Endometrial cancer and obesity: Addressing the awkward silence : JAAPA

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Review Article

Endometrial cancer and obesity

Addressing the awkward silence

King, Lacey PA-C, RD, LD, CLC; Gajarawala, Shilpa DMSc, PA-C; McCrary, Melissa D. PA-C

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JAAPA 36(1):p 28-31, January 2023. | DOI: 10.1097/01.JAA.0000902884.01725.a3
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Abstract

FU1-6
Figure

Endometrial cancer is the most common cancer of the female reproductive system in the United States and developed world.1,2 The American Cancer Society estimates 65,950 new cases of uterine cancer (endometrial cancers and uterine sarcomas) in 2022.1 This is an increase of 6.6% from 2019.3 Risk factors for endometrial cancer include advancing age, early menarche, nulliparity, late menopause, hormone replacement therapy, obesity, type 2 diabetes, polycystic ovarian syndrome, and genetic disorders such as Lynch syndrome.4 The average age of diagnosis is 60 years.1 The most common clinical presentation of a woman with endometrial cancer is abnormal postmenopausal vaginal bleeding.4 Physical examination findings are limited, because peritoneal abnormalities and adnexal masses are more indicative of advanced disease.4

ENDOMETRIAL CANCER AND OBESITY

Overweight and obesity are growing public health crises defined by BMI.5 BMI is a screening tool used to assess body fat based on height and weight.5 BMI of 25 kg/m2 or greater is considered overweight; 30 kg/m2 and greater is considered obese.5 The CDC reports that the prevalence of obesity in the United States was 42.4% in 2017-2018 and has increased 11.9% in 18 years.6 Projecting 1999-2013 estimates into the future indicates that by 2030, nearly half of adults in the United States will be obese.7 Obesity increases the morbidity of dyslipidemia, hypertension, coronary heart disease, stroke, type 2 diabetes, gallbladder disease, osteoarthritis, respiratory problems, and several cancers, along with cardiovascular disease mortality.8,9 The World Cancer Research Fund reported a 50% increased risk of endometrial cancer per every increase of 5 BMI units.2 Reductions in BMI also reduce poor health outcomes, even in patients with endometrial cancer.10

The most well-studied risk for developing endometrial cancer is exposure to unopposed estrogen, which can arise from endogenous and exogenous sources.11 Exogenous sources of estrogen include estrogen-only hormone replacement therapy.2 Causes of increased endogenous estrogen are early menarche, nulliparity, anovulation, late menopause, and excess adipose tissue.2,11 An estimated 57% of endometrial cancers are the result of unopposed endogenous estrogen exposure after menopause, resulting from excessive adipose tissue associated with BMI of 25 kg/m2 or greater.11

FB1
Box 1

The excess adipose tissue acts as a complex endocrine organ that produces hormones, generates inflammatory responses, and stimulates cell proliferation pathways.12 The primary mechanism by which adipose tissue contributes to endometrial cancer is by aromatizing androstenedione to estrone. The endogenous estrogen directly stimulates endometrial cell proliferation and growth through activation of the estrogen receptor ERa.12 Obesity promotes the production of proinflammatory adipokines, which promotes insulin resistance and overexpression of antiapoptotic and proangiogenic cells that are linked to carcinogenesis.12

The survival rate for endometrial cancer is 81% at 5 years after diagnosis.13 Patients with a BMI of 25 kg/m2 or greater have worse outcomes.14 A prospective study by Calle and colleagues found that disease-specific mortality related to female reproductive cancers increases as BMI increases.14 The highest risk for mortality is in women with BMI of 40 kg/m2 or greater.15 Women who are diagnosed with endometrial cancer more often die from cardiovascular disease (also associated with obesity) than from the cancer itself.16 Encouraging women to make lifestyle changes to reduce BMI may reduce the incidences of endometrial cancer and cardiovascular disease; continuing to reduce BMI during cancer treatment may improve survival rates.16

THE AWKWARD SILENCE

Despite growing obesity rates and oncologist recognition that addressing a patient's weight should be included in preventive and survivorship care, clinicians still struggle to bring up obesity with their patients.17,18 Barriers may include time constraints, a focus on acute issues, the challenge of finding appropriate language, concerns about compromising trust and rapport, concerns about being seen as a hypocrite based on the clinician's BMI, and lack of training and self-confidence.18-21

