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Obesity management in gynecologic cancer survivors: provider practices and attitudes

Published:February 08, 2013DOI:https://doi.org/10.1016/j.ajog.2013.02.002

      Objective

      Obesity is associated with the development and risk of death from several women's cancers. The study objective was to describe and compare oncologic providers' attitudes and practices as they relate to obesity counseling and management in cancer survivors.

      Study Design

      Society of Gynecologic Oncology members (n = 924) were surveyed with the use of a web-based, electronic questionnaire. χ2 and Fisher exact tests were used to analyze responses.

      Results

      Of the 240 respondents (30%), 92.9% were practicing gynecologic oncologists or fellows, and 5.1% were allied health professionals. Median age was 42 years; 50.8% of the respondents were female. Of the respondents, 42.7% reported that they themselves were overweight/obese and that ≥50% of their survivor patients were overweight/obese. Additionaly, 82% of the respondents believed that discussing weight would not harm the doctor-patient relationship. Most of the respondents (95%) agreed that addressing lifestyle modifications with survivors is important. Respondents believed that gynecologic oncologists (85.1%) and primary care providers (84.5%) were responsible for addressing obesity. More providers who were ≤42 years old reported undergoing obesity management training (P < .001) and were more likely to believe that survivors would benefit from obesity education than providers who were >42 years old (P = .017). After initial counseling, 81.5% of the respondents referred survivors to other providers for obesity interventions.

      Conclusion

      Oncology provider respondents believe that addressing obesity with cancer survivors is important. Providers believed themselves to be responsible for initial counseling but believed that obesity interventions should be directed by other specialists. Further research is needed to identify barriers to care for obese cancer survivors and to improve physician engagement with obesity counseling in the “teachable moment” that is provided by a new cancer diagnosis.

