Research article
Cancer Screening in Women: Body Mass Index and Adherence to Physician Recommendations

https://doi.org/10.1016/j.amepre.2007.02.004Get rights and content

Background

The reasons that obese women are less likely to obtain mammograms and Papanicolaou tests (Pap smears) are poorly understood. This study evaluated associations between body mass index (BMI) and receipt of and adherence to physician recommendations for mammography and Pap smear.

Methods

Data from the 2000 National Health Interview Survey (8289 women aged 40 to 74 years) were analyzed in 2006 using logistic regression. Women with previous hysterectomy were excluded from Pap smear analyses (n=5521). Outcome measures were being up-to-date with screening, receipt of physician recommendations, and women’s adherence to physician recommendations for mammography and Pap smear.

Results

After adjusting for sociodemographic variables, healthcare access, health behaviors, and comorbidity, severely obese women (BMI > 40 kg/m2) were less likely to have had mammography within 2 years (odds ratio [OR]=0.50, 95% confidence interval [CI]=0.37–0.68) and a Pap smear within 3 years (OR=0.43, 95% CI=0.27–0.70). Obese women were as likely as normal-weight women to receive physician recommendations for mammography and Pap smear. Severely obese women were less likely to adhere to physician recommendations for mammography (OR=0.49, 95% CI=0.32–0.76). Women in all obese categories (BMI > 30 kg/m2) were less likely to adhere to physician recommendations for Pap smear (ORs ranged from 0.17 to 0.28, p<0.001).

Conclusions

Obese women are less likely to adhere to physician recommendations for breast and cervical cancer screening. Interventions focusing solely on increasing physician recommendations for mammography and Pap smears will probably be insufficient for obese women. Additional strategies are needed to make cancer screening more acceptable for this high-risk group.

Introduction

The prevalence of obesity, defined as body mass index (BMI) > 30 kg/m2, among adults in the United States has increased from 23% in the 1988–1994 period to 32% in 2003–2004. In addition, the prevalence of severe obesity (BMI > 40 kg/m2) increased from about 1 in 35 adult Americans to 1 in 20.1, 2 Obesity is associated with increased incidence of breast and cervical cancer,3, 4 later-stage breast cancer diagnosis,5, 6, 7, 8 and higher breast and cervical cancer mortality rates.9, 10

Obese women, particularly those with a BMI > 35 to 40, have lower rates of mammograms and Papanicolaou tests (Pap smears).11, 12, 13, 14, 15, 16, 17, 18 One of the strongest and most consistent predictors of cancer screening is a physician’s recommendation.19, 20, 21 It is unclear whether the lower rates of cancer screening in obese women are due to lack of physician recommendations or patients failing to adhere to physician recommendations. Factors associated with physician recommendations for mammography include having private insurance, higher income, higher education, younger age, greater number of visits, regular physician, greater number of physicians seen, personal history of breast problems, recent Pap smear, and taking medications.22, 23, 24 Factors associated with physician recommendations for the Pap smear include younger age, being born in the U.S., and having contact with a specialist or general physician in the past year.25 It is unknown if physicians are less likely to recommend mammogram or Pap smears to obese women. Obese patients are stereotyped to have less willpower and be less concerned about their health than non-obese patients.26, 27 Physicians may subconsciously feel that obese patients are less interested in preventive care, and thus be less likely to suggest cancer screening. Increasing BMI is associated with a greater number of different physicians seen,28 so that physicians may assume that someone else will order cancer screening. In addition, physicians may be less likely to pursue pelvic examinations in severely obese patients due to technical difficulties or increased comorbidity.29, 30

The degree to which obese women adhere to physician recommendations for breast and cervical cancer screening is also unknown. Factors associated with adherence to mammography recommendation are having private insurance, being seen in family practice, and having a recent Pap smear.22 There are no studies exploring the relationship between BMI and adherence to physician recommendations for mammography or Pap smear. The purpose of this study was to determine if BMI is associated with receipt of and adherence to physician recommendations for mammography and Pap smear.

Section snippets

Study Population

This study, conducted in 2006, analyzed data collected from the 2000 National Health Interview Survey (NHIS), a cross-sectional in-person health survey conducted annually by the National Center for Health Statistics, Centers for Disease Control and Prevention (CDC).31 It uses a multistage, stratified, clustered sampling design to obtain health-related information of the U.S. population. In 2000, one adult, randomly selected from each of 43,437 households, answered a supplemental Cancer Control

Results

Table 1 shows the characteristics of women in the study sample by BMI categories. Overall, 42% were normal weight, 32% were overweight, and 26% were obese. Increasing BMI was significantly associated with age, Black race/ethnicity, lower education, lower incomes, Medicaid insurance, contact with a primary care physician, greater number of visits, and higher number of comorbidities.

Table 2 shows unadjusted associations between BMI categories and each outcome. There were significant differences

Discussion

This study suggests that patient barriers are more important than physician barriers for decreased rates of Pap smears and mammograms in obese women, particularly severely obese women. Since physician recommendation is the strongest predictor of cancer screening in women, it is reassuring that physicians are as likely to recommend mammograms and Pap smears to obese as to non-obese women. The lower prevalence of breast and cervical cancer screening in severely obese women is not due to lack of

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    Copyright © 2007 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.