The US Preventive Services Task Force (USPSTF) recommends using the 5 A's construct for clinical counseling; this construct can be applied to weight loss and a variety of other topics (Table 1).18 The 5 A's, developed for smoking cessation, have since been adapted for obesity management and have shown a promising association with improved clinician-patient interaction and motivation to lose weight.18,22

TABLE 1. - The 5 A's for obesity counseling
© College of Family Physicians of Canada
Ask
  • Ask permission to discuss weight

  • Be nonjudgmental

  • Explore readiness to change

Assess
  • Assess health status, BMI, waist circumference, waist-hip ratio, root causes of weight gain, and effects of weight on psychosocial functioning

Advise
  • Advise about risks of obesity; explain benefits of modest weight loss and the need for long-term strategies

  • Explore all treatment options, including pharmacologic and surgical management

Agree
  • Negotiate respectfully to achieve realistic weight loss expectations and targets using the SMART goal framework

Assist
  • Address facilitators (motivation, support) and barriers (social, medical, emotional, and economic) that make weight management challenging

  • Provide resources and assist in identifying and consulting with appropriate providers

  • Arrange follow-up to keep the conversation going


Ask

Conversations about weight loss are important because patients are more likely to attempt weight loss after counseling with a clinician.23,24 Clinicians must take care when introducing the sensitive topic of obesity because patients may feel embarrassment, fear, blame, and stigma.25 By asking permission to discuss weight status, clinicians can create a nonjudgmental environment.25

A few practical suggestions for how to initiate conversation:

  • “May we discuss different ways to reduce your risk for future disease and cancer?”
  • “May we discuss ways to improve survival outcomes based on your current diagnosis?”
  • “Can we talk about your weight today?”
  • “How do you feel about your weight?”25,26

If a patient does not want to engage in conversations about weight status, the American Society of Clinical Oncology recommends discontinuing the conversation and consider approaching the topic at a subsequent appointment.21 Multiple attempts may be required to prepare patients for a lifestyle change.21

Assess

The next step is to inform patients of their weight status while avoiding stigmatizing language about weight status, such as fat, heavy, overweight, and obese.27,28 Neutral terms like weight or elevated BMI are preferred.27,28 Use people-first language (patient with obesity), rather than condition-first language (obese person).

Advise

Several studies show that patients are unaware of the link between endometrial cancer and obesity.24,29-31 After establishing a nonjudgmental environment and assessing patient weight status, clinicians can communicate health risks of obesity and explore all treatments with patients.25 Treatments that can be explored include behavior modification using cognitive behavior therapy or motivational interviewing, pharmacologic treatment, and bariatric surgery.

Agree

Collaborate with the patient to develop a plan to address weight.25 Avoid the typical recommendations of diet and exercise without further clarification, because this suggestion may imply that a diagnosis of obesity indicates laziness or a lack of control.32 The SMART goal framework may be used to create lifestyle modifications that are specific, measurable, attainable, rewarding, and time-bound.25 Additional tools of behavioral therapy, such as self-monitoring, addressing barriers, problem-solving, providing support, and positive reinforcement, may all be used.25

Assist

Finally, once a goal is established, discuss who and what in the patient's life may help them in achieving goals or prove to be a barrier.25 Setting up a designated time for the patient to meet with a registered dietitian or their primary care provider can help establish and monitor the goals set forth.25 Clinicians also must be mindful of available resources. The decision to refer the patient to a registered dietitian or the primary care provider should be made based on the patient's insurance status and willingness to pay for further management.33

CONCLUSION

The link between endometrial cancer, the most common malignancy in female reproductive organs in the United States, and obesity is clearly defined. Clinicians have a responsibility to discuss the causal relationship with patients diagnosed with obesity. Diagnosis of endometrial cancer may also be used as a valuable teaching moment to discuss how obesity affects overall survivorship. Start the conversation by using tailored behavioral therapy tools and the 5 A's for obesity management to promote BMI reduction in patients at risk for or diagnosed with endometrial cancer.

REFERENCES

1. American Cancer Society. Key statistics for endometrial cancer. www.cancer.org/cancer/endometrial-cancer/about/key-statistics.html. Accessed October 20, 2022.
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3. American Cancer Society. Cancer facts and figures 2019. www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf. Accessed September 29, 2022.
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      Keywords:

      endometrial cancer; BMI; 5 A's; weight reduction; uterine; vaginal bleeding

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