2) and obese (OR, 1.70; 95% CI, 1.10–2.63) women.23 The reason for this is not clear, as cervical cancer is usually associated with human papillomavirus.

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COLORECTAL CANCER

While it is widely recognized that overweight and obesity significantly raise the risk of developing colorectal cancer, obesity is also associated with poorer outcomes, including cancer recurrence, cancer-specific mortality, and a lower rate of disease-free survival.24 Obesity in early life (adolescence and young adulthood) appears to further increase risk of colorectal cancer in women in later life.25 National data have shown that obese patients with colorectal cancer have more surgical complications, a greater prevalence of comorbidities and perioperative mortality, and greater health care utilization.26 In some studies, obese patients undergoing rectal cancer surgery had increased conversion rates of laparoscopic to open surgery and increased postoperative morbidity.27 Although laparoscopic surgery is considered superior to open procedures in obese patients, the risks of infection and anastomotic leak from laparoscopic surgery are significantly greater in obese patients than in patients of normal weight.28

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CHALLENGES IN TREATING CANCER IN OBESE WOMEN

Because chemotherapy doses are calculated on the basis of body surface area (BSA) and generally capped at a BSA of 2 m2 to prevent toxicity, obese women may receive insufficient chemotherapy to treat their cancer effectively.29, 30 Increased visceral fat (the “apple-shaped” body type) in postmenopausal women receiving neoadjuvant chemotherapy for breast cancer is associated with poorer outcomes, including shorter disease-free survival.31

Posttreatment complications. Breast cancer survivors, especially women who were premenopausal at breast cancer diagnosis and received a long course of chemotherapy, are significantly more likely to gain 5% or more of their prediagnosis body weight within 23 months after diagnosis.32 This weight gain is believed to result from treatment-induced menopause and such associated changes as fat accumulation, altered fat distribution, and reduced lean body mass. Compared with women of normal weight, obese women experience more wound complications (seroma, hematoma, skin dehiscence, and delayed healing), perfusion complications (fat and flap necrosis), and infections with surgical treatment, as well as face significantly higher costs related to complications of breast reconstruction following mastectomy.33

Gynecologic cancer surgery complications, such as venous thromboembolism, wound infection, 30-day readmission, and delayed wound healing, are more likely to occur when the patient is obese.34, 35 When operating on obese women, it may be more difficult for surgeons to visualize the operative field.36 Estimated blood loss, operating time, and hospital length of stay are all greater for obese women treated surgically for endometrial cancer.37 Using minimally invasive surgical techniques may minimize complications for obese women.35

Obesity complicates radiation therapy, particularly when the radiation is directed at the pelvis, because the beams must travel a greater depth to reach targeted organs, thereby exposing healthy organs to more radiation.38 Obese women treated with radiation for endometrial cancer experience significantly more severe radiation toxicity affecting both skin and internal organs.39 Obese women whose breast cancer is treated with radiation therapy have been found to experience more severe treatment-related symptoms, poorer quality of life, and worse functional well-being, both during treatment and for long periods afterward.40

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DISCUSSING WEIGHT AND WEIGHT LOSS IN CANCER

Broaching the subject of weight loss with a patient is challenging under any circumstances, but it may be even more so when the patient has been diagnosed with or treated for cancer. Both patients and their families may believe that maintaining weight, or even having some weight “to spare,” is somehow protective in cancer. While cachexia associated with cancer is obviously a concern, intentional weight loss by an overweight or obese patient is another matter entirely, and family and friends who don't realize this may actively discourage weight loss in cancer survivors, believing that weight loss indicates disease progression.

The weight of the health care provider—and the patient's response to that weight, or the response the provider anticipates—are also potential barriers to initiating a discussion of weight loss. Nurses and other health care providers who are themselves overweight or obese may hesitate to introduce the subject of weight loss with patients.41 How patients perceive and respond to a provider's weight seems to vary. One study found that patients were less likely to follow weight loss suggestions from an overweight or obese physician,42 but another found that overweight patients may identify more readily with and be more motivated by health care professionals whose weight status is similar to their own.43 Overweight nurses have reported feeling self-conscious about the way they are perceived by patients but have also reported being more critical of overweight patients, perhaps because they are critical of their own weight status.44 Nevertheless, the overweight or obese health care provider may be able to build a therapeutic alliance with the patient by virtue of their empathy and understanding of the fact that losing weight can be a struggle. When a health care provider talks to patients in a nonjudgmental manner about the health risks of excess weight, patients are more likely to attempt to lose weight.45 Patient–provider rapport is important. Studies have shown that when health care practitioners demonstrate empathy and provide reassurance, patients are more satisfied and more likely to attempt weight loss.46

