Welcome to Study of the Week from Patient Worthy. In this segment, we select a study we posted about from the previous week that we think is of particular interest or importance and go more in-depth. In this story we will talk about the details of the study and explain why it’s important, who will be impacted, and more.
If you read our short form research stories and find yourself wanting to learn more, you’ve come to the right place.
This week’s study is…
Estimated Performance of Transvaginal Ultrasonography for Evaluation of Postmenopausal Bleeding in a Simulated Cohort of Black and White Women in the US
We previously published about this research in a story titled “TVUS Ineffective in Diagnosing Endometrial Cancer in Black Women” which can be found here. The study was originally published in the scientific journal JAMA Oncology. You can view the abstract of the study here.
This research team was affiliated with the University of Washington School of Medicine.
What Happened?
Statistics have revealed that in the US, Black women are at a substantially higher likelihood of being diagnosed with advanced-stage endometrial cancer. Because of this, the mortality rate for these patients is at least 90 percent higher when compared to white women. Most of the time endometrial cancer is detected in the early stages with an approach called transvaginal ultrasound (TVUS). In effect, people with postmenopausal bleeding are screened with the goal of measuring endometrial thickness. The results of these screenings are then used to determine if a biopsy, which would be used for the official diagnosis, is necessary.
Using a simulated cohort of women that were experiencing symptoms, the performance of TVUS was compared across different racial groups. This retrospective cohort study used data from the Surveillance, Epidemiology, and End Results (SEER) national cancer registry from 2012-2016 as well as data from published estimations of fibroid prevalence and ET distribution. 367,073 white and Black women that had post-menopausal bleeding were involved, and a total of 36,708 endometrial cancer patients were a part of that group.
The study found that Black women had a risk of false-negative results at a rate that was more than four times that of white women. The difference was partially explained by the greater frequency of non-endometroid histology type and fibroids in Black women. These findings represent a completely unacceptable disparity in cancer detection along racial lines, and likely is a major contributor to the extreme disparity in outcomes and mortality. The scientists also found that the prevalence of high-risk endometrial cancer was higher in black women.
About Endometrial Cancer
Endometrial cancer is a cancer that affects the endometrium, which is the lining of the uterus. It is often most characterized by vaginal bleeding that occurs after menopause has taken place and is therefore not associated with menstruation. Certain genetic disorders can cause endometrial cancer. There are several risk factors, many of which are linked to high levels of estrogens. These include obesity, old age, late menopause, not having children, breast cancer, diabetes, and the breast cancer drug tamoxifen. Symptoms include post-menopausal bleeding, heavy bleeding before menopause, abnormal menstruation, enlarged uterus, lower abdominal pain, pelvic cramps, white or clear vaginal discharge, trouble urinating, pain while urinating, and painful sex. With treatment, which may include surgery, chemotherapy, radiation therapy, targeted therapies, or hormone therapy, the five-year survival rate stands at 80 percent. To learn more about endometrial cancer, click here.
Why Does it Matter?
The findings from this trial highlight a very serious example of a racial disparity that is causing great harm to Black women with endometrial cancer, who have a far worse chance of a positive outcome compared to white patients. In addition, these results highlight a grave weakness inherent to the TVUS approach that is so widely used to detect this disease in its early stages, when it can best be treated.
The key to TVUS, in this case, is the measurement of endometrial thickness, but endometrial cancer doesn’t always increase the thickness, meaning that some cases are going to be missed. The presence of fibroids, which are non-cancerous, can also interfere with an accurate result. In addition, the studies that were used to develop this approach drew on populations from Hong Kong, Italy, and Scandinavia. Therefore, Black women were excluded from this critical research, as Black people too often are. This is a stark example of scientific and medical racism.
Clinicians should understand from these findings that solely using TVUS for detection can mean a significant number of missed diagnoses, particularly for Black patients. Patients themselves, particularly those that know they have fibroids, should ask for a biopsy instead of just TVUS. The next step for this research will involve a similar method but in a real-world context. This could help confirm the validity of the findings from this study and spur further action that can address the clear disparity that Black women are facing.
