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Extremely obese women are less likely than nonobese women to receive breast and cervical cancer screening examinations. Reasons for this disparity are unclear and may stem from patient and/or physician barriers. This sequential mixed-methods study used individual in-depth interviews of 15 family physicians followed by a mail survey of 255 family physicians (53% response rate) to understand the barriers they faced in performing cancer screening examinations in extremely obese women. Barriers fell into three main areas: (i) difficulty doing pelvic and breast exams; (ii) inadequate equipment; and (iii) challenges overcoming patient barriers and refusal. This led some physicians to avoid performing breast and pelvic examinations on extremely obese women. Having more knowledge about specific examination techniques was associated with less difficulty in palpating lumps on breast and pelvic examinations (P < 0.005). Physicians perceived that embarrassment, aversion to undressing, and avoidance of discussions related to their weight were the most frequent barriers extremely obese women had with getting physical examinations. Educating and/or motivating patients and addressing fears were strategies used most frequently when patients refused mammograms or Pap smears. Interventions focusing on physician barriers, such as educating them on specific examination techniques, obtaining adequate equipment and supplies, and providing resources to assist physicians in dealing with patient barriers and refusal, may be fruitful in increasing cancer screening rates in extremely obese patients. Future research studies testing the effectiveness of these strategies are needed to improve cancer outcomes in this high-risk population.
The prevalence of extreme obesity (BMI ≥ 40 kg/m2), formerly called “morbid obesity,” has increased dramatically in the United States, from 1 in 35 adults during the 1990s to 1 in 20 in 2004 (refs. 1,2) Obesity is associated with higher incidence of breast cancer (3), later-stage breast cancer diagnosis (4,5), and higher breast and cervical cancer mortality (6). Despite having a higher risk of developing and dying from cancer, obese women, especially extremely obese women, are less likely than nonobese women to receive breast and cervical cancer screening examinations (7-20). Reasons for this disparity are unclear and may stem from patient and/or physician barriers.
Limited research suggests that obese women may delay health care or avoid Pap smears because of embarrassment (11,15,21-23), negative provider attitudes (11), inadequate equipment (11), or unsolicited weight-loss advice and routine weighing (11,22-24). However, few studies examine physician barriers to cancer screening in obese women. One survey study found that some physicians were reluctant to perform pelvic examinations in “very obese and very reluctant patients,” but it did not explore reasons for this (21). Another survey study of mostly obstetrics/gynecology (OB/GYN) mid-level providers found that they had difficulty examining obese women, were dissatisfied with resources available, and lacked adequate supplies (11). We could find no studies regarding family physicians’ barriers to cancer screening in obese women. The purpose of this study was to better understand the barriers that family physicians face in performing breast and cervical cancer screening examinations in extremely obese women.
This was a sequential mixed-methods study (25) using in-depth interviews of 15 family physicians to identify themes related to challenges to cancer screening in obese women and to develop questions relevant for a subsequent mail survey of 255 family physicians. For the interviews, physicians were recruited from preceptors affiliated with the University of Medicine and Dentistry of New Jersey–New Jersey Medical School Department of Family Medicine and the New Jersey Family Medicine Research Network. Physicians were purposely sampled to obtain maximum variation regarding age, gender, location, and patient population. The survey sample consisted of all physician members (N = 364) of the New Jersey Family Medicine Research Network and a randomized sample of 136 additional family physicians selected from a Blue Cross Blue Shield provider directory from counties within New Jersey that were not well represented in the New Jersey Family Medicine Research Network. The study was approved by the institutional review board of University of Medicine and Dentistry of New Jersey.
A semi-structured interview guide was used to elicit detailed stories from physicians and help them reconstruct perceptions of events and experiences related to care of extremely obese patients. Recall of recent patient encounters was used to ground the discussion. Physicians were asked to describe extremely obese patients who they recently saw, performed a physical on, and who were not up-to-date in mammograms and Pap smears (see Supplementary data online for interview guide). The 30–60 min interviews were conducted iteratively by a trained research assistant, audiotaped, and transcribed verbatim. Physicians received $100 incentive. Transcripts were imported into ATLAS.ti (Berlin, Germany) for coding and text retrieval. Thematic analysis was conducted using an immersion/crystallization technique (26). Ongoing analysis and interviews continued until consensus and saturation were reached.
