obesity is a growing problem in the united states over the past 20  years with the prevalence remaining high despite new regulations and interventions implemented by the u.s .
department of health and human services , the centers for disease control and prevention ( cdc ) , the institute of medicine , and the u.s .
results from the 20112012 national health and nutrition examination survey ( nhanes ) estimated that 34% of u.s .
adults are overweight , 35% are obese , and 6% are extremely obese ( fryar and ogden , 2014 ) .
obese women are a vulnerable population who face not only economic hardships and social isolation , but medical comorbidities as well .
they are at increased risk of heart disease , diabetes , hypertension , stroke , hyperlipidemia , osteoarthritis , sleep apnea , and certain cancers such as endometrial , breast , and colon cancer . among these ,
endometrial cancer has the highest association with obesity with up to a 9-fold increased risk of mortality in women with body mass index ( bmi )  >  40 compared to women of normal weight ( rr 6.25 , p  <  0.001 , 95%ci 3.7510.42 ) ( calle et al . , 2003 ,
unfortunately , obesity predisposes women not only to pre - invasive and invasive uterine cancer , but it also places them at higher risk for complications related to surgical treatment options .
the integration of minimally invasive surgical techniques in gynecologic oncology has improved peri - operative morbidity and length of hospital stay ( walker et al .
however , there remain specific risks related to obesity that warrant pre - operative discussion such as longer operative time , diminished tissue oxygenation and immune function , and increased risks for deep venous thrombosis , pulmonary embolism , respiratory failure and need for mechanical ventilation , cardiac complications , nerve injury , infection and bleeding ( bamgbade et al . , 2007 , choban et al . , 1995 , dossett et al . , 2008 ) . despite a growing medical interest establishing the link between obesity it is unclear how much information is effectively communicated to patients to heighten their understanding . given that obesity is a modifiable risk factor with widespread implications in cancer prognosis and treatment options , it is imperative to first ascertain where gaps in knowledge exist in order to design effective interventions to guide patient education .
there is limited but growing evidence that women are unaware that obesity increases the risk for complex atypical hyperplasia ( cah ) and endometrial cancer ( ligibel et al . , 2014 , ackermann et al . , 2005 ) .
however , to our knowledge , there are no studies to date that focus on their understanding of the impact obesity has on surgical management options and potential complications .
therefore , we aimed to evaluate knowledge of obesity - related peri - operative risks in women with newly - diagnosed cah or endometrial cancer and to identify areas for improvement in peri - operative counseling .
we performed a single institution survey study of 98 women newly - diagnosed with cah or endometrial cancer between january 2011 and july 2014 . prior to the initiation of the study ,
all procedures were reviewed and approved by washington university 's human research protection office ( hrpo#201101905 ) .
all participants were at least 18  years of age , able to read and write in english and provide signed informed consent .
we included patients with cah given that this disease is part of a continuum of uterine pathology with shared risk factors for endometrial cancer and evidence to suggest that up to 43% of women with cah have occult grade 1 endometrial cancer ( trimble et al . , 2006 ) .
diagnoses were established by pre - operative endometrial tissue sampling and all specimens underwent central review by the department of pathology at barnes jewish hospital .
furthermore , both obese and non - obese patients were included to assess for differences in knowledge of surgical risks related to obesity based on body mass index ( bmi ) .
we excluded patients with recurrent disease and confirmed all diagnoses by documented histology on pathology reports .
all patients invited to participate were under the care of gynecologic oncologists at washington university school of medicine and siteman cancer center , a national cancer institute - designated comprehensive cancer center .
no patients were eligible or approached after surgery . during their preoperative - planning , outpatient appointment , patients were approached if eligible and were assured of anonymity and confidentiality . they were allowed to complete the questionnaire at the time of their appointment in a private room , or later at home returning forms in a self - addressed envelope provided .
those who did not return the survey after 2  weeks were followed up with a telephone call as a courtesy reminder .
however each question in the survey was supported by prior studies citing specific surgical complications related to obesity and was validated by review by a panel of gynecologic oncologists .
the questionnaire also obtained sociodemographic information including age , race , history of smoking , alcohol and illicit drug use , and highest level of education .
we reviewed electronic medical records to confirm each patient 's past medical and surgical history , as well as obtain their american society of anesthesiologists ( asa ) score .
bivariate analysis was conducted using pearson 's chi - square or fisher 's exact tests where appropriate for categorical variables .
the anderson  darling test along with visual assessment of histograms were used to determine whether the distribution of continuous variables was gaussian .