      Key words

      Obesity is the second leading cause of death in the United States.
      • Hurt R.T.
      • Frazier T.H.
      • McClave S.A.
      • Kaplan L.M.
      Obesity epidemic: overview, pathophysiology, and the intensive care unit conundrum.
      The US Centers for Disease Control and Prevention report that more than two-thirds of US adults are obese or over weight and that obesity has become the leading public health problem facing industrialized nations.
      • Flegal K.M.
      • Carroll M.D.
      • Ogden C.L.
      • Curtin L.R.
      Prevalence and trends in obesity among US adults, 1999-2008.
      Increasing body mass index (BMI) is a risk factor for all-cause and cancer-related death; in women, it is a major risk factor for the development of several female cancers, which include endometrial, breast and ovarian cancers.
      • Abu-Abid S.
      • Szold A.
      • Klausner J.
      Obesity and cancer.
      • Ahn J.
      • Schatzkin A.
      • Lacey Jr, J.V.
      • et al.
      Adiposity, adult weight change, and postmenopausal breast cancer risk.
      • Reeves G.K.
      • Pirie K.
      • Beral V.
      • et al.
      Cancer incidence and mortality in relation to body mass index in the million women study: cohort study.
      • Reeves K.W.
      • Carter G.C.
      • Rodabough R.J.
      • et al.
      Obesity in relation to endometrial cancer risk and disease characteristics in the women's health initiative.
      Over one-half of breast and ovarian cancer survivors and approximately 80% of endometrial cancer survivors are obese.
      • Abu-Abid S.
      • Szold A.
      • Klausner J.
      Obesity and cancer.
      • Reeves G.K.
      • Pirie K.
      • Beral V.
      • et al.
      Cancer incidence and mortality in relation to body mass index in the million women study: cohort study.
      • Calle E.E.
      • Rodriguez C.
      • Walker-Thurmond K.
      • Thun M.J.
      Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults.
      Many studies have shown that obese women with and without cancer have poorer health outcomes and quality of life than their nonobese counterparts.
      • Abu-Abid S.
      • Szold A.
      • Klausner J.
      Obesity and cancer.
      • Courneya K.S.
      • Karvinen K.H.
      • Campbell K.L.
      • et al.
      Associations among exercise, body weight, and quality of life in a population-based sample of endometrial cancer survivors.
      • Fader A.N.
      • Gil K.
      • von Gruenigen V.E.
      Quality of life in endometrial cancer survivors: What does obesity have to do with it?.
      Furthermore, obesity is a significant risk factor for progression of and death from cancer.
      • Reeves G.K.
      • Pirie K.
      • Beral V.
      • et al.
      Cancer incidence and mortality in relation to body mass index in the million women study: cohort study.
      • Calle E.E.
      • Rodriguez C.
      • Walker-Thurmond K.
      • Thun M.J.
      Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults.
      See related editorial, page 341
      For Editors' Commentary, see Contents
      In May 2012, the Institute of Medicine released an urgent report calling for American citizens to take swift action to prevent obesity by stating that, if current trends continue, nearly one-half of the population would be obese by the year 2030 and that obesity-related health care expenditures would rise to >$200 billion annually in the United States.
      Institute of Medicine
      Accelerating progress in obesity prevention: Solving the weight of the nation.
      Yet, recent reports suggest that physician assessment and behavioral management of obesity in adults is at a low level relative to the magnitude of the problem. The Institute of Medicine, STOP Obesity Alliance, and other leading organizations have outlined the scope of the obesity epidemic and stated that physicians must take an aggressive lead in fighting obesity by asking patients about their weight and recommending exercise.
