Why do patients at higher risk for endometrial cancer wait longer for treatment?

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.