Racial Disparities in Endometrial Cancers

Dr Steven R. Goldstein is a leading NYC Gyn and transvaginal ultrasound specialist in NYC and shares on the Racial Disparities in Endometrial Cancers.

Another area of tremendous importance is the racial disparities and endometrial cancer mortality comparing Black women with Caucasian women. There is no question that inherent racial bias and social determinants of health play an important role in racial disparities.

However, some recent publications specifically by Kemi Doll entitled, “Estimated Performance of Transvaginal Ultrasonography for Evaluation of Postmenopausal Bleeding in a Simulated Cohort of Black and White Women in the U.S.,” received a tremendous amount of publicity. In it, they concluded, “the findings of the simulated cohort study suggest the use of endometrial thickness as measured by transvaginal ultrasound to determine the need for endometrial cancer diagnostic testing in symptomatic women may exacerbate racial disparities in endometrial stage of diagnosis. In simulated data, transvaginal ultrasound endometrial thickness screening missed almost five times more cases of endometrial cancer among Black women versus White women, owing to the greater prevalence of fibroids and nonendometrioid histologic type in Black women.” Thus, Doll et al. combined two issues that may undermine the use of transvaginal ultrasound in black women: a higher incidence of fibroids, making visualization sub optimal and higher incidents of what are known as Type II endometrial cancers.

There were subsequent letters to the editor by various key opinion leaders in the imaging community that stated what should be obvious. Any attempt to use transvaginal ultrasound measurements in patients with postmenopausal bleeding actually requires that the endometrial lining be well visualized in its entirety from the cervix to fundus. Anything, such as fibroids, that obscures the ability to see the lining, would disqualify the use of transvaginal ultrasound as a means of potentially ruling out endometrial cancer in a patient, regardless of their race.

Interestingly, the original ACOG committee opinion from 2009 had already stated, “meaningful assessment of the endometrium by ultrasonography is not possible at all patients. In such cases, alternative assessments should be completed.” Since that time, much more information has come out. The article by Wong et al., which was utilized in ACOG’s revision of that Committee Opinion, actually excluded 20.2% of women with postmenopausal bleeding from their analysis because an endometrial lining was unmeasurable on transvaginal ultrasound. The average number of years since the final menstrual period in that group was five years. An article that I authored, “Ability to Successfully Image the Endometrium on Transvaginal Ultrasound in Asymptomatic Postmenopausal Women,” found that among 407 women who were asymptomatic, 38% of the time the examination was not deemed satisfactory to be able to measure a reliable endometrial thickness. The most common reasons were fibroids, adenomyosis, and the position of the uterus being axial, that is, straight up and down rather than anteverted or retroverted.

The average number of years from the final menstrual period in those patients was 14. Thus, in such cases, although pointed out by ACOG as early as 2009, alternative assessment will become necessary. However, this issue about Type II endometrial cancers is a real concern and education about it has previously been lacking. Most uterine cancer, also known as Type I, is related to increased amounts of unopposed estrogen, and one of the greatest risk factors is obesity. Adipose tissue makes a weak form of nonovarian estrogen indefinitely. So obese patients have higher risks of breast and uterine cancers and, interestingly enough, less risk of osteoporosis because of this production of nonovarian estrogen.

Type II cancers are not estrogen dependent. They are more lethal in general, but instead of arising from too much estrogen, they will often arise in a backdrop of atrophy. This may make transvaginal ultrasound assessment less reliable. However, this will also make blind endometrial sampling less reliable in that they are more likely to not be global in their nature and thus more likely to even be missed by such blind endometrial sampling.

The relative risk of African American women having Type II cancer is about two and a half times greater than the relative risk in a White Women (realize relative risk is not the same as absolute risk). The overwhelming majority of cancers in all racial groups are estrogen related Type I cancers. However, if an African American woman, especially one with no risk factors for Type I endometrial cancers, such as obesity, has postmenopausal bleeding, and even in spite of a thin endometrial lining, the possibility of a Type II cancer could certainly be entertained and more extensive evaluation than simply transvaginal ultrasound may well be appropriate. Such information needs wider dissemination among practitioners.

Dr Steven R. Goldstein is a leading gynecologist in NYC and a tenured Professor of Obstetrics and Gynecology at New York University School of Medicine. He was also the Director of Gynecologic Ultrasound at NYU Langone Medical Center from 1995 to 2019 and is a pioneer in the field of gynecological ultrasound. His clinical research has had a significant influence on the way Gynecology is practiced.