      Institute of Medicine
      Accelerating progress in obesity prevention: Solving the weight of the nation.
      • Ferguson C.
      • Langwith C.
      • Muldoon A.
      • Leonard J.
      Although many cohorts have a favorable cancer prognosis with the potential for long-term survival, obese cancer survivors are at risk for significant morbidity and death. Unfortunately, compared with other overweight survivor cohorts, obese gynecologic cancer survivors are not losing weight or making healthy lifestyle modifications after a cancer diagnosis.
      • Von Gruenigen V.E.
      • Courneya K.S.
      • Gibbons H.E.
      • Kavanagh M.B.
      • Waggoner S.E.
      • Lerner E.
      Feasibility and effectiveness of a lifestyle intervention program in obese endometrial cancer patients: a randomized trial.
      • Von Gruenigen V.E.
      • Tian C.
      • Frasure H.
      • Waggoner S.
      • Keys H.
      • Barakat R.R.
      Treatment effects, disease recurrence, and survival in obese women with early endometrial carcinoma: a gynecologic oncology group study.
      Providers who care for these women are positioned uniquely to impact the general and cancer-related health outcomes of their patients by counseling them on the risks that are associated with excess weight and initiating obesity interventions during the “teachable moment” that is provided by a new cancer diagnosis. However, there are no data regarding the educational background and approach of these providers with regards to the management of obesity in the survivorship period. The study purpose was to describe the backgrounds, attitudes, and practices of providers who care for women with gynecologic malignancies regarding lifestyle counseling and obesity management in this cohort.

      Materials and Methods

      The institutional review board at the Greater Baltimore Medical Center in Baltimore, MD, approved this study. After further approval by the Society of Gynecologic Oncology to conduct the study, an email invitation to participate was sent to all actively practicing North American Society of Gynecologic Oncology members in September and October 2011. Those members who did not complete the survey immediately were sent 2 additional invitations to participate. Participation was voluntary; there was no incentive or compensation offered, and the email invitation provided an “opt-out” option.
      The online, 47-item survey assessed provider demographics and health information, practice characteristics, availability of obesity education resources, provider knowledge of obesity and its relationship to cancer, and opinions and practices regarding approaching obesity counseling and treatment in obese gynecologic cancer survivors. Most questions were formatted in a multiple-choice fashion. To measure the extent to which respondents agreed or disagreed with questions, many questions used a Likert Scale. Many questions were based on previous, similar survey studies in the literature.
      • Power M.L.
      • Coggswell M.E.
      • Schulkin J.
      Obesity prevention and treatment practices of US obstetrician-gynecologists.
      • Forman-Hoffman V.
      • Little A.
      • Wahls T.
      Barriers to obesity management: a pilot study of primary care clinicians.
      • Leverence R.R.
      • Williams R.L.
      • Sussman A.
      • Crabtree B.F.
      RIOS Net Clinicians
      Obesity counseling and guidelines in primary care: a qualitative study.
      The survey also included a needs assessment to identify the scope of the obesity problem among gynecologic cancer survivors as perceived by provider respondents and to determine the preparedness of cancer providers to address obesity counseling and treatment with their patients.
      Descriptive statistics were calculated with the number of responses as the denominator. Fisher exact test and the χ2 test were used to detect differences in responses among groups with the use of Stata statistical software (version 11.1; StataCorp, College Station, TX).

