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.
NORTH
AND SOUTH
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.
FEAR
AND LOATHING
"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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