A diagnosis of cancer provides a teachable moment for many patients and their families. In the face of a life-threatening illness over which the patient and their loved ones have little control, changing behaviors or lifestyle is often a means of achieving control. Patients may be encouraged to learn that there is good evidence weight loss in overweight breast cancer survivors lowers levels of estrone and estradiol, both of which are associated with cancer recurrence,47 and weight loss has been found to lower the risk of cardiovascular disease in postmenopausal breast cancer survivors.48

The terms used to discuss overweight, obesity, and weight management affect how the patient receives the message. The public has been shown to prefer terms such as “weight” and “unhealthy weight” to terms like “morbidly obese,” “obese,” or “fat.”49 In an attempt to seem less judgmental, health care providers may use vague terms or euphemisms when speaking about weight, but this choice to “soften” the terminology used to characterize a patient's weight problem may not sufficiently motivate the patient to attempt weight loss. In one study of primary care providers, physicians avoided using the word “obese” to describe their patients’ obesity and instead used such phrases as “your weight may be damaging to your health.”50 However, patients in the study reported that the word “obesity” highlighted the seriousness of their health issue and considered the term less upsetting than the euphemism.

The importance of nutrition. Nurses have been shown to have limited awareness of the importance of good nutrition in cancer survivorship.51 For this reason, many may not raise the topic with their patients, even though commonsense advice to follow the American Cancer Society recommendations (see www.cancer.org/healthy/eat-healthy-get-active/acs-guidelines-nutrition-physical-activity-cancer-prevention/summary.html) can prompt patients to initiate lifestyle changes. While nurses aren't expected to provide detailed weight loss interventions to patients, they can certainly discuss the risks of being overweight or obese in the context of cancer prevention and survivorship, as well as the benefits of maintaining a healthy weight and participating in physical activity.

Interventions to address overweight and obesity. While counseling patients on intensive weight loss strategies is beyond the scope of practice for most nurses, there are some evidence-based interventions that can be encouraged. Although little research has been conducted on weight control interventions for cancer survivors,21 Chlebowski and Reeves reviewed randomized controlled trials of weight loss interventions and concluded that telephone-based interventions are feasible and effective in motivating female cancer survivors; in all trials reviewed, however, weight loss maintenance was the biggest challenge.52

A review of commercial weight loss programs found that, after 12 months, Weight Watchers and Jenny Craig were more effective in producing weight loss in participants than education and counseling,53 though this review did not target trials that specifically included cancer survivors.

Pharmacologic agents and bariatric surgery have proven effective in reducing weight in noncancer populations,54 but their role in cancer survivors has not been established.

Whether exercise in addition to weight loss improves outcomes in cancer survivors has also not been established,55 but 150 minutes of moderate to vigorous physical activity with two sessions of strength training per week, which is deemed safe for cancer survivors and effective in both alleviating fatigue and improving quality of life,56 may also aid in weight loss. Furthermore, research presented at the 2018 Cancer Survivorship Symposium found that exercise can have both short- and long-term benefits for patients undergoing anticancer treatment, including chemotherapy.57

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Discussion techniques. There are a number of techniques nurses can use to initiate a discussion about weight loss with patients. These include motivational interviewing58 and the brief negotiation interview,59 both of which may be helpful, though they are somewhat complex and time consuming (see Motivational Interviewing60 and The Brief Negotiation Interview59). Another technique, the 5 A's model (see The 5 A's Model61), is mandated by the Centers for Medicare and Medicaid Services when counseling patients about weight.62 It is simple to use and familiar to many health care providers because of its use in tobacco cessation counseling. The 5 A's are ask, assess, advise, assist, and arrange.

