Why do patients at higher risk for endometrial cancer wait longer for treatment?
Endometrial cancer—cancer of the lining of the uterus—is becoming more common and killing more women each year in Canada. In fact, it is now the most common gynecologic cancer in Canada. And women with obesity—those most vulnerable to the disease—face greater obstacles in getting care.
In the world of women’s health, scientists and physicians have been successful in finding ways to prevent some cancers. Cervical cancer can be prevented with vaccination, and women who have a genetic risk for breast and ovarian cancer can undergo preventive surgeries.
On the other hand, there is no screening tool for detecting endometrial cancer. It tends to present at an early stage with abnormal vaginal bleeding. This can mean a change in menstrual periods (periods getting heavier or more frequent), or any vaginal bleeding after a woman has gone through menopause. Cancerous cells can be detected with an endometrial biopsy, which is a simple office procedure. If the cancer is detected at an early stage, it can be cured with a hysterectomy. If the diagnosis is delayed and the cancer spreads, women may need to undergo radiation and chemotherapy, and the disease can be fatal. Because of this, the Society of Obstetricians and Gynecologists of Canada recommends that doctors perform an endometrial biopsy for any woman over the age of 40 who has abnormal bleeding.
The number of women with endometrial cancer increased by 2.6 percent year over year between 2005 and 2013. And according to Cancer Care Ontario, the trend is continuing, with endometrial cancer representing more than seven percent of all new cancer diagnoses in Ontario women in 2018.
Many studies demonstrate that the striking upsurge of endometrial cancer in Canada can be attributed to the rise in obesity. Fat cells produce estrogen, a hormone that can lead to overgrowth of cells in the uterus. This overgrowth, also called endometrial hyperplasia, can cause cells to become abnormal and eventually transform into a cancer. According to a recent U.S. study, there is a 50 percent increase in the chance of developing endometrial cancer for every five-point increase in Body Mass Index (BMI). Almost 60 percent of endometrial cancer diagnoses in the United States are linked to obesity.
One might imagine that the women who are at highest risk for this disease would get the fastest diagnosis and treatment. But a recent study from University of Toronto, which is being prepared for publication, shows just the opposite.
Andrea Simpson and colleagues reviewed thousands of data points from the Institute for Clinical Evaluative Sciences Ontario (ICES) database and compared the surgical wait times for women with endometrial cancer who have class III, or “extreme” obesity (BMI >40) vs. those who do not.
“We looked at how long it took from the day they were diagnosed until the day they had surgery,” says Nancy Baxter, general surgeon at St. Michael’s Hospital in Toronto, and one of the study’s main authors. “Women who had morbid obesity waited nine days longer for surgery than women without.”
She argues that this number alone is not the greatest cause for alarm. More concerning is the fact that fewer than 40 percent of women with morbid obesity actually underwent surgery within the Cancer Care Ontario target time frame which is 28 days for high-risk cases and 84 days for low-risk cases (48 percent of women without morbid obesity underwent surgery within the target time frame).
Surgical delay can have serious consequences, as surgery can be a cure for endometrial cancer only when the disease is treated at an early stage. The data doesn’t clarify what effect a nine-day delay or having 60 percent of women miss target time frames will have on outcomes, but it does raise concern about the quality and speed of care that women with obesity receive.
Simpson and her team believe that the delay from diagnosis to surgery is multifactorial. On one hand, “Operating on people with obesity is challenging,” says Baxter. “They have more co-morbidities and you can have more [surgical] complications.” Community gynecologists who don’t have specialized training in operating on patients who have obesity may be reluctant to do so and choose to refer them to a cancer centre where there are more resources. These centres are few in number and have limited capacities, which may increase the wait time for surgery. Many patients also choose to undergo robotic surgery, a highly specialized form of minimally invasive, or keyhole, surgery. This allows women with extreme obesity to undergo surgery without a large abdominal incision. As of 2017, there were only 31 surgical robots across Canada, which are shared among many surgical departments.
Beyond that, says Baxter, anti-obesity bias is a very real and prevalent problem.
“[Weight] seems to be the last thing that you can openly discriminate [against],” she says. “People seem to be free to express bias against people with obesity.”
The medical community is not immune to this. In their study, Baxter and Simpson’s group conducted interviews with women with obesity who underwent treatment for endometrial cancer. They reported feeling very stigmatized, especially while being passed from one doctor to the next.
Sarah Ferguson, a gynecologic cancer specialist at Princess Margaret Hospital and the gynecology lead for Cancer Care Ontario, adds that for patients with obesity, “There is a major blame component. These patients feel shamed.”
Ferguson also researches this topic, and believes that the delay from diagnosis to surgery is just the tip of the iceberg. There is also a major delay in patients getting a diagnosis in the first place. “We don’t actually know how long these women were symptomatic before they had access to treatment.”
She thinks women with obesity are less likely to go to the doctor when they do experience abnormal bleeding. “Patients don’t want to go see doctors because of stigma,” she says. “The delay leads to worse outcomes. People can die from this.” Especially, she says, when you combine a delay in diagnosis with a delay in time to surgery.
Anti-weight stigma may also mean that doctors are more likely to attribute symptoms to obesity, and less likely to investigate and treat other serious conditions in women who are obese. A study published in the journal Obesity Reviews in 2015 supports this, suggesting that physicians’ attitudes about obesity lead to them having worse medical judgment and lower quality patient interactions.
Yoni Freedhoff, a primary care physician who specializes in the care of patients with obesity, says the key to solving this problem lies in taking the onus off of patients with obesity to feel more comfortable going to the doctor and sharing concerns, and instead requiring primary care doctors and gynecologists to stop “provid[ing] a stigmatizing and hateful environment.”
Ferguson says education about the signs of endometrial cancer is also key. “There is no public awareness of this problem,” she says. “Even many physicians are unaware.” Her interviews with cancer patients show that most women didn’t realize bleeding can be a sign of a serious health problem. And none knew that obesity was a risk factor for cancer in the first place.
This is where Freedhoff says much of the work needs to be done. If primary care physicians create safe and non-judgmental environments, they can open the doors to preventive education, he says. In the context of a respectful relationship, a family doctor can talk to women with obesity about their unique health risks, and emphasize that any abnormal bleeding warrants an urgent visit back to the office.
“Women are so normalized to bleeding,” says Ferguson. “This is extra challenging in pre-menopausal women, and there is an increased rate of [endometrial] cancer in young women [with obesity].”
“We are not even aware of our bias,” she says. “We haven’t been well-trained on how to approach this topic at all.”
Michael Chaikof is a fourth-year resident in obstetrics and gynecology at University of Toronto and a freelance writer who is participating in the Certificate in Health Impact program, which is offered by the Dalla Lana School of Public Health, the University of Toronto Faculty of Medicine and the Munk School of Global Affairs and Public Policy.