Themes emerging from the interviews and information from previous literature were used to develop the mail survey. Survey questions addressed areas such as challenges doing breast and pelvic examinations on extremely obese patients, availability of equipment to accommodate extremely obese patients, perceptions on obese patients’ barriers in getting physical and cancer screening exams, and strategies used when patients refuse cancer screening exams (see Supplementary data online for survey questions). Other areas of the survey included general care and weight management of extremely obese patients and are described in a separate article (27). Physicians were also asked about their demographic and practice characteristics, and whether they performed Pap smears in the office. The survey was pretested with five family physicians, modified as appropriate, and mailed to the 500 family physicians using a modified Dillman method (28). A $10 bookstore gift card was offered as incentive.
All returned surveys were optically scanned, digitally processed, and data analyzed with SAS 9.1 software (SAS Institute, Cary, NC). χ2-Tests of independence, Fisher’s exact test or exact Mantel–Haenszel χ2-test were used to examine bivariate associations of physician demographic and practice characteristics with responses to each item. Ordinal logistic regression using the proportional odds model was performed to control for potential confounders (29). Bonferroni corrections were made for multiple comparisons. All reported odds ratios and 95% confidence intervals were adjusted for physician age, gender, patient volume, and percent of patients that are extremely obese.
Table 1 summarizes characteristics of interview and survey participants. Fifteen family physicians (mean age 48 years, s.d. 9) were interviewed. A total of 255 of 483 eligible physicians completed the survey (53% response rate). A 41% of survey respondents were overweight and 12% obese. There was no significant differences in gender (P = 0.21) or practice setting (P = 0.96) between respondents and nonrespondents. On average, physicians estimated that 29.4% of their patients were obese (BMI ≥30), and 8.5% extremely obese (BMI ≥40). Most of their patients were white (62.5%) with commercial or Medicare insurance (82%). Compared to males, female physicians were younger (mean age 45 years vs. 50; P = 0.012), in practice for fewer years (18% vs. 49% over 20 years; P < 0.0001), spent fewer hours per week in patient care (12% vs. 34% over 40 h; P < 0.0001), and saw fewer patients per week (25% vs. 52% over 100 patients; P < 0.0001).
Themes emerging from the physician interviews are described below with illustrative quotes, followed by survey data confirming or expanding findings.
Barriers included: difficulty doing pelvic exams, difficulty getting the patient up on the exam table, unavailability of large speculums, and priority of other medical issues. These barriers caused some physicians to avoid doing Pap smears on extremely obese women. For example,
“I can’t get her up onto the examination table easily to perform any exam. I’m also very concerned that I’m going to do an inadequate exam and, therefore, shy away from doing an inadequate exam, for example, pap smears…I have done a breast exam on her, but I have not done a pap smear on her since I’ve known her…I have the fear that I’m going to get the person up in that position and then not be able to get the job done.” (MD11, male)
“I don’t feel [the pelvic exams] are fully adequate… partly it’s not being able to get a good visualization of the cervix…also when you’re trying to do the bimanual exam, because of her obesity…it’s difficult to really even feel the uterus, let alone the ovaries.” (MD12, female)
“The hardest part of the exam is to locate the cervix, because if you don’t have a big enough speculum and you don’t have wide enough stirrups and a big enough table… it’s hard to find the cervix without a long, wide speculum to separate the tissue.” (MD7, male)
“We’ve been dealing with such specific problems each time that we haven’t actually had an appointment set aside for a complete physical and going over those things.” (MD14, male)
Although 84% of respondents performed Pap smears in their office, 11% of them did not perform Pap smears on extremely obese women. Female physicians were more likely than males to perform Pap smears in the office (93% vs. 78%; P = 0.001) and to perform Pap smears on extremely obese patients (97% vs. 83%; P = 0.002). Many physicians encountered the following challenges: palpating masses (90%), separating thighs (79%), and visualizing the cervix (76%).
Difficulty palpating lumps and extra time required for breast exams were reported as challenges. For example,
“…cause of the sheer size of the breasts, it’s hard to feel anything, which, I guess, is one of the other reasons I don’t do them. I’m not sure I really pick up much, or add much to [a mammogram], because of the amount of fat that makes it hard to feel anything.” (MD2, male)
“…there’s just a lot of breast tissue there and…in my mind, I’m thinking to myself, ‘This is taking a really long time, to actually touch every area and make sure that there’s nothing going on there.’ I feel like in the context of family medicine, we’re supposed to be moving along and not spending too much time…I’m thinking to myself, ‘It’s taking me an extra five whole minutes to do that.’” (MD13, male)
An 80% of respondents reported difficulty palpating lumps at least sometimes, and 73% reported breast exams required extra time.