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THE PATIENT PERSPECTIVE

Many women, even those who have been diagnosed and treated for cancer, don't realize that obesity raises the risks of developing cancer and of cancer recurrence.63 In a study of women with endometrial cancer, fewer than half knew that obesity was a risk factor for their cancer (44.4%) or about the association between obesity and breast cancer (49.6%) or obesity and colorectal cancer (48.1%).63 Only 38% had discussed their weight with an oncologist. Research suggests, however, that gynecologic cancer survivors are eager to receive information from their health care providers about weight management, including weight loss and lifestyle changes that can aid in weight loss. In fact, of 244 patients with gynecologic cancer who responded to a survey on this subject, 79% reported that they would try to lose weight if a physician suggested they do so.64

Social factors may influence a woman's receptivity to the suggestion of weight loss. The fat acceptance movement, which promotes the acceptance of overweight and obesity, has gained increasing support over the past decade.65 Demographic data and responses to a survey concerning beliefs about personal weight were collected from 150 women who self-identified as African American.66 Of the participants, one (0.7%) was underweight, 34 (23%) were normal weight, 36 (24%) were overweight, 57 (38%) were obese, and 22 (15%) were morbidly obese. Although more than three-quarters of the sample were overweight, obese, or morbidly obese, 51% of the entire sample reported feeling good about themselves, and only 50% recognized their weight as a risk factor for serious health problems. (The survey did not specifically ask about cancer.)

Emotional eating is not uncommon in the context of depression or posttraumatic stress disorder.67 Cancer survivors may experience symptoms of posttraumatic stress,68 and this may prompt them to reach for unhealthy food to self-medicate and reduce their bad feelings. It is important for nurses to talk about this openly and help patients find more effective coping strategies to deal with stressors and to encourage them to seek out family members and friends who support their weight loss efforts.

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HEALTH CARE PROVIDERS’ RESPONSIBILITY

Evidence linking obesity to the development and recurrence of cancer, as well as to cancer treatment complications, is strong. Associations such as the American Society of Clinical Oncology69 recognize this link and have prioritized initiatives focused on obesity prevention and treatment. The responsibility for addressing this issue, however, lies with all health care providers, especially those who care for women, in whom nearly 10% of new cancer diagnoses are associated with obesity.2 Lifestyle changes are challenging to make, but nurses who recognize and take advantage of teachable moments can do much to raise awareness of the importance of maintaining a healthy weight for overall good health.

