World Cancer Day: Fat-Shaming in Cancer Treatment
Everyone wants their best shot at combating cancer. Fat people don’t get that shot.
Much has been made about the links between obesity and cancer—how the more fat you are, the more likely you are to contract x, y, or z cancer. Apart from common health complications associated with obesity, overweight cis-women are at an additional health risk for several forms of organ cancer compared to overweight men. This is in part due to higher levels of endogenous estrogen associated with increased weight in cis-women, creating an increased risk particularly for breast and cervical cancer.
This article, however, is not about increased risk. This article is about increased death. It would be easy to stick with the correlation—if obese cis-women are more at risk because of their own bodies, then of course they must have higher mortality rate because of their bodies, too. Fat people dying because they are fat is an easy story to tell.
The harder story to tell is this one: fat people are dying because at every step in their cancer journey, the medical establishment systemically acts on anti-fat bias to deliver a lesser quality of care. Specifically, the increased death rate of overweight cis-women from breast and cervical cancer can be directly linked to anti-fat bias. Negative physician attitudes, a lack of equipment accessibility, and incomprehensive medical practices have a direct detrimental effect on the prevention, diagnosis, and treatment of cervical and breast cancer, making the effects of the medical establishment’s shortcomings easily identifiable and trackable throughout the care process.
The majority of literature on interactions between providers and overweight patients points to an ingrained pervasiveness of anti-fat stigmatization. The way providers view their overweight patients socially and in terms of personal discipline is overwhelmingly negative across a variety of measures. More than 50 percent of physicians describe their obese patients as awkward, unattractive, ugly, noncompliant, lacking motivation, and annoying. Additionally, about 30 to 45 percent of physicians view obese patients as weak-willed, sloppy, and lazy, according to the International Journal on Obesity. In a peer reviewed study, 80 percent of healthcare providers viewed overweight patients as lacking discipline, and 70 percent reported their overweight patients just wanted an “easy way out” of their health goals. These negative views contribute to over 50 percent of providers feeling that their treatment on fat people is ineffective, as well as physicians reporting that treating overweight patients was a waste of their time.
The negative attitudes providers hold of their larger patients do not exist in the vacuum of simply thoughts, but rather these views directly impact the attention and individualization of treatment that patients receive. Provider’s lack of personal desire and annoyance at their overweight patients contributes directly to a decreased level of treatment, as physicians reported that the heavier a patient was, the less time they would spend with them due to their frustration and disgust. This sentiment is backed up by empirical research that shows that providers spend on average eight minutes less with overweight patients versus average weight patients.
Fat people know that doctors don’t like them. Over 45 percent of patients in a an Archives of Family Medicine survey reportedbeing treated disrespectfully by medical professionals due to their weight, with 30 percent reporting that a doctor said “critical or insulting things” to them directly about their weight. Healthcare professionals are rated by overweight and obese people as one of the top sources of fat stigma in their lives. Additionally, doctor’s offices are often not equipped with proper equipment for overweight patients. Patient interviews show that when equipment is either not available or too small, overweight patients feel incredible shame both internally and from the providers in the clinic. Overweight patients also report inaccessible equipment as making the procedures unpleasant, and in some cases even painful. These factors create a culture of aversion, in which overweight cis-women cite “fear” of shame, embarrassment, and pain as a deterrent to medical care twice as likely as average weight cis-women.
Preventative care might be one of the most important services provided by doctors in the fight against cancer. For high-risk populations like obese cis-women, preventative screening is particularly important for early detection and proper treatment. However, overweight cis-women have disproportionately low preventative screening care rates, specifically for breast and cervical cancer screenings over other cancers. The barrier of fear due to anti-fat attitudes is exacerbated in preventative care for cervical and breast cancer due to the invasive and exposing procedures involved. Rates of avoidance due to shame and fear are higher for screening services due to the manual manipulation and disrobing necessary for breast and cervical cancer, specifically mammography, breast clinical examination, gynecologic examination, and Pap smear tests. When you know your doctor hates your body, why would you want them seeing so much of it, touching it, manipulating it?
At the diagnosis stage of breast and cervical cancer, systemic anti-fat bias has also led to inadequately trained doctors. This problem is severe, with 85 percent of providers stating that gynecological exams were more difficult to conduct in obese patients. Over 50 percent of those same providers also responded that they had received no specific training on conducting gynecological exams on obese patients, demonstrating the lack of regard and comprehensiveness in medical practices. When our medical establishment disregards fat people to the extent that providers cannot diagnose cancer accurately, our medical establishment is failing.
At the treatment stage, obese cis-women who have been diagnosed with cervical and breast cancer receive a lower quality of treatment due to discrepancies in chemotherapy dosage practices. The current widely used chemotherapy dosing practice in the United States is based on a patient’s estimated body surface area, or BSA. When treating overweight patients, many providers use ideal body weight or adjusted ideal body weight in order to cap a patient’s BSA, rather than use obese patients’ actual body weight. Capping BSA is most often done due to concerns about the toxicity of exposing patients to too much chemotherapy. However, systematic literature reviews have found that these toxicity concerns are unfounded, and thus, the capping of BSA is arbitrary.
As a result of this outdated treatment practice that is still widely used, it is estimated that up to 40 percent of obese patients receive inadequate chemotherapy doses as well as unnecessary reductions. This is a troubling statistic given that practically all medical data supports that chemotherapy increases chances of survival, and decreased chemotherapy dosing is associated with cancer recurrence and increased mortality rates. By systemically underdosing fat patients, fat people are given less of a shot at survival than their average weight counterparts.
In extremely direct ways, such as underdosing, and more discrete ways like the maintenance of a hostile clinic environment, the medical establishment is a major contributor to the deaths of overweight cis-women. The stigmatization of fat bodies in our society is not a change that can occur overnight, but our medical community needs to lead the charge through small reforms that pave the way for a greater change. Medicine is supposed to help, not hurt, and in our current medical establishment overweight people are being directly hurt by the effects of anti-fat stigma.
Experts estimate that 1,219 cancer diagnoses are missed or delayed in overweight cis-women every three years. Due to the diagnosis of cancer at later stages in overweight patients, the effects of a decreased preventative screening rate is estimated to result in over 3,027 additional deaths in five years. I mourn these women this World Cancer Day.