JULY 2008


Obese cheated out of Pap tests

Patient fear, doctor bias to blame for low screening rate

Do you offer your obese patients the same cervical cancer screening options as you do your slimmer patients?

Are you sure?

Canadian women with a BMI of 35 or higher are a whopping 40% less likely to be screened for cervical cancer by Pap test than other women, according to a University of Alberta study in the August American Journal of Preventive Medicine. So clearly something's going wrong. The blame for this worrying trend is probably shared pretty equally between patients and their physicians, say the researchers.

When obesity specialist Dr Raj Padwal and his colleagues set out to conduct their study, they didn't expect to come to this result. Similar studies had been done in the US, and the team assumed that the imbalance in screening there was a result of so many poor Americans not being able to afford healthcare (obesity is often associated with low socioeconomic status). "We were thinking that with our public healthcare system, we wouldn't see it here," says Dr Padwal.

"The severely obese are at higher risk for adenocarcinoma," he notes, referring to the type of cervical cancer that makes up about 10 to 20% of diagnoses, "so we should actually be seeing higher screening in these patients."

The researchers looked at rates for three types of screening: Pap smears, mammography and fecal occult blood testing (the last in women and men). The three tests are recommended by the Canadian Task Force for Preventive Health Care for cervical, breast and colorectal cancer screening. Fortunately for Canada, breast and colorectal screening rates were not affected by weight. This was not the case in the US.

"Probably a lot of the barrier is on the patient side," says Dr Padwal. "The morbidly obese aren't worried about normal things — they're worried about being able to breathe and other complications. A Pap test isn't a priority for them."

On the physician side, the picture is a little murkier, and yes, an obesity bias does appear to be at play. "This is especially true when we're talking about the super obese, with a BMI over 50," says Dr Padwal. He notes that poor hygiene is also common among the very obese, simply because it's difficult to wash. "This can cause some embarrassment on the provider end — they're not necessarily biased, but they think 'I don't want to embarrass her.'"

He says more prosaic factors come into it too, like simply not having the right equipment for very large women. "You might have a patient who weighs 350 to 400lbs — how are you going to fit her on the table and get a good sample?"

Dr Padwal notes that this is going to become more and more problematic as the obesity epidemic worsens. "This equipment is quite expensive — it can cost tens of thousands of dollars," he says. "This is a problem in my own practice. I struggle to make these patients comfortable." Dr Padwal says physicians in Alberta, where he practises, are lucky because the province recently introduced new billing codes for doing screening in obese patients. But he says he's not aware of any province that's willing to help doctors with the cost of special equipment.



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