      Results

      Two hundred forty oncology providers (30%) responded to the survey. Provider demographics are listed in Table 1. Most respondents were gynecologist oncologists or fellows (92.9%) who reported practicing in an urban setting (66.8%) and at a university hospital (52.7%). The median respondent age was 42 years (range, 29-77 years), and 80.7% of respondents were white. Respondents were well distributed by gender, number of years in practice, and region of the country. Respondent self-reported health information is also detailed in Table 1. Approximately 42% of respondents reported a BMI in the overweight or obese range (≥25 kg/m2). Most under- and normal-weight respondents were <42 years old (53.8%); the majority of overweight or obese respondents (61.6%) were ≥42 years old (P = .020). Male respondents were more commonly overweight or obese than female respondents (65.9% vs 20.69%; P < .001).
      TABLE 1Provider-respondent demographics
      Characteristicn%
      Job
       Gynecologic oncologist19180.2
       Gynecologic Oncology fellow3012.7
       Medical Oncologist10.4
       Radiation Oncologist31.3
       Allied health professional125.1
       Other10.4
      Region
       New England2410.1
       Mid Atlantic4217.7
       Midwest5422.7
       Southeast5523.1
       Southwest2811.8
       West3514.7
      Practice setting
       Urban15966.8
       Suburban6527.3
       Rural145.9
      Practice type
       Federal government41.7
       University hospital12552.7
       Community hospital229.3
       Hybrid4418.6
       Solo private practice73.0
       Group private practice2912.2
       Other62.5
      Years in practice
       ≤37431.6
       4-158335.5
       ≥167732.9
      Age, y
       <4211046.4
       ≥4212753.6
      Sex
       Female12150.8
       Male11749.2
      Race
       White19180.6
       Black104.2
       Hispanic73.0
       Asian229.3
       Other73.0
      Body mass index
       Underweight41.7
       Normal weight13055.6
       Overweight7130.3
       Obese2912.4
      Adhere to American Cancer Society dietary guidelines
       Not very often135.5
       Sometimes6125.9
       Most of the time13456.8
       Always2811.9
      Exercise habits, d/wk
       None2510.6
       1-27832.9
       3-511247.3
       6-7229.3
      Jernigan. Gynecologic cancer providers and obesity. Am J Obstet Gynecol 2013.
      When asked about previous training in obesity management, 54.6% reported self-directed learning; the less popularly reported modes of education included posttraining continuing medical education classes (18.3%), informal training with colleagues (17.9%), formal didactics (15.0%), and continuing medical education classes while in training (6.3%). Twenty-nine providers (12.1%) reported no training on the subject. Compared with older providers, more providers who were <42 years old reported having attended a formal course regarding obesity management during residency or fellowship training (23.6% vs 7.9%; P = .001) or informal training with colleagues (25.8% vs 11.8%; P = .007). Participation in continuing medical education courses after residency training was reported more commonly by providers who were >42 years old (26.8% vs 9.1%; P = .000) and providers who had been in practice longer (4.1%, 21.7%, and 29.9% of those respondents with <3, 4-15, and ≥16 years of experience, respectively; P < .001).
      Ninety-nine percent of respondents reported that ≥50% of their patients were overweight or obese. Most providers “agreed” or “strongly agreed” that they had adequate training regarding the association of obesity with surgical complication rates (88.6%), cancer development and prognosis (66.1%), adjuvant treatment outcomes (59.1%), and physical activity recommendations (52.3%).
      Approximately one-half of the respondents reported that overweight and obese gynecologic cancer survivors did not have a good understanding of the general and cancer-related implications of body weight (50%), eating habits (47.1%), or physical activity (47.7%). Most of the respondents believed that it was beneficial to educate survivors regarding the health risks of obesity (93%), healthy eating habits (96.6%), goal weight (96%), physical activity guidelines (96%), and the association of obesity with general health (96%) and gynecologic cancer prognosis (94.8%).
      Table 2 stratifies provider beliefs regarding obesity interventions by provider age, sex, and BMI. An overwhelming majority of respondents (94.9%) “agreed” or “strongly agreed” that addressing weight and lifestyle modifications in women with obesity-associated gynecologic cancers is important. However, less than one-half of them (48.6%) believed that actually discussing weight goals alone was likely to help obese survivors lose weight. Female respondents (P = .042) and providers with a BMI of <25 kg/m2 (P = .045) were more likely to “strongly agree” with the importance and benefit of intervention and patient education on obesity than male and overweight providers. Furthermore, provider respondents who were <42 years old were more likely than their older counterparts to “strongly agree” that survivors benefitted from education on obesity in relationship to their cancer prognosis (P = .017).
      TABLE 2Provider beliefs regarding importance of addressing weight/lifestyle modifications
      VariableProvider age, %Provider sex, %Provider body mass index, %
      <42 y≥42 yP valueFemaleMaleP value<25 kg/m2≥25 kg/m2P value
      It is important to address weight and lifestyle modifications..863.043.045
       Strongly agree64.460.070.153.579.851.3
       Agree29.935.327.638.425.042.1
      It is necessary to educate gynecologic cancer survivors on the health risks of obesity..179.003.313
       Strongly agree45.332.151.126.544.232.4
       Agree47.760.742.066.349.560.8