the variable ,  age  was found to be normally distributed and bivariate analysis was conducted with the student 's t - test .
analysis was performed using stata 10 ( college station , texas ) and an association was considered statistically significant if p  <  0.05 .
between 2011 and 2014 , 107 women met eligibility criteria and consented for study enrollment , of whom 98 women ( 92% ) completed the self - administered questionnaire .
kg / m and of these women , 79 ( 93% ) acknowledged their obesity while 6 ( 7% ) were unsure if they met criteria for obesity .
overall , the mean age was 58  years , 83% were white , 54% had achieved a college education or higher , and half had grade 1 endometrioid adenocarcinoma ( 51% ) on preoperative endometrial biopsy . compared to patients with bmi  <  30  kg / m , obese patients had more comorbidities such as hypertension ( p  =  0.009 ) , diabetes ( p  =  0.004 ) , and hyperlipidemia ( p  =  0.04 ) . there were no significant differences between obese and non - obese women with regards to asa score or number of prior surgeries ( table  1 ) . while the overwhelming majority of women correctly recognized obesity as a risk factor for high blood pressure , diabetes , and heart attacks , they had more limited appreciation of the association between obesity and cancer .
nearly half of obese patients and 31% of non - obese patients answered that endometrial cancer is more common in overweight or obese people .
next we explored patients ' understanding of their surgical risks . among obese patients , 92% reported that their physician had discussed specific risks associated with the indicated procedure versus only 64% recalled obtaining information about obesity - related surgical risks . among all patients
, 75% understood that the risks of surgery are increased in obese patients compared to patients of normal weight .
however , 16% of obese and 38% of non - obese women responded that they were unsure of the specific peri - operative risks associated with obesity .
there was a substantial gap in understanding among obese patients regarding their increased risks of respiratory problems ( 29% ) , thromboembolism ( 29% ) , heart attack ( 35% ) , or longer operating time ( 35% ) and hospital stay ( 47% ) ( table  2 ) .
however , although a significant minority of obese women were unaware of the link , obese patients were more aware of wound infection risks associated with obesity than their non - obese counterparts ( 72% vs. 31% , p  =  0.004 ) .
patients with cah and endometrial cancer appear to be well - informed that obesity is a risk factor for medical comorbidities such as hypertension , diabetes , and heart disease , but their scope of knowledge beyond this is limited . only half of obese patients recognized that their weight places them at increased risk for endometrial cancer and 36% were not aware of obesity - related surgical risks .
furthermore , they report being knowledgeable about the risks associated with their planned operative procedure ; however , more than a quarter are unaware of the impact obesity has on respiratory problems , thromboembolism , wound infection , heart attack or longer operating time and hospital stay .
our findings provide new insight into patients ' limited awareness of the peri - operative risks related to obesity and reinforce the need for more focused education about obesity - related risks . in 2003 ,
harvard university 's interfaculty program for health system 's improvement conducted a national poll of 1,002 men and women aged 18 or older to explore their knowledge about obesity .
similar to our findings , most americans knew that obesity increases the risk of hypertension ( 86% ) , diabetes ( 78% ) , and heart disease ( 86% ) , but only half of participants were aware that obesity also increases the risk of some cancers ( obesity as a public health issue : a look at solutions , 2003 ) .
2008 ) conducted a study among women in the houston community assessing their knowledge of obesity and endometrial cancer risk .
again , consistent with our results , 58% were not aware that obesity increased the risk for endometrial cancer .
there was no association between personal weight and knowledge of obesity - associated risks ; however , they did find that black women were least knowledgeable about the relationship between obesity and cancer .
these gaps in knowledge are clinically significant , as obesity is a modifiable risk factor that is becoming a central challenge in cancer prevention and care with widespread impact on diagnosis , available treatment options , and ultimately survival outcomes ( ligibel et al . , 2014 ) . a landmark study by calle et al
they reported that women with a bmi  >  40  kg / m have a 60% higher death rates from all cancer compared to women of normal weight .
furthermore , they predicted the proportion of deaths from cancer that is attributable to overweight and obesity in u.s .
adults aged 50 or older may be as high as 20% in women ( calle et al . , 2003 ) .
appropriately , obesity has become a pivotal issue in women 's health ( acog committee opinion , 2005 ) .
the american society of clinical oncology ( asco ) recently released a policy statement ( ligibel et al . , 2014 ) identifying 4 priorities to address the obesity 
cancer link including : 1 ) increasing providers ' and patients ' core knowledge about the role of energy balance in cancer risk and prevention ; 2 ) developing clinical guidance and resources to help providers educate their patients ; 3 ) research promotion ; and 4 ) improving access to evidence - based obesity treatment services for cancer patients and survivors .