Some physicians described using specific techniques to help them examine extremely obese patients. For instance,
“Sometimes I can put a glove around the speculum and open the end, so when I open up the speculum the glove holds up the side walls.” (MD15, male)
“I’ve got my technique down of holding [the breast] with one hand and feeling with the other…pressing and going around in circles.” (MD8, female)
A 47% of respondents had little or no knowledge in specific helpful examination techniques; however, 80% reported education on these techniques would be helpful or crucial in improving care, and 72% desired more education on this topic. Having more knowledge in specific examination techniques was associated with less difficulty in palpating lumps on breast and pelvic exam (P < 0.005).
Lack of equipment such as tables, large speculums, and extra large gowns were cited as barriers to examining extremely obese women. Reasons for not having adequate equipment included expense, too few extremely obese patients in the practice, and just not thinking of it. For example,
“The biggest obstacle that I’ve faced with obese patients is that I have to purchase special equipment that costs a significant amount of money that I can’t use on a significant portion of my population.” (MD3, female)
Figure 1 shows the percentage of respondents with equipment to accommodate extremely obese patients. Most had large speculums, whereas only 57% had extra large gowns. Having equipment to accommodate extremely obese patients was reported by 85% of respondents to be helpful or crucial in improving care.
Physicians stated obese patients sometimes refused or did not comply with their recommendations for cancer screening. Weight-related reasons included: embarrassment, pain or discomfort, inadequate equipment, limited mobility, other health or family priorities, or disrespectful treatment from healthcare providers. For example,
“Some women are embarrassed…don’t want to take their clothes off…And often I will give them a gown and say, ‘I’m going to step out of the room while you put this on, and I’ll be back with a nurse.’ And there have been a couple of occasions where they say, ‘I just prefer not to have the exam done.’ Or you come back and they don’t have the gown on…or, they put the gown on top of their clothes.” (MD4, male)
“…because it’s too painful to get a mammogram, especially if they have large breasts. And they just refuse it. I then will do an actual physical exam, and let them know that it’s not satisfactory, but it’s better than nothing.” (MD5, male)
“I think they have some fears…our tables, when we pull out the foot rest, many times they feel the foot rest is not going to support them adequately. They may have more difficulty in maneuvering down to the end of the table to have the Pap smear performed.” (MD1, female)
“One time a patient told me that she went to a GYN’s office. And every time that she went, he kept saying ‘Boy, you’re getting fat.’ Or he’d slap her on the leg…she was in the stirrups and he’d go, ‘Boy you even got bigger than you did last year.’” (MD6, female)
Table 2 shows the responses to the question “Which of the following barriers do you think your extremely obese patients have with getting physical exams?” Embarrassment and aversion to undressing were most highly rated. When asked “How often do your extremely obese patients offer you the following reasons for not getting a mammogram?” “I just keep putting it off” was reported most frequently (86%), followed by mammograms cause too much pain (73%), fear of finding cancer (67%), and having too many other health (56%) or family priorities (51%). Similarly, just putting it off was the most frequently reported reason women gave for not getting a Pap smear (84%), followed by difficulty getting on the exam table (67%), embarrassment (58%), and too many other health (56%) or family priorities (53%). Difficulty getting an appointment, low perceived risk of cancer, and receipt of disrespectful treatment from health-care providers were least reported barriers for getting mammograms and Pap smears.
Several strategies were used when patients refused cancer screening tests. For example,
“You basically just try to ask them why and try to address any possible questions and issues.” (MD6, female)
“I try to motivate her to take care of herself so she can be there to take care of her children.” (MD4, male)
“They may be resistant, but that’s just their choice, and I respect their choice. I inform them of the facts and then it’s their right to make a choice. I can’t coerce them into doing things.” (MD5, male)
Table 3 shows the frequency of different strategies used by respondents when patients refused mammograms or Pap smears. Although 61% of physicians persisted in recommending exams until patients complied, ~20% did not persist when they knew the answer would be no. A 56% of physicians referred patients who refused mammograms or Pap smears to OB/GYN.
Table 4 shows survey responses that differed significantly by gender. After adjusting for age, patient volume, and percentage of extremely obese patients in the practice, male physicians reported less difficulty with palpating masses on pelvic exams (odds ratio 0.41; 95% confidence interval 0.23, 0.73), and they were less likely to report that extremely obese patients were too embarrassed to get physicals (odds ratio 0.39; 95% confidence interval 0.22, 0.68). Male physicians more often referred patients who refused mammograms or Pap smears to OB/GYN (odds ratio 2.92; 95% confidence interval 1.71, 4.98).