      Discussing weight goals with overweight and obese cancer survivor can help them lose weight..037.055.105
       Strongly agree11.69.413.67.111.69.3
       Agree46.529.445.531.034.742.7
      Patients benefit from education on
       Goal weight.441.000.002
       Strongly agree67.455.875.048.270.850.7
       Agree29.139.521.647.129.240.0
       Healthy eating habits.714.005.006
       Strongly agree72.066.380.757.677.160.0
       Agree25.629.118.236.522.932.0
       Physical activity.885.008.030
       Strongly agree72.168.680.760.077.162.7
       Agree23.327.918.236.921.929.3
       Obesity and cancer prognosis.017.000.038
       Strongly agree72.153.578.447.170.853.3
       Agree22.141.919.345.927.137.3
       Obesity and general health.099.001
       Strongly agree74.459.379.554.174.058.7.097
       Agree22.136.018.240.024.034.7
      Jernigan. Gynecologic cancer providers and obesity. Am J Obstet Gynecol 2013.
      Ninety percent of respondents believed that a multidisciplinary approach to obesity interventions in cancer survivors was important. They most commonly selected both the gynecologic oncologist and primary care provider as responsible for providing obesity counseling to gynecologic cancer survivors (Figure 1). However, 70% of those who were <42 years old believed the gynecologic oncologist was responsible, compared with only 54.3% of those who were ≥42 years old (P = .013). Most respondents believed that a cancer diagnosis was not a contraindication to aggressive weight reduction in an obese survivor (93.6%) and that addressing obesity with cancer survivors does not harm the doctor-patient relationship (94.8%). Nonetheless, 24.4% reported difficulty empathizing with obese survivors (men were more likely than women to report this [32.5% vs 15.9%; P = .019]), and only 60.4% of respondents reported making accommodations for obese patients in the outpatient setting.
      Figure thumbnail gr1
      FIGURE 1Provider beliefs regarding who is responsible for counseling obese cancer survivors about their weight and its implications on cancer prognosis and general health
      Cancer providers believe that they share responsibility for obesity counseling with primary care physicians and other health care providers
      Med Onc, Medical Oncology; PCP, primary care physician.
      Jernigan. Gynecologic cancer providers and obesity. Am J Obstet Gynecol 2013.
      Most respondents (62.8%) believed that even a 10% weight reduction was sufficient to decrease obesity-related health complications and believed they had helped at least 1 patient achieve healthier lifestyle modifications, with those respondents who were >42 years old more likely to believe they had helped at least 1 person maintain weight loss (73.4% vs 25.2%; P = .024). However, two-thirds of respondents did not believe that a 10% weight reduction would be enough to improve health in survivors. Providers reported measuring patient height (87%), weight (100%), or calculating BMI (82%) “always” or “most of the time.” Conversely, 66.3% “never” measured waist circumference. A considerable majority of them (87.9%) was comfortable providing initial counseling followed by referral to a commercial weight loss program (35.0%), primary care physician (23.6%), or hospital bariatrics program (22.9%). Most providers (89.1%) were uncomfortable prescribing weight loss medications for overweight/obese cancer survivors, and only 6.4% of them supervised lifestyle interventions alone. A select few of the respondents (8.9%) did not perform any counseling or referrals for obesity management.
      In terms of practice patterns regarding obesity management, more than one-half of provider respondents regularly addressed healthy eating habits (54.3%) and physical activity (61.6%) but less than one-third of them addressed goal weight (29.1%) with cancer survivors. Figure 2 shows the frequency with which providers reported addressing American Cancer Society guidelines with survivors. Notably, oncology providers were more likely to counsel survivors regarding tobacco cessation (84.2%) than on obesity-related American Cancer Society guidelines such as fruit and vegetable intake (23.0%) and exercise (38.2%). Providers more commonly counseled their survivor population on the long-term general health risks and all-cause death that are related to obesity than on cancer-specific obesity-driven outcomes (Figure 3). Finally, in terms of time devoted to lifestyle counseling, 62% of respondents believed that 10 minutes was adequate to counsel obese cancer survivors at each visit. Ninety percent of them reported actually using <10 minutes in practice. Respondents were divided regarding when to initiate obesity counseling with survivors, with 37.3% of them preferring to initiate a discussion at the first visit, 36.7% at a subsequent visit, and 22.2% after treatment or during a surveillance period. Most readdressed obesity counseling sporadically (62.9%); 27% of them reported addressing this topic at every clinical visit.
      Figure thumbnail gr2
      FIGURE 2Frequency with which providers report addressing American Cancer Society guidelines with patients and cancer survivors
      Providers report much greater fidelity addressing tobacco omission than diet and exercise recommendations that are endorsed by the American Cancer Society.
      Jernigan. Gynecologic cancer providers and obesity. Am J Obstet Gynecol 2013.
      Figure thumbnail gr3
      FIGURE 3What providers emphasize when counseling on obesity-related health risks for the gynecologic cancer survivor
      Cancer providers emphasize the general health consequences more commonly than the cancer-related outcomes that are associated with obesity.
      Jernigan. Gynecologic cancer providers and obesity. Am J Obstet Gynecol 2013.

