Obesity and screening for breast, cervical, and colorectal cancer in women: a review

Pre-operative gynecologic evaluation of bariatric surgery patients: improving cancer detection in a high-risk population

BACKGROUND

Obesity is strongly associated with endometrial and breast cancers; further, obese women are less likely to undergo recommended cancer screening. The objective was to determine the preoperative practices of bariatric surgeons with regard to gynecologic assessment and cancer screening.

STUDY DESIGN

A 28-question survey was mailed to 1,503 US bariatric surgeons to assess self-reported perceptions of gynecologic cancer screening, preoperative evaluation of female patients, and gynecologic oncology awareness and knowledge.

RESULTS

Of 1,503 surgeons, 274 responded (18%) and 11 incomplete surveys were excluded, leaving 263 (17%) for analysis. Mean surgeon age was 46.8 years. Surgeons averaged 13.9 years postresidency and were predominantly male (89%). Eighty percent obtained gynecologic histories, but 56% and 49%, respectively, did not require Pap tests or mammograms before bariatric surgery. Only 21% had ever referred a patient for endometrial evaluation. Female surgeons were more likely to obtain menstrual and cancer-related family histories (p < 0.05). Surgeons who graduated from residency 10 or more years ago were more likely to obtain a pregnancy history (p = 0.006). One-fifth of surgeons reported that they do not consistently counsel their patients about increased cancer risks due to obesity. Last, surgeons correctly identified the following signs and risk factors of endometrial cancer at variable rates: postmenopausal bleeding (99%), obesity (97%), irregular or heavy periods (69%), hereditary nonpolyposis colorectal cancer (21%), infertility (20.2%), diabetes (14.1%), and hypertension (4.9%).

CONCLUSIONS

Given the massive increases in morbid obesity and bariatric surgery in women, surgeons could serve a vital role in educating patients about both gynecologic and nongynecologic malignancy risks. With appropriate referral for cancer screening, patient outcomes could improve.

Obesity and receipt of clinical preventive services in veterans

Although obese individuals utilize health care at higher rates than their normal weight counterparts, they may be less likely to receive certain preventive services. We conducted a retrospective cohort study of veterans with visits to 136 national Veterans Affairs (VA) outpatient clinics in the United States in the year 2000. The cohort included 1,699,219 patients: 94% men, 48% white, and 76% overweight or obese. Overweight and obese patients had higher adjusted odds of receiving each of the targeted clinical preventive services as recommended over 5 years compared with normal weight patients. The odds for receiving vaccinations increased linearly with BMI category: influenza (men: odds ratio (OR) = 1.13 for overweight to OR = 1.42 for obese class 3; women: OR = 1.15 for overweight to OR = 1.61 for obese class 3) and pneumococcus (men: OR = 1.02 for overweight to OR = 1.15 for obese class 3; women: OR = 1.08 for overweight to OR = 1.28 for obese class 3). The odds for receiving the cancer screening services typically peaked in the mild-moderately obese categories. The highest OR for prostate cancer screening was in obese class 2 (OR = 1.29); for colorectal cancer, obese class 1 (men: OR = 1.15; women OR = 1.10); for breast cancer screening, obese class 2 (OR = 1.19); and for cervical cancer screening, obese class 2 (OR = 1.06). In a large national sample, obese patients received preventive services at higher, not lower, rates than their normal weight peers. This may be due to the VA health service coverage and performance directives, a more homogeneous patient demographic profile, and/or unmeasured factors related to service receipt.

An interactive diary for diet management (DAI): a new telemedicine system able to promote body weight reduction, nutritional education, and consumption of fresh local produce

BACKGROUND

The aim of this multicenter, longitudinal, single-arm, pre-post comparison was to test a telemedicine system able to promote body weight reduction, nutritional education, and consumption of fresh local produce.

METHODS

DAI (MeTeDa srl, San Benedetto del Tronto, Italy) is a software for mobile phones to support patients following a specific dietetic program. It facilitates the communication between the patient and dietician via short text messages. Overall, three specialized dieticians enrolled 140 consecutive patients with body mass index (BMI) >or=25 kg/m(2) who voluntered to follow a specific diet program to be managed with DAI. At baseline and after 20 weeks, data on body weight, waist circumference, BMI, fasting blood glucose, lipid profile, food habits, and physical activity were collected and compared by the Wilcoxon test or the McNemar test.

RESULTS

Overall, 115 individuals (82.1%) completed the follow-up. The mean (95% confidence interval) reduction in body weight was -2.5 (-3.2; -1.8) kg, whereas the reduction in waist circumference was -3.7 (-4.6; -2.9) cm, and that in BMI was 1.0 (-0.7; -1.2) kg/m(2). The software was useful as an educational tool: participants achieving the Mediterranean diet targets increased from 14.4% to 69.8% after 20 weeks. On average, each patient recognized and chose fresh local vegetables eight times per week during the follow-up. Participants regularly communicated with dieticians through short text messages.