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REFERENCES

1. Hales CM, et al Prevalence of obesity among adults and youth: United States, 2015-2016 NCHS Data Brief 2017 288 1–8
2. Arnold M, et al Global burden of cancer attributable to high body-mass index in 2012: a population-based study Lancet Oncol 2015 16 1 36–46
3. Han X, et al Body mass index at early adulthood, subsequent weight change and cancer incidence and mortality Int J Cancer 2014 135 12 2900–9
4. Arnold M, et al Duration of adulthood overweight, obesity, and cancer risk in the Women's Health Initiative: a longitudinal study from the United States PLoS Med 2016 13 8 e1002081
5. Greenlee H, et al Trends in obesity prevalence in adults with a history of cancer: results from the US National Health Interview Survey, 1997 to 2014 J Clin Oncol 2016 34 26 3133–40
6. Zhang X, et al Adult body size and physical activity in relation to risk of breast cancer according to tumor androgen receptor status Cancer Epidemiol Biomarkers Prev 2015 24 6 962–8
7. Picon-Ruiz M, et al Obesity and adverse breast cancer risk and outcome: mechanistic insights and strategies for intervention CA Cancer J Clin 2017 67 5 378–97
8. Berrino F, et al Metabolic syndrome and breast cancer prognosis Breast Cancer Res Treat 2014 147 1 159–65
9. Bitzur R, et al Metabolic syndrome, obesity, and the risk of cancer development Eur J Intern Med 2016 34 89–93
10. Hellmann SS, et al Body mass index and participation in organized mammographic screening: a prospective cohort study BMC Cancer 2015 15 294
11. Bandera EV, et al Obesity, body fat distribution, and risk of breast cancer subtypes in African American women participating in the AMBER Consortium Breast Cancer Res Treat 2015 150 3 655–66
12. Neuhouser ML, et al Overweight, obesity, and postmenopausal invasive breast cancer risk: a secondary analysis of the Women's Health Initiative randomized clinical trials JAMA Oncol 2015 1 5 611–21
13. Rosner B, et al Short-term weight gain and breast cancer risk by hormone receptor classification among pre- and postmenopausal women Breast Cancer Res Treat 2015 150 3 643–53
14. Chan DS, et al Body mass index and survival in women with breast cancer—systematic literature review and meta-analysis of 82 follow-up studies Ann Oncol 2014 25 10 1901–14
15. Playdon MC, et al Weight gain after breast cancer diagnosis and all-cause mortality: systematic review and meta-analysis J Natl Cancer Inst 2015 107 12 djv275
16. Biganzoli E, et al Recurrence dynamics of breast cancer according to baseline body mass index Eur J Cancer 2017 87 10–20
17. Jiralerspong S, Goodwin PJ Obesity and breast cancer prognosis: evidence, challenges, and opportunities J Clin Oncol 2016 34 35 4203–16
18. Nevadunsky NS, et al Obesity and age at diagnosis of endometrial cancer Obstet Gynecol 2014 124 2 Pt 1 300–6
19. Elizondo-Montemayor L, et al Gynecologic and obstetric consequences of obesity in adolescent girls J Pediatr Adolesc Gynecol 2017 30 2 156–68
20. Stevens VL, et al Body weight in early adulthood, adult weight gain, and risk of endometrial cancer in women not using postmenopausal hormones Cancer Causes Control 2014 25 3 321–8
21. Laskey RA, et al Obesity-related endometrial cancer: an update on survivorship approaches to reducing cardiovascular death BJOG 2016 123 2 293–8
22. Luo J, et al Intentional weight loss and endometrial cancer risk J Clin Oncol 2017 35 11 1189–93
23. Lee JK, et al Mild obesity, physical activity, calorie intake, and the risks of cervical intraepithelial neoplasia and cervical cancer PLoS One 2013 8 6 e66555
24. Doleman B, et al Body mass index and colorectal cancer prognosis: a systematic review and meta-analysis Tech Coloproctol 2016 20 8 517–35
25. Kim H, Giovannucci EL Sex differences in the association of obesity and colorectal cancer risk Cancer Causes Control 2017 28 1 1–4
26. Hussan H, et al Morbid obesity is associated with increased mortality, surgical complications, and incremental health care utilization in the peri-operative period of colorectal cancer surgery World J Surg 2016 40 4 987–94
27. Qiu Y, et al Outcome of rectal cancer surgery in obese and nonobese patients: a meta-analysis World J Surg Oncol 2016 14 1 23
28. Fung A, et al Laparoscopic colorectal cancer resections in the obese: a systematic review Surg Endosc 2017 31 5 2072–88
29. Fontanella C, et al Impact of body mass index on neoadjuvant treatment outcome: a pooled analysis of eight prospective neoadjuvant breast cancer trials Breast Cancer Res Treat 2015 150 1 127–39
30. Raman R, et al Effect of body mass index- and actual weight-based neoadjuvant chemotherapy doses on pathologic complete response in operable breast cancer Clin Breast Cancer 2016 16 6 480–6
31. Iwase T, et al Impact of body fat distribution on neoadjuvant chemotherapy outcomes in advanced breast cancer patients Cancer Med 2016 5 1 41–8
32. Vance V, et al Weight gain in breast cancer survivors: prevalence, pattern and health consequences Obes Rev 2011 12 4 282–94
33. Huo J, et al Post-mastectomy breast reconstruction and its subsequent complications: a comparison between obese and non-obese women with breast cancer Breast Cancer Res Treat 2016 157 2 373–83
34. Kuroki LM, et al Wound complication rates after staples or suture for midline vertical skin closure in obese women: a randomized controlled trial Obstet Gynecol 2017 130 1 91–9
35. Suidan RS, et al Impact of body mass index and operative approach on surgical morbidity and costs in women with endometrial carcinoma and hyperplasia Gynecol Oncol 2017 145 1 55–60