      Comment

      There is increasing evidence that obesity is a risk factor for several malignancies, particularly gynecologic cancers, and may impact adversely the risk of cancer recurrence and survival.
      • Abu-Abid S.
      • Szold A.
      • Klausner J.
      Obesity and cancer.
      • Ahn J.
      • Schatzkin A.
      • Lacey Jr, J.V.
      • et al.
      Adiposity, adult weight change, and postmenopausal breast cancer risk.
      • Reeves G.K.
      • Pirie K.
      • Beral V.
      • et al.
      Cancer incidence and mortality in relation to body mass index in the million women study: cohort study.
      • Courneya K.S.
      • Karvinen K.H.
      • Campbell K.L.
      • et al.
      Associations among exercise, body weight, and quality of life in a population-based sample of endometrial cancer survivors.
      • Fader A.N.
      • Gil K.
      • von Gruenigen V.E.
      Quality of life in endometrial cancer survivors: What does obesity have to do with it?.
      • Calle E.E.
      • Rodriguez C.
      • Walker-Thurmond K.
      • Thun M.J.
      Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults.
      In a large prospective cohort study that examined the role of BMI with cancer-related death, Calle et al
      • Calle E.E.
      • Rodriguez C.
      • Walker-Thurmond K.
      • Thun M.J.
      Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults.
      demonstrated a significant association between higher weight and death for women with breast, uterine, cervix, and ovarian cancers. Additionally, data show that, compared with individuals who have not had cancer, cancer survivors are at greater risk for the development of second malignancies and other obesity-driven diseases or conditions, such as cardiovascular disease, diabetes mellitus, osteoporosis, and functional decline.
      • Abu-Abid S.
      • Szold A.
      • Klausner J.
      Obesity and cancer.
      • Reeves G.K.
      • Pirie K.
      • Beral V.
      • et al.
      Cancer incidence and mortality in relation to body mass index in the million women study: cohort study.
      Fader et al
      • Fader A.N.
      • Gil K.
      • von Gruenigen V.E.
      Quality of life in endometrial cancer survivors: What does obesity have to do with it?.
      demonstrated that health-related quality of life also deteriorates in obese gynecologic cancer survivors when compared with their thinner counterparts. In spite of this, phase III studies suggest that healthful lifestyle practices and successful weight management may prevent progressive or recurrent cancer. A recent randomized controlled trial demonstrated that behavior change and weight loss are achievable in overweight and obese endometrial cancer survivors; however, the clinical implications of these changes are as yet unknown and require a larger trial with a longer follow-up period.
      • Von Gruenigen V.
      • Frasure H.
      • Kavanagh M.B.
      • et al.
      Survivors of uterine cancer empowered by exercise and healthy diet (SUCCEED): a randomized controlled trial.
      However, randomized studies in survivors with other obesity-driven cancers such as breast and colorectal cancer demonstrate that healthy lifestyle modifications and weight loss decrease the risk of recurrence and improve survival outcomes.
      • Chlebowski R.T.
      • Blackburn G.L.
      • Thomson C.A.
      • et al.
      Dietary fat reduction and breast cancer outcome: interim efficacy results from the women's intervention nutrition study.
      • Demark-Wahnefried W.
      • Clipp E.C.
      • Lipkus I.M.
      • et al.
      Main outcomes of the FRESH START trial: a sequentially tailored, diet and exercise mailed print intervention among breast and prostate cancer survivors.
      These data highlight the importance of lifestyle interventions in cancer survivors with obesity-associated malignancies and the need for health care provider engagement to address this critical health issue with their patients.
      The current study is the first to characterize the beliefs and practices of gynecologic oncologists and other oncology providers regarding obesity counseling and treatment for overweight or obese gynecologic cancer survivors. This is an important first step towards the identification of deficiencies in the knowledge, resources, and practices of providers who have the opportunity to address obesity with patients in the setting of cancer prevention and treatment. Providers reported that most of their gynecologic cancer survivor population is overweight/obese; most respondents (94.8%) agreed that addressing lifestyle modifications with obese survivors is important. Respondents also believed that gynecologic oncologists and primary care providers both were responsible for addressing obesity with survivors and that discussing a patient's weight would not harm the doctor-patient relationship. More providers who were ≤42 years old reported undergoing formal training in obesity management (23.6% vs 7.9%; P < .001); those who were ≤42 years old, female, and normal weight providers were most likely to believe in the value of obesity counseling. Although they believed that 10 minutes was adequate to devote to counseling, in practice, almost all providers spent <10 minutes addressing obesity issues. Last, although most gynecologic oncologists preferred to initiate obesity counseling with their patients, respondents eventually referred survivors to other providers for obesity interventions. This indicates a preference for a multidisciplinary approach to obesity intervention.
      Our survey study included a needs assessment to identify the scope of the obesity problem among gynecologic cancer survivors (as perceived by oncology providers) and to determine the preparedness of cancer providers to address obesity counseling and treatment with their patients. The current study findings are consistent with reports of obese patients without cancer that demonstrate physicians' desire to help their patients modify obesity-related risk factors.