CONCLUSIONS

This study allowed the documentation of the efficacy of a new telemedicine system in supporting people who need to lose body weight. The tool was also suitable for a more articulated initiative of "nutritional education" aiming to promote the healthy properties of the Mediterranean diet and the consumption of local produce.

Identifying barriers to Papanicolaou smear screening in Korean women: Korean National Health and Nutrition Examination Survey 2005

OBJECTIVE

This study was conducted to provide a nationwide analysis on barriers to cervical cancer screening in Korea.

METHODS

Data used for this study was obtained in a survey called Korean National Health and Nutrition Examination Survey (KNHANES) 2005, which collected data from 2,590 Korean women aged older than 21 years who had not had a hysterectomy and were eligible for Papanicolaou (Pap) smears. Multivariate analysis was adopted to control each demographic factor and unhealthy behavior variable. Demographic factors included age, education, income, job and region; health-related behavior factors were defined as current smoking, obesity, hormone replacement therapy and disability.

RESULTS

The study found that cervical cancer screening rate was significantly positively associated with income (odds ratio [OR], 1.002; 95% confidence interval [CI], 1.001 to 1.002), with education (OR, 1.324; 95% CI, 1.030 to 1.703), with job (OR, 1.420; 95% CI, 1.030 to 1.957), and with hormone replacement therapy (OR, 3.732; 95% CI, 2.354 to 5.916). Meanwhile, the age (OR, 0.977; 95% CI, 0.968 to 0.985), disability (OR, 0.358; 95% CI, 0.143 to 0.894) and smoking (OR, 0.447; 95% CI, 0.280 to 0.715) were significantly negatively associated with one's chances to take cervical cytology.

CONCLUSION

In order to increase the rates of Korean women taking Pap test, cervical cancer screening programs will have to pay special attention to the elderly, low-income group, smokers, and the disabled.

Adherence to cervical cancer screening guidelines for U.S. women aged 25-64: data from the 2005 Health Information National Trends Survey (HINTS)

BACKGROUND

Although it is widely accepted that Papanicolaou (Pap) screening can reduce cervical cancer mortality, many women still do not maintain regular cervical cancer screenings.

OBJECTIVE

To describe the prevalence of cervical cancer screening and the demographic, behavioral, psychological, and cancer-related knowledge factors associated with adherence to U.S. Preventive Services Task Force (USPSTF) cervical cancer screening guidelines among women in the United States.

METHODS

Data for women aged 25-64 were obtained from the National Cancer Institute's (NCI) 2005 Health Information National Trends Survey (HINTS). Women were considered adherent to screening guidelines if they had two consecutive, on-schedule screenings and planned to have another within the next 3 years. The sample comprised 2070 women.

RESULTS

Ninety-eight percent of women reported ever having a Pap smear, 90% reported having had a recent Pap smear (within 3 years), and 84% were adherent to USPSTF screening guidelines. Maintaining regular cervical cancer screening was significantly associated with having health insurance, normal body mass index (BMI), smoking status (nonsmoker), mood (absence of a mood disturbance), and being knowledgeable about cervical cancer screening and human papillomavirus (HPV) infection.

CONCLUSIONS

Based on the observation that women who were current smokers, obese, or experiencing a substantial degree of psychological distress were significantly less likely to adhere to recommended screening guidelines, we suggest that healthcare providers pay particular attention to the screening needs of these more vulnerable women.

Race moderates the relationship between obesity and colorectal cancer screening in women

OBJECTIVE

To determine if the relationship between obesity and usage of colorectal cancer (CRC) screening in women varies when stratifying by race.

METHODS

Using nationally representative data from the 2005 National Health Interview Survey, we examined the relationship between obesity and CRC screening for white and African-American women aged 50 and older. Screening usage variables indicated if a woman was up-to-date for any CRC screening test, colonoscopy, or FOBT. We used multivariable logistic regression models that included interaction terms to determine if race moderates the obesity-screening relationship. We also calculated adjusted up-to-date colonoscopy rates using direct standardization to model covariates.

RESULTS

The relationship between obesity and screening differed by race for any CRC screening test (P = 0.04 for interaction) and for colonoscopy (P = 0.01 for interaction), but not for FOBT. Obese white women had a lower adjusted colonoscopy rate (30.2%, 95% CI 25.9-34.8) than non-obese white women (39.1%, 95% CI 36.1-42.2). Obese African-American women, on the other hand, had a higher adjusted colonoscopy rate (41.2%, 95% CI 31.6-51.4) than their non-obese counterparts (35.6%, 95% CI 28.3-43.6). Overall, adjusted colonoscopy rates were lowest among obese white women.

CONCLUSIONS

Obesity is associated with lower CRC screening rates in white, but not African-American women.

Breast and cervical cancer screening specific effects of depression and obesity

BACKGROUND

Obesity and depression may each be associated with lower rates of cervical and breast cancer screening. Studies have examined obesity or depression alone, but not together, despite the established link between them.

PURPOSE

This article aims to disentangle the effects of depression and obesity on receipt of breast and cervical cancer screening.

