Common strategy to diagnose endometrial cancer may not be reliable for Black women

Abstract

A common diagnostic approach to identifying endometrial cancer based on endometrial thickness (ET) may not be reliable in Black women according to a retrospective study published in JAMA Oncology.¹

The study found that up to 11% of the time, according to the level of ET considered, pelvic transvaginal ultrasonography (TVUS) failed to diagnose endometrial cancer in a cohort of Black women.

Guidelines currently suggest that women with postmenopausal bleeding, a common sign of endometrial cancer, undergo TVUS to assess ET. An ET of 4 mm or greater is a common threshold used to indicate the need for triage for further workup with a tissue biopsy.

Kemi M. Doll, MD, a gynecologic oncologist at the University of Washington School of Medicine and the Fred Hutchinson Cancer Center, who served as the lead author of the study, says that the study is the largest to date to use actual patient encounters (real-world clinical scenarios) to assess the accuracy of endometrial thresholds from TVUS in Black women.

Doll and her colleagues retrospectively reviewed ultrasound data from 10 health centers for 1494 Black women who underwent a hysterectomy, 210 of whom had endometrial cancer. At the <5-mm ET threshold, an 11.4% probability existed that someone with endometrial cancer would be classified as not having it; at the 4-mm (cumulative) threshold, the probability was 9.5%.

Classic risk factors for endometrial cancer, including age, body mass index, and postmenopausal bleeding, did not improve the performance of triaging patients based on ET thickness. On the basis of these results, the authors recommend tissue sampling in all Black women who present with postmenopausal bleeding.

Commenting on the study, an editorial board member (who has chosen to remain anonymous) of the journal Cancer noted the limitations of the study, including its retrospective design (which carries the potential for bias) and the sole focus on Black women. “My concern is that this is presented in a Black-only cohort, inferring that it is not the case in non-Black women, which is not necessarily the case,” she says. “If this was a larger study of an unbiased group of women, and they showed a differential outcome of this screening in Black women matched for non-Black women, then I would be jumping on it.”

Dr Doll says that the focus on Black women is a strength of the study “given that studies on which current ACOG [American College of Obstetricians and Gynecologists] guidelines are based did not include Black women, and in subsequent work, their numbers were exceedingly small.”

She also emphasizes that the primary limitation of the study is that it included only women in whom endometrial cancer had been identified after hysterectomy and did not include women with abnormal uterine bleeding who had not undergone a hysterectomy. “This means the noncancer group is likely more symptomatic than the general population of women presenting with bleeding,” she says. “It does not, however, change the composition of the endometrial cancer group, all of whom go on to hysterectomy, and therefore it doesn’t change the accuracy of the endometrial thickness analysis.”