Acceptability of bariatric surgery in young women with endometrial cancer and atypical endometrial hyperplasia: a qualitative study

Objectives: Development of endometrial cancer (EC) or atypical hyperplasia (AH) in young women with obesity is often the first significant obesity-related comorbidity they experience. The current approach to fertility-preserving endometrial cancer treatment is with progestin; however, this does not address the underlying cause - obesity - and its associated metabolic abnormalities. Significant, sustained weight loss through bariatric surgery may result in a more durable response by addressing obesity directly, and subsequently improve both oncologic and reproductive outcomes. However, it is not known whether bariatric surgery is acceptable to this patient population. Methods: We performed a qualitative study to understand the acceptability of bariatric surgery among women of reproductive age (≥ 18 and ≤41 years) with obesity (body mass index [BMI] ≥ 35) and grade 1 endometrioid EC or AH. Participants were recruited from Princess Margaret Hospital, in Toronto, after referral for fertility-sparing management. Semi-structured interviews were used to explore participant perceptions towards their weight, fertility, and the possibility of bariatric surgery as part of the treatment strategy for their EC/AH. Interviews were transcribed, coded and analyzed inductively and deductively using Transtheoretical Model as theoretical framework and thematic analysis. Thematic sufficiency was reached after 11 interviews. Results: Eleven participants with median age of 33 years (range 27-38) and BMI of 42.1 (35.1-56.9) were interviewed. Two (18%) participants had grade 1 endometrioid EC, and 9 (82%) had AH. Patients were reluctant to accept bariatric surgery as a treatment option due to 1) lack of knowledge about the procedure, 2) stigma attached to bariatric surgery, and 3) fear of the unknown. The desire to conceive was highlighted as the strongest motivator for patients to consider bariatric surgery. Their perception towards their weight, fertility and diagnosis of EC/AH were characterized by concepts of ‘helplessness’, ‘isolation’, ‘frustration’ and ‘guilt’. We observed a significant gap in participant understanding of the complex interplay between their cancer, fertility and obesity. Patients highlighted the need for compassionate care from their health providers, as well as more resources or education about their diagnoses and treatment options. Conclusions: There is an urgent unmet need for patient education regarding EC/AH diagnosis, and the interplay of their EC/AH with fertility and weight. More supports and resources are required, with patient-oriented counseling focused on implication of their weight on their cancer diagnosis and fertility, before presenting bariatric surgery as a treatment option.