METHODS

A stratified sampling design was used to recruit women aged 40-65 years with information on BMI from an integrated health plan in Washington State in 2003-2005. A telephone survey included the Patient Health Questionnaire-9 for depression, weight, and height. Automated data assessed Paps for 3097 women over a 3-year period and screening mammograms over a 2-year period for 2163 women aged > or =51 years. Logistic regression models (conducted in 2008) examined the association between obesity and depression and receipt of screening tests.

RESULTS

In univariate logistic regression models, women were less likely to receive a Pap if they were obese (OR=0.53, 95% CI=0.41, 0.69) or depressed (OR=0.60, 95% CI=0.42, 0.87). Further, women were less likely to receive a screening mammogram if they were depressed (OR=0.45, 95% CI=0.30, 0.67). In multivariable models, only obesity remained significantly associated with a lower likelihood of Pap screening (OR=0.67, 95% CI=0.0.49, 0.93), and only depression remained significantly associated with lower rates of screening mammography (OR=0.49, 95% CI=0.31, 0.76). Obesity and depression did not interact significantly in either model.

CONCLUSIONS

Obesity and depression appear to have specific effects on receipt of different cancer-screening tests.

Comorbidities of obesity

Obesity, especially visceral adiposity, is associated with morbidity and mortality through endocrine and mechanical processes. Clinical manifestations due to effects of obesity on the cardiovascular, respiratory, gastrointestinal, musculoskeletal, immune, and integumentary systems have been described. Further studies are needed to understand the pathologic processes underlying these clinical manifestations to improve disease prevention.

Common variation at the adiponectin locus is not associated with colorectal cancer risk in the UK

A recent study examined common genetic variants at the adiponectin locus (ADIPOQ) in two case-control colorectal cancer (CRC) series from the USA and reported a positive association between a single nucleotide polymorphism (SNP) in the 5' region of the gene (rs266729) and decreased disease risk. In an attempt to replicate the previously reported association, we examined data from two CRC genome-wide association studies based on the UK population. The first cohort comprised 931 familial colorectal tumour cases and 929 cancer-free controls. The second included 1216 individuals with Dukes stage B or C CRCs from two clinical trials and 1436 controls from the 1958 Birth Cohort. We tested associations between CRC risk and 82 SNPs in a region of 250 kb around the ADIPOQ gene; nine of these SNPs were located in the coding and promoter regions. None of the markers tested was significantly associated with CRC risk after correction for multiple testing under any of the models in any of the two cohorts. A meta-analysis of the data also failed to detect any association. We, therefore, failed to replicate an association between common variants at ADIPOQ and CRC risk in the UK, and suggest that the previous report is either population-specific or a false-positive result.

'Weighing in' on screening mammography

BACKGROUND

Obesity is associated with increased post-menopausal breast cancer risk. Overweight and obese women also tend to have a poorer prognosis when diagnosed with breast cancer compared with their matched normal weight peers. In previous studies obesity was associated with decreased utilization of screening mammography. We present a study examining the association between Body Mass Index (BMI) and compliance with recommended mammographic screening using data from the 2004 Behavioral Risk Factor Surveillance Survey (BRFSS).

PATIENTS AND METHODS

We included 130,185 female participants, aged 40 and older, who were randomly selected to participate in the world largest telephone survey. After weighted analysis, this is representative of 56,226,220 non-institutionalized US women. The primary outcome was the proportion of women who underwent screening mammography within the last 2 years preceding the survey stratified by BMI. The mammography screening behavior of normal weight women (BMI 18.5-24.99) was compared with underweight (<18.5), overweight (25-29.99), and women with obesity class I (30-34.99), class II (35-39.99), and class III (>or=40) using logistic regression analysis and weighted to provide estimates of women in the United States (US).

RESULTS

Our sample included 1.91% underweight, 37.91% normal weight, 30.15% overweight and 14.36%, 5.44%, and 3.49% women with obesity classes' I-III respectively. Approximately 7% of women age 40 and older had insufficient information to calculate their BMI. Adjusting for age, race, smoking status, general health perception, level of education, and income level, underweight women had lower odds of complying with regular screening mammography (OR 0.57; 95% CI, 0.48-0.68). Women with obesity class III (OR 0.97; 95% CI, 0.84-1.13) showed a trend towards underutilization of screening mammograms which was not clinically significant. In contrary, in overweight women a significantly higher association with appropriate mammography utilization was identified OR 1.08 (95% CI, 1.01-1.15). Although not statistically significant, women with class I and II obesity showed a trend towards a higher utilization 1.08 (95% CI, 0.99-1.18) and 1.10 (95% CI, 0.98-1.25) respectively, when compared to women at desired weight.

CONCLUSION

We present a weighted analysis of the BRFSS, evaluating the association of BMI and appropriate screening mammography among women 40 years and older. These results are generalizable to the US population of women in this age range. Underweight women had significantly lower odds of utilizing screening mammography appropriately when compared with women at desired weight. Results from previous studies reporting underutilization of screening mammography in high risk, obese, and overweighed women were not confirmed in this largest population based analysis performed to date.