      • Chlebowski R.T.
      • Blackburn G.L.
      • Thomson C.A.
      • et al.
      Dietary fat reduction and breast cancer outcome: interim efficacy results from the women's intervention nutrition study.
      • Demark-Wahnefried W.
      • Clipp E.C.
      • Lipkus I.M.
      • et al.
      Main outcomes of the FRESH START trial: a sequentially tailored, diet and exercise mailed print intervention among breast and prostate cancer survivors.
      The timing of interventions may be critically important because the teachable moment may best be capitalized on if interventions are offered soon after diagnosis. In a survey study of 978 breast and prostate cancer survivors, Demark-Wahnefried et al
      • Demark-Wahnefried W.
      • Clipp E.C.
      • Lipkus I.M.
      • et al.
      Main outcomes of the FRESH START trial: a sequentially tailored, diet and exercise mailed print intervention among breast and prostate cancer survivors.
      found that the most preferred lifestyle interventions were initiated at diagnosis or soon thereafter. Similarly, in the current study, >70% of providers believed that an obesity intervention should be introduced at the time of cancer diagnosis or soon after at a subsequent visit. However, further research is required to determine the optimal timing of lifestyle interventions that may need to be individualized based on cancer survivor age, disease stage, need for adjuvant therapies, general health and insurance statuses, and distance from providers.
      Although most providers in this study believed that obesity was important to address with survivors, formal obesity management training was largely lacking among survey respondents, with many providers believing they would benefit from additional formal training. Moreover, although obesity is the modifiable risk factor most associated with gynecologic malignancies, survey respondents reported they were more likely to counsel survivors on tobacco cessation than on diet and exercise. This bias and potential educational gap among providers may be a barrier to providing adequate care for obese survivors and suggests that the incorporation of obesity counseling and management into gynecologic cancer fellowship curricula and oncology society course offerings may improve physician engagement and efficacy with lifestyle counseling. Another identified barrier to addressing lifestyle changes with cancer survivors was a moderate sense of futility among survey respondents. Despite published data that suggest that even a 10% reduction in weight is sufficient to change health outcomes,
      Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary. expert panel on the identification, evaluation, and treatment of overweight in adults.
      more than one-third of survey respondents did not agree with this statement, especially among providers who were >42 years old. Although there is considerable evidence in prospective studies that consistent obesity counseling by health care providers does help patients make healthier choices and achieve weight loss,
      • Greenwood M.
      Help not hype: getting real about weight loss.
      • Kreuter M.W.
      • Chheda S.G.
      • Bull F.C.
      How does physician advice influence patient behavior? Evidence for a priming effect.
      less than one-half of the respondents in our study believed that it was likely that discussing weight goals with cancer survivors could help them lose weight. Moreover, it is well-documented that physicians often harbor negative feelings or biases towards overweight/obese patients.
      • Harvey E.L.
      • Hill A.J.
      Health professionals' views of overweight people and smokers.
      This study was no different in this regard, with 1 in 4 respondents reporting a lack of empathy for obese cancer survivors. However, these responses may be more likely to reflect clinicians' self-assessment of their ineffectiveness with obesity counseling/management rather than a lack of interest or knowledge of the scope of the problem. These biases are critical to address in the development of any curricula or programs regarding obesity management.
      Study limitations include the 30% response rate from Society of Gynecologic Oncology membership and that a selection bias is possible, with those who completed the survey potentially more concerned about obesity and its implications to gynecologic cancer survivors. However, this response rate is concordant with previously published survey studies that have been performed within the society. Furthermore, our results closely resemble the demographic results of the 2010 Society for Gynecologic Oncologists State of the Subspecialty Survey, which indicate that this sample, although small, is representative of US gynecologic oncology providers as a whole.
      Society of Gynecologic Oncology
      Further, the study was a needs assessment and significant first step towards the identification of the attitudes and practices of gynecologic oncology providers with respect to an important cancer survivor public health problem that will inform future survivorship intervention studies.
      In conclusion, obesity is a serious public health crisis in the United States and globally and a significant risk factor for the development of several women's cancers. Studies demonstrate that healthy lifestyle modifications in overweight/obese cancer survivors improve cancer-related and overall health outcomes. A new gynecologic cancer diagnosis in an obese woman provides a unique “teachable moment” to educate the patient about the relationship of obesity to gynecologic and other cancers and to her long-term health and quality of life. This survey identifies knowledge gaps and areas for potential improvement in obesity management education for oncologic health care providers. Further research is needed to identify barriers to care for obese cancer survivors and to improve physician engagement with obesity and lifestyle counseling.

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