Ethical Considerations in Cancer Care: Size and Weight as a Threat to Access

Introduction

Access is a central ethical issue across disciplines and life experiences. Access to healthcare is thought to hold special moral importance, and the threat to access among certain special patient populations is of significant concern. The aim of this review is to address the many dimensions of access as these serve as barriers to prevention, detection, treatment, and follow-up in the face of cancer care. Obesity as a risk factor for a number of cancers is presented along with specific strategies to overcome access barriers to care, acknowledging weight and size as realistic barriers. A case study is included herein.

Access as an Ethical Term

Access as an ethical term is derived from the ethical principle of justice and evolved from the issue of just distribution or allocation of scare healthcare goods and services. ¹ In this case, nurses are challenged to consider awareness of the barriers to access such as knowledge of the practical barriers to care posed by issues of weight. For example, consider not only the economic barriers that affect uninsured and underinsured individuals, but also the practical challenges that serve as access barriers to the patient of size.

Economic Concerns of Access

From an economic perspective, millions of Americans continue to have little or no access to basic healthcare services because they are either uninsured or underinsured. Recognizing this injustice, a number of groups have sought to design universal access to healthcare through legislation or private services. From a moral perspective, concern for justice and the common good, and its call for advocacy on behalf of people who are vulnerable, is the first step.

However, this is not the case, as evidenced by data recently released by the U.S. Census Bureau that indicate that 46.6 million people living in the United States lacked healthcare coverage in 2005. This 2005 figure is an all-time high. Significantly, 5.4 million more people lacked health insurance in 2005 than in the 2001 recession, primarily because of the loss of employer-based insurance. Only 60% of those employed were covered by an employment-associated plan in 2005. Premiums are currently rising at three times the rate of inflation. Most people who have healthcare insurance receive it as a part of a benefit plan provided by their employer or qualify for a government-sponsored plan. Not surprisingly, people with annual incomes of less than $25,000 were three times as likely to be uninsured when compared with those whose incomes exceed $75,000. Among obese individuals, research suggests, weight is an independent risk factor in unemployment and underemployment. Further, research suggests a relationship between obesity and lower incomes earned. ² Both of these factors suggest special challenges in healthcare insurance access among individuals of size.

Moral Importance of Healthcare

Norman Daniels explains that healthcare is of special moral importance because it helps to preserve our status as fully functioning citizens. By itself, healthcare arguably cannot be distinguished from food or housing, which also meet basic needs of citizens by preserving normal functioning. However, the issue is that medical needs are more unequally required and distributed than these other needs and can be catastrophically expensive and therefore unavailable to certain patient populations. ³ This is especially true in the face of malignant disease such as cancer, where barriers to access exist in the process of diagnosis, intervention, and necessary follow-up. ⁴

Special Threat of Cancer and Obesity

Excess weight is thought to be associated with nearly 100,000 U.S. cancer deaths each year. ⁵ Based on 2002 data from the ACS, cancers linked to obesity comprise approximately 51% of all new cancers among women and 14% among men. ⁶ Further research from the ACS suggests that, at least in the United States, obesity is responsible for 20% of all cancer deaths in women and 14% in men. ⁷ The ACS further estimates that 90,000 people each year are dying from obesity-related cancers. Experts concluded that cancers of the colon, breast (postmenopausal), endometrium, kidney, and esophagus are associated with obesity. ⁸ Breast cancer alone is expected to account for 26% (178,480) of all new cancer cases among women. ⁹ Some studies have also reported links between obesity and cancers of the gallbladder, ovaries, and pancreas. ¹⁰ Obesity and physical inactivity may account for 25–30% of several major cancers—colon, breast (postmenopausal), endometrial, kidney, and esophageal. ¹¹ Despite data to suggest an association between cancer and adiposity, researchers suggest that most Americans do not realize that being overweight is a risk factor for many forms of cancer. ¹² Perhaps providers overlook the relationship between obesity and malignancy simply because of the urgency presented by other health issues, such as the significant comorbidities that pose everyday struggles, such as sleep apnea, diabetes mellitus, dyslipidemia, and more. ¹³

The incidence and severity at diagnosis are especially problematic for larger, heavier individuals. Although the mechanism of incidence is debatable, the severity of cancer at initial diagnosis may be due to delays in diagnosis. The severity of cancer on initial diagnosis may occur either because the examining physician is reluctant to perform proper examinations or because the patient is hesitant to allow a comprehensive assessment. Early diagnosis is key and may impact survival rate. For example, in terms of mortality, for women, obesity-related cancers are estimated to comprise 28% of cancer-related deaths in 2002: 15% are breast cancers (39,600 deaths), 2% are uterine cancers (6,600 deaths), and 11% are colorectal cancers (28,800 deaths). Among men, obesity-related cancers are estimated to comprise 13% of cancer-related deaths in 2002: 10% are colorectal cancers (27,800 deaths) and 3% are kidney cancers (7,200 deaths). For example, one study, which specifically examined the relationship between breast and cervical cancer and unrecognized barriers to screening among obese women, presents the threat of delays in preventive and early intervention. ¹⁴

Barriers to Access

Obesity may impact access to diagnosis and treatment across practice settings. Obese individuals must be aware of recommended cancer-screening procedures as early preventive measures. However, the reason why cancer diagnosis is often delayed is more accurately because of the challenges associated with the screening procedures themselves. Patients may fail to ask providers about access to cancer-screening procedures. Staff members scheduling procedures should be advised of the patient's body weight to ensure providers or technicians have the opportunity to preplan for procedures. When scheduling procedures, patients should ask if the facility is able to accommodate their weight and body configuration. Sometimes patients report embarrassment about their physical appearance, and are particularly reluctant to allow procedures such as mammography, colonoscopy, pelvic exams, and more. (See “Case Study: Mrs. Talito” in this article.) Patients should ask about appropriately fitting gowns. If the facility does not have provisions for larger patients, individuals should feel comfortable to bring a clean, properly fitted gown. Determine before any physical preparation if the exam table or diagnostic equipment will accommodate the patient's width or weight.

Intervention as simple as IV drug administration can be challenging if clinicians have difficulty with IV access among larger, heavier patients whose veins may be hidden deep beneath the skin surface. Radiation therapy tables may not accommodate the weight of a larger person, and radiation may not penetrate through extensive fatty tissue. Radiologic examination can pose issues and interfere with diagnostic studies. But more importantly, patients report hesitation in bringing attention to themselves, and this reluctance can cost dearly in time lost in the early diagnosis and treatment of aggressive disease.

Case Study: Mrs. Talito

The aim of this case study is to humanize the access challenges that patients of size face when planning diagnostic procedures. Like many individuals over 50 years old, Mrs. Talito had hesitation scheduling a colonoscopy. However, what made it worse was the fact that she was a 280-pound woman with a BMI of 55, which meant she was only 5 feet tall. When scheduling the test, she was reassured that the center could accommodate her weight. Yet, when she arrived, everything changed. Many patients of size report that their providers complain throughout procedures—and this situation was no different. The technicians were overheard discussing the numerous difficulties … from gowns to waiting room furniture, table height, and more. Mrs. Talito was humiliated. The exam was rescheduled, but Mrs. Talito failed to return to the diagnostic center. Ethical questions this case raises might include the following:

Summary

Recognizing the increasing risks of cancer among obese individuals and the increasing numbers of obese individuals, it becomes of interest to find ways to overcome barriers to access for patients at risk. Bariatric nurses are in a position to identify and create practical methods to improve access.

Disclosure Statement

No competing financial interests exist.