This is the first study to use mixed-methods to describe family physicians’ barriers to cancer screening in extremely obese women. This integration of qualitative and quantitative data is very useful for exploring new topics and gaining better understanding of results.(25) Barriers fell into three main areas: (i) difficulty doing exams, (ii) inadequate equipment, and (iii) challenges overcoming patient barriers and refusal. Similar to findings by Amy et al. (11) difficulty doing exams and lack of adequate equipment were commonly experienced. This may have caused some physicians to avoid performing cancer screening examinations on extremely obese women. This avoidance, as well as not persisting when patients refuse, may contribute to the lower rates of cancer screening in obese women, a high-risk group that often delays cancer screening exams. Our findings support those of Adams et al. that some physicians are more reluctant to perform pelvic examinations in patients who are very obese and those who are very reluctant,(21) and our study offers reasons for this reluctance.
Although more of the OB/GYN providers in Amy et al.’s study had large-sized exam tables, a higher percentage of our family physician respondents had scales, gowns, armless chairs, and blood pressure cuffs for large patients (11). Still, availability of these supplies was less than optimal. For instance, 43% of respondents did not have extra large gowns, which may compound the embarrassment obese patients experience and their avoidance in getting undressed. As extremely obese persons comprise an increasing segment of the US population (2), more practices will need equipment and supplies to better accommodate them.
Survey respondents were generally perceptive regarding obese patients’ barriers to receiving physical examinations. Embarrassment, aversion to undressing, and avoidance of discussions related to their weight were highly rated by physicians, congruent with barriers elicited from studies with patients (11,15,21-24). Additionally, 40% of survey respondents reported disrespectful treatment from health-care providers was a reason patients gave for not getting mammograms and Pap smears, similar to the 36% of women answering affirmative to this statement in Amy et al.’s study.(11)
Similar to others, we found female family physicians were more likely than male physicians to perform Pap smears in the office (30,31). This may be due to greater emphasis on prevention by female physicians (30,32), their greater comfort and skill with performing Pap smears (31), or patient preference for female physicians when obtaining Pap smears (32). Male physicians reported less difficulty than females with palpating masses on pelvic exams. This may be due to the higher percentage of female physicians performing Pap smears on extremely obese women. As expected, male physicians were more likely than female physicians to refer obese patients who refuse cancer screenings to OB/GYN. More research is needed to examine the influence of physician gender on delivery of preventive services for extremely obese patients.
To increase cancer screening rates in extremely obese women, interventions targeting specific patient and physician barriers are needed. We elucidate physician barriers that are potential targets for future interventions. For example, many family physicians were interested in receiving education on specific examination techniques. This may decrease difficulties that physicians have and subsequent avoidance of examinations on extremely obese patients. Second, practices may obtain equipment and supplies to help them examine extremely obese patients. For physicians who cannot afford to purchase these supplies or do not have the comfort or skills to perform breast and pelvic examinations on extremely obese patients, referring these patients to physicians that can accommodate them should be encouraged, with follow-up to ensure patient compliance. Finally, resources to assist physicians in dealing with patient refusal and overcoming patient barriers are needed. Publications which give advice on improving the office environment and interactions with obese patients should be disseminated (33,34).
Limitations of this study should be considered. For the interviews, we used purposive sampling to obtain maximum variation regarding age, gender, location, and patient population, but we may not have obtained all possible responses. We relied on physician recall of specific patient encounters, which may be an incomplete picture of barriers faced. For the surveys, although a 53% response rate is generally acceptable for this type of survey research, the results cannot be generalized to other specialties or physicians outside of New Jersey. Responders may have more interest in obesity and cancer screening, so barriers may have been understated. Finally, all data were self-reported and not objectively measured, so true barriers may be lower or higher than suggested.
Interventions focusing on physician barriers, such as educating them on specific examination techniques, obtaining adequate equipment and supplies, and providing resources to assist physicians in overcoming patient barriers and refusal, may be fruitful in increasing cancer screening rates in extremely obese patients. Future research studies testing the effectiveness of these strategies are needed to improve cancer outcomes in this high-risk population.
This study was supported by a research career development award (JMF) from the National Cancer Institute (K07CA101780). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute and the National Institutes of Health. The study was conducted in conjunction with the New Jersey Family Medicine Research Network (NJFMRN), a shared resource of the Cancer Institute of New Jersey. Data collection was supported by the Cancer Institute of New Jersey’s Survey Research and Qualitative Methods Shared Resource.