Jiaxin Niu, MD, PhD
Imagine a woman with a weight problem who, two weeks after chemotherapy, goes to her doctor with a urinary tract infection and a rash on her upper chest.
When the woman, who weighs 345 pounds, tries to sign in, the doctor’s receptionist ignores her. After a while the patient’s back starts to hurt, so she looks for a comfortable chair but instead has to squeeze into one that is narrow and has armrests. She picks up a magazine to find images of thin models and food.
Staff members are unable to weigh the patient because she’s too heavy for their scale. They have to search for a larger cuff in order to take her blood pressure, the phlebotomist sticks her three times before going to find a larger needle, and she’s too big to successfully use a urine-sample cup. Finally, the oncologist prescribes an antibiotic without meeting her eyes.
The patient is sent away with some pamphlets on weight loss, but without any discussion.
Weight bias is common among healthcare providers and in their facilities, and it must be weeded out because it can negatively affect the health and quality of life of obese and overweight women, according to a panel of five experts from Arizona who spoke Friday during the 40th Annual Congress of the Oncology Nursing Society (ONS). That’s especially critical in the breast cancer arena, the experts pointed out: Because obesity has been shown to truncate the potential gains that can come with treatment, and to increase the risk of recurrence, women of higher body weight should be watched especially carefully.
Aggravating their risk is the fact that obese women may be less willing to seek breast screenings due to embarrassment or shame about their size, noted Brenda Keith, MN, RN, AOCNS, a senior oncology clinical coordinator with Genentech, who offered the audience the description of the obese patient visiting her doctor.
The session was planned in collaboration with the ONS Breast Care Special Interest Group.
Obesity and Breast Cancer
People who are obese—with a body mass index (BMI) of 30 kg/m2 or higher—comprise more than 30%1
of the American population, a percentage higher than that in western Europe or Southeast Asia, and which continues to rise, said speaker Jiaxin Niu, MD, PhD, a medical oncologist from Scottsdale.
Obesity causes 80,000 cancers2
per year and is expected to overtake tobacco3
as the leading cause of the disease. In breast cancer, it is a poor prognostic factor: Tumors in obese patients are likely to be higher-grade, hormone receptor-negative and biologically more invasive, Niu said. He added that obese patients are more likely to experience joint aches and pains while on hormonal therapy for breast cancer, and thus to discontinue the treatment.
Finally, Niu noted, obese women who develop breast cancer face a 41% higher total mortality rate4
than women of normal weight, according to a meta-analysis of 82 studies including 200,000 patients with breast cancer. For postmenopausal women who are obese, the risk is 34% higher than for normal-weight women, and for premenopausal women, the risk is 75% higher than for women with normal-range BMIs.
Yet there are obstacles when it comes to ensuring that these women get the care they need.
Barriers to Care
From an obese patient’s point of view, Keith said, going for a checkup can be difficult because paper gowns are too small, mammograms are especially painful, staff members may make unkind remarks or jokes and exams take longer.
Physicians can be frustrated, she said, because imaging quality can be poor in patients with extra body weight, causing false positives; patients may exceed weight limits for CAT scan and MRI tables; scissors and needle holders may not be long enough; and certain complications after breast cancer treatment are more likely—those associated with healing from wounds, breast reconstruction, radiation therapy, and arm edema.
Providers can do a better job by having equipment that accommodates people of all sizes, Keith suggested, and by avoiding words like “fat” and “morbidly obese,” instead using terms such as “unhealthy weight” “high BMI” and “persons with obesity.”
Oncologists must also consider whether chemotherapy doses based on actual body weight, rather than ideal body weight will be more effective in obese patients, Niu said; the American Society of Clinical Oncology recommended that tactic in a 2012 guideline.5
Although many providers have some level of bias against obese people, thinking of them as “noncompliant,” “lazy” or “unsuccessful,” it’s incumbent upon healthcare professionals to achieve a comfort level in treating such patients and discussing their health and weight problems neutrally and non-judgmentally—possibly with the help of staff-wide diversity training, Keith said.
Closing the Gap
A good start, said speaker Amy Malensek, RN, CBCN, OCN, the panel’s coordinator and an education specialist at Cancer Treatment Centers of America, is for healthcare practitioners to avoid an intimidating, all-business attitude during checkups of such patients, instead sitting down at eye level, speaking in a soft, concerned tone, actively listening, and offering help with any problems put on the table.
It’s likely better to establish a rapport early on and save discussions about weight until after the patient has completed treatment and is moving into survivorship, Malensek suggested.
“We’ve just told the patient she had cancer, and now that we are going to take her hair away, and maybe her breasts, and her femininity with hormones,” she said. “She’s probably not wanting to discuss her weight.”