the asco policy statement also highlights that a cancer diagnosis may serve as a teachable moment to discuss risk - reducing or health - protective behaviors . a survey of u.s .
gynecologic oncology providers affirmed this window of opportunity , stating that 85% agreed or strongly agreed on the importance of addressing obesity with cancer survivors ( jernigan et al . , 2013 ) .
historically , oncologists have played a limited role in weight loss management for their patients , as the direct implications of obesity on treatment options may not have been fully realized in the past .
however with time , the growing obesity epidemic has pushed not only the upper limits of bmi values , but also the number of safe management options we can offer our patients . for many obese women with cah or endometrial cancer , robotic surgery has provided a feasible surgical approach , but for others with extreme obesity ( bmi    40  kg / m ) , the risks of surgery may outweigh the benefits , and alternative treatment options such as radiation , chemotherapy and/or hormonal therapy should be discussed . while our findings provide insight to women 's knowledge regarding obesity - related risks as they pertain to medical comorbidities , endometrial cancer , and peri - operative risks , this study is not without limitations .
we acknowledge our small sample size and the potential for selection and recall bias that is inherent to any survey study .
time constraints in the clinic and uneasiness with the topic are potential reasons more patients were not enrolled or were not enrolled more quickly over our 4-year study period .
furthermore , physicians were not blinded and the amount of discussion time spent in the pre - operative visit regarding obesity - related risks could have directly influenced providers ' decisions to enroll eligible patients into this survey study . despite these limitations , we also recognize that potential selection biases would likely favor inclusion of more knowledgeable patients , suggesting that 36% may be an underestimation of women 's awareness of obesity - related peri - operative risks .
regardless , our findings are in congruence with prior published reports and provide evidence that pre - operative counseling for obese women with newly diagnosed cah or endometrial cancer should incorporate more focused education about obesity - related risks .
our knowledge of the link between obesity and cancer risk and survival outcomes continues to expand and gain momentum .
obesity is a multifactorial disease that warrants a concerted action at both the individual and societal levels , beginning first with improved patient awareness and education .
these discussions should not only address the link between obesity and cancer , but also should incorporate the impact of weight on surgical management and specific obesity - related peri - operative risks .
gynecologic oncologists are in a pivotal position to positively impact survival outcomes by recognizing and seizing teachable moments about obesity and lifestyle modifications throughout our lifelong relationship with our cancer patients .
this publication was supported by the washington university institute of clinical and translational sciences ( icts ) grant ul1 tr000448 from the national center for advancing translational sciences .
the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institute of health .
bradley evanoff is the pi for the clinical and translational science award that supports all washington university itcs and clinical research training center activities .
 objectivesthe aim of this study is to evaluate knowledge of obesity - related peri - operative risks in women newly diagnosed with complex atypical hyperplasia and endometrial cancer.methodswe conducted a cross sectional study of patients newly diagnosed with complex a typical hyperplasia or endometrial cancer who underwent preoperative counseling between 2011 and 2014 , using a 17-item questionnaire . 
 obesity was defined as body mass index ( bmi ) of 30  kg / m2 or greater . 
 bivariate analysis was conducted using pearson 's chi - square or fisher 's exact tests where appropriate and mann  whitney u for continuous variables.resultsof 98 patients recruited , mean age was 58  years , 87% were obese , 83% white , and 51% had grade 1 endometrioid adenocarcinomas . 
 sixty - four percent of obese women reported that their physicians had discussed surgical risks related to obesity . 
 however , 17% of obese and 42% of non - obese patients responded that they were unsure of the peri - operative risks associated with obesity . 
 there was a substantial lack of understanding among obese patients regarding their increased risks of respiratory problems ( 29% ) , thromboembolism ( 29% ) , heart attack ( 35% ) , or longer operating time ( 35% ) and hospital stay ( 47% ) . 
 however , obese patients were more aware of wound infection risks associated with obesity compared to their non - obese counterparts ( 72% vs. 31% , p  =  0.004).conclusionspre - operative counseling for obese women with newly diagnosed endometrial cancer should incorporate more focused education about obesity - related risks . 
 they report being knowledgeable about the risks associated with their surgery ; however , more than a quarter are unaware of the impact obesity has on respiratory problems , thromboembolism , wound infection , heart attack or longer operating time and hospital stay . 
Background
Materials and methods
Results
Conclusion
Conflict of interest statement