36. Onstad MA, et al Addressing the role of obesity in endometrial cancer risk, prevention, and treatment J Clin Oncol 2016 34 35 4225–30
37. Orekoya O, et al The impact of obesity on surgical outcome in endometrial cancer patients: a systematic review J Gynecol Surg 2016 32 3 149–57
38. Yavas G, et al The impact of body mass index on radiotherapy technique in patients with early-stage endometrial cancer: a single-center dosimetric study Int J Gynecol Cancer 2014 24 9 1607–15
39. Dandapani SV, et al Radiation-associated toxicities in obese women with endometrial cancer: more than just BMI? ScientificWorldJournal 2015 2015 483208
40. Fang P, et al High body mass index is associated with worse quality of life in breast cancer patients receiving radiotherapy Breast Cancer Res Treat 2013 141 1 125–33
41. Miller SK, et al Overweight and obesity in nurses, advanced practice nurses, and nurse educators J Am Acad Nurse Pract 2008 20 5 259–65
42. Puhl RM, et al The effect of physicians’ body weight on patient attitudes: implications for physician selection, trust and adherence to medical advice Int J Obes (Lond) 2013 37 11 1415–21
43. Leske S, et al Patient-practitioner relationships desired by overweight/obese adults Patient Educ Couns 2012 89 2 309–15
44. Brown I, Thompson J Primary care nurses’ attitudes, beliefs and own body size in relation to obesity management J Adv Nurs 2007 60 5 535–43
45. Pool AC, et al The impact of physician weight discussion on weight loss in US adults Obes Res Clin Pract 2014 8 2 e131–e139
46. Gudzune KA, et al Physicians build less rapport with obese patients Obesity (Silver Spring) 2013 21 10 2146–52
47. Rock CL, et al Results of the Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) trial: a behavioral weight loss intervention in overweight or obese breast cancer survivors J Clin Oncol 2015 33 28 3169–76
48. Thomson CA, et al Changes in body weight and metabolic indexes in overweight breast cancer survivors enrolled in a randomized trial of low-fat vs. reduced carbohydrate diets Nutr Cancer 2010 62 8 1142–52
49. Puhl R, et al Motivating or stigmatizing? Public perceptions of weight-related language used by health providers Int J Obes 2013 37 4 612–9
50. Tailor A, Ogden J Avoiding the term ‘obesity’: an experimental study of the impact of doctors’ language on patients’ beliefs Patient Educ Couns 2009 76 2 260–4
51. Rodman SR, Murphy JL Nutrition knowledge and attitudes of pre-registered and registered nurses in relation to cancer survivorship. Proc Nutr Soc 2011;70 E307; doi:10.1017/S0029665111003922.
52. Chlebowski RT, Reeves MM Weight loss randomized intervention trials in female cancer survivors J Clin Oncol 2016 34 35 4238–48
53. Gudzune KA, et al Efficacy of commercial weight-loss programs: an updated systematic review Ann Intern Med 2015 162 7 501–12
54. Liu L, et al Obesity education strategies for cancer prevention in women's health Curr Obstet Gynecol Rep 2015 4 4 249–58
55. Ma C, et al Effects of weight loss interventions for adults who are obese on mortality, cardiovascular disease, and cancer: systematic review and meta-analysis BMJ 2017 359 j4849
56. Schmitz KH, et al American College of Sports Medicine roundtable on exercise guidelines for cancer survivors Med Sci Sports Exerc 2010 42 7 1409–26
57. Urciuoli B Exercise has short- and long-term benefits for cancer survivors. Cure: Cancer Updates, Research and Education 2018 Feb 12. https://www.curetoday.com/articles/fda-grants-lorlatinib-a-priority-review-for-lung-cancer-treatment.
58. Miller WR, Rollnick S Motivational interviewing: helping people change 2013 3rd ed. New York, NY Guilford Press
59. Pantalon MV, et al Important medical decisions: Using brief motivational interviewing to enhance patients’ autonomous decision-making J Psychiatr Pract 2013 19 2 98–108
60. Katz A Katz A Motivational interviewing A healthcare provider's guide to cancer and obesity 2017 Pittsburgh, PA Oncology Nursing Society 93–108
61. Jay M, et al Physicians’ use of the 5As in counseling obese patients: is the quality of counseling associated with patients’ motivation and intention to lose weight? BMC Health Serv Res 2010 10 159
62. Gudzune KA, et al Primary care providers’ communication with patients during weight counseling: a focus group study Patient Educ Couns 2012 89 1 152–7
63. Connor EV, et al Obesity risk awareness in women with endometrial cancer Arch Gynecol Obstet 2017 295 4 965–9
64. Zaleta AK, et al Perceptions of weight management counseling among gynecologic cancer survivors: opportunities for enhancing survivorship care Support Care Cancer 2017 25 5 1537–45
65. Burke MA, Heiland FW Evolving societal norms of obesity: what is the appropriate response? JAMA 2018 319 3 221–2
66. Pickett S, Peters RM Beliefs about personal weight among African American women Clin Nurs Res 2017 26 2 191–204
67. Ouwens MA, et al Possible pathways between depression, emotional and external eating. A structural equation model Appetite 2009 53 2 245–8
68. Shand LK, et al Correlates of post-traumatic stress symptoms and growth in cancer patients: a systematic review and meta-analysis Psychooncology 2015 24 6 624–34
69. Ligibel JA, Wollins D American Society of Clinical Oncology obesity initiative: rationale, progress, and future directions J Clin Oncol 2016 34 35 4256–60

For 137 additional continuing nursing education activities on women's health, go to www.nursingcenter.com/ce.

Keywords:

cancer; obesity; obesity-related cancer; overweight; women

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