When it is time to discuss weight, providers should be on the lookout for issues that can stand in the way of weight loss: mobility problems, weight gain and mood changes caused by hormone blockers, underlying metabolic factors, neuropathy, pain, and depression.
Practitioners may feel uncomfortable counseling patients about weight because they’re overweight themselves, but being honest with patients about that concern can work well, Malensek said.
“We’re not asking them to get to a size 6,” she added. “We want to help patients have longevity. [It’s a victory] if we can help them make modest changes in lifestyle.”
Once patients have begun discussing their weight, many will ask about weight-loss supplements, on which Americans spend $2 billion per year,6
said Adam Kerievsky, ND, LAC, FABNO, a naturopathic physician at Cancer Treatment Centers of America.
The three most common ingredients in weight-loss supplements are stimulants: caffeine and green tea extract, which may have a modest effect on weight, and green coffee bean extract, about which less is known, Kerievsky said. While there are some encouraging data, he added, there’s no solid evidence that any supplement can reduce body weight.
Kerievsky cautioned that supplements aren’t reviewed or approved by the FDA before they go on the market, and could be tainted with chemicals. That issue aside, he added that patients should be counseled to check with their healthcare providers before taking supplements in order to avoid drug interactions or unexpected side effects. In general, it’s not a good idea to take supplements in combination with chemotherapy, targeted anticancer drugs, immunotherapy or hormonal therapy, Kerievsky said.
To find out more about safety and drug interactions, he recommended that patients and their healthcare providers check online at epocrates.com, naturaldatabase.com, and consumerlab.com.
Food for Thought
And then, of course, there are issues of diet. At any oncology practice, a dietician or other practitioner should assess a patient’s readiness and willingness to lose weight and take a history of weight loss and gains, food preferences, body composition, energy needs, the amount of energy expended while at rest, waist circumference, and physical activity, said Sarah Kiser, RD, a dietician with Cancer Treatment Centers of America. An assessment should also include a look at metabolic health via tests for insulin resistance, lipid levels, aerobic fitness, fasting glucose, blood pressure, and triglycerides, she said.
Intervention should take the form of diet modification and physical activity. According to the National Weight Control Registry,7
Kiser said, the habits of people who have lost 30 pounds or more and kept it off for at least a year include eating breakfast, checking weight weekly, watching less than 10 hours of television a week and exercising for an hour a day.
When it comes to weight loss, what a patient eats doesn’t matter as much as making sure she ends up with a negative calorie balance every day, Kiser said. The gold standard for measuring that is through indirect calorimetry, or, if that’s not available, via the Mifflin-St. Jeor formula, she said.
However, what a patient eats can have an effect on health. There is evidence from the Women’s Intervention Nutrition Study (WINS)8
that dietary fat creates a risk factor for breast cancer, Kiser said. She recommended checking the American Institute for Cancer Research (AICR.org) website for information about healthy, plant-based foods. Kiser also warned that, according to WINS, more than three alcoholic drinks per week can increase the risk of breast cancer or a recurrence.
Even if adherence to these guidelines does not spark a large weight loss, such changes can still generate important health benefits, Kiser emphasized.
Providers should set calorie limits for their patients and ask them to keep food journals, she suggested, but encourage them to take “small steps at a time.”
Centers for Disease Control and Prevention. Overweight and Obesity. http://www.cdc.gov/obesity/data/adult.html
National Cancer Institute. National Institutes of Health. Obesity and Cancer Risk. http://www.cancer.gov/cancertopics/causes-prevention/risk/obesity/obesity-fact-sheet
Collins SPK. Obesity is about to surpass tobacco as the leading cause of cancer. Thinkprogress.org. Posted November 6, 2014. http://thinkprogress.org/health/2014/11/06/3589905/obesity-tobacco-cancer/
Schapira L. Why breast cancer patients should be big losers. Medscape Multispecialty. http://www.medscape.com/viewarticle/828851
American Society of Clinical Oncologists. ASCO guideline recommends the use of actual body weight to calculate appropriate dose of chemotherapy drugs for obese patients. http://www.asco.org/press-center/asco-guideline-recommends-use-actual-body-weight-calculate-appropriate-dose
National Institutes of Health. Office of Dietary Supplements. Dietary supplements for weight loss. http://ods.od.nih.gov/factsheets/WeightLoss-HealthProfessional/
Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr. 2005;82(1):2225-2255. http://ajcn.nutrition.org/content/82/1/222S.long
National Cancer Institute. National Institutes of Health. A clinical trial to determine the efficacy of a dietary fat reduction program provided in addition to systemic adjuvant therapy in the management of patients with primary invasive breast cancer. NCT NCT00002564. http://www.cancer.gov/clinicaltrials/search/view?cdrid=63537&version=HealthProfessional
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