Experts suggest that a common screening technique used to assess the risk of endometrial cancer may be less effective in black women, and that a tissue biopsy would be more accurate.
This follows a study, published in JAMA Oncology, that discovered that pelvic transvaginal ultrasonography (TVUS) led to false negatives in a portion of black females who actually had endometrial cancer.
TVUS, which uses soundwaves to produce a picture of the inside of the pelvis, is routinely recommended to women experiencing postmenopausal bleeding, a symptom of this particular cancer.
If the TVUS reveals that the person has a thicker endometrial thickness (ET), according to doctors, they should also get a tissue biopsy to screen for EC.
Some women with the cancer have a relatively thin endometrial thickness – as a result, they don’t get a biopsy, and the cancer is missed, but early detection is crucial.
“Since we know that ultrasound assessment is not always accurate in black women, other screening modalities are essential for early cancer detection, including symptom awareness and advocacy,” Elena Ratner, MD, MBA, a gynaecological oncologist at Yale Cancer Centre and Smilow Cancer Hospital, told Healthline.
Study shows gaps
The report evaluated the health data of 1 494 black women who underwent pelvic ultrasonography with an ET measurement before a hysterectomy.
Of the group, 210 had EC. In addition, 78% had fibroids, 71% had vaginal bleeding, and 57% had pelvic pain. Of the 210 who had EC, about 11% had an ET that was below the diagnostic threshold for detection (4mm).
The study found that roughly 9.5% of cancers detected in black females were detected below the threshold of 4mm, and 3.8% were in women who had an ET less than 3mm.
An estimated 11.5% of the cancers would have been missed because the women had relatively thin ETs, said the researchers, who added that their findings suggest the most accurate way to identify endometrial cancer in black women is through a tissue biopsy.
Diana Pearre, MD, a board certified gynaecological oncologist at The Roy and Patricia Disney Family Cancer Centre in California, said that the lead researcher of the study, Dr Kemi Doll, University of Washington, had significantly added to the scant research surrounding health inequities in the diagnosis and treatment of endometrial cancer.
“The main takeaway … we cannot rely simply on the image we see on an ultrasound report to determine whether to biopsy a patient with postmenopausal bleeding,” Pearre said.
Why TVUS may be less reliable
In many patient populations, TVUS is an effective way to measure ET and provide a risk assessment for endometrial cancer
“It is often used to determine whether patients should get a biopsy of the internal lining of the uterus and make sure there are no cancerous or precancerous changes in the lining,” said Amer Karam, MD, a gynaecological surgeon with Stanford Medicine.
However, the procedure doesn’t appear to be as reliable in black women, with previous research showing that those with postmenopausal bleeding are less likely to get an endometrial biopsy – and more likely to get false negative transvaginal ultrasounds than white females.
“In publications, ultrasound findings of being below a certain endometrial thickness threshold rule out the possibility of endometrial cancer. In black women, that does not appear to be the case,” Ratner said.
According to Karam, most studies examining the accuracy of TVUS have focused on mostly white patients.
The researchers of the new report suspect that the decreased visibility of the cancers in black females and the increased prevalence of fibroids may make the cancer harder to detect via TVUS alone.
“One other factor not examined in the current study is the higher prevalence of aggressive types of endometrial cancer that present with thinner linings among black patients,” Karam said.
Biopsies can ID a greater percentage of cancers
Pearre suspects many physicians will be surprised by these new findings.
“I hope they take this study into account and refer patients to gynaecologists when they report bleeding, regardless of how thick the inner lining of their uterus is,” she said.
The researchers suggest that a tissue biopsy should always be done to provide an accurate diagnosis of EC.
According to Pearre, endometrial sampling is the cornerstone of diagnosis.
“If a patient reports bleeding after menopause or even heavy bleeding prior to menopause, endometrial sampling is probably the next best strategy in their workup.”
Study details
Endometrial thickness as diagnostic triage for endometrial cancer among black individuals
Kemi Doll, Mindy Pike, Julianna Alson, et al.
Published in JAMA Oncology on 27 June 2024
Abstract
Importance
Poor performance of the transvaginal ultrasonography triage strategy has been suggested as a contributor to racial disparity between black individuals and white individuals in endometrial cancer (EC) stage at diagnosis in population-level simulation analyses.
Objectives
To examine the false-negative probability using ultrasonography-measured endometrial thickness (ET) thresholds as triage for EC diagnosis among Black individuals and assess whether known risk factors of EC modify ET triage performance.
Design, Setting, and Participants
This retrospective diagnostic study of merged abstracted electronic health record data and secondary administrative data (January 1, 2014, to December 31, 2020) from the Guidelines for Transvaginal Ultrasound in the Detection of Early Endometrial Cancer sample assessed black individuals who underwent hysterectomy in a 10-hospital academic-affiliated health care system and affiliated outpatient practices. Data analysis was performed from January 31, 2023, to November 30, 2023.
Exposure
Pelvic ultrasonography within 24 months before hysterectomy.
Main Outcome and Measures
Ultrasonography performed before hysterectomy as well as demographic and clinical data on symptom presentation, endometrial characterisation, and final EC diagnosis were abstracted. Endometrial thickness thresholds were examined for accuracy in ruling out EC diagnosis by using sensitivity, specificity, and negative predictive value. False-negative probability was defined as 1 − sensitivity. Accuracy measures were stratified by risk factors for EC and by factors hypothesised to influence ET measurement quality.
Results
A total of 1494 individuals with a uterus (median [IQR] age, 46.1 [41.1-54.0] years) comprised the sample, and 210 had EC. Fibroids (1167 [78.1%]), vaginal bleeding (1067 [71.4%]), and pelvic pain (857 [57.4%]) were the most common presenting diagnoses within 30 days of ultrasonography. Applying the less than 5-mm ET threshold, there was an 11.4% probability that someone with EC would be classified as not having EC (n = 24).
At the 4-mm (cumulative) threshold, the probability was 9.5%, and at 3 mm, it was 3.8%. False-negative probability at the 5-mm threshold was similar among EC risk factor groups: postmenopausal bleeding (12.4%; 95% CI, 7.8%-18.5%), body mass index greater than 40 (9.3%; 95% CI, 3.1%-20.3%); and age 50 years or older (12.8%; 95% CI, 8.4%-18.5%). False-negative probability was also similar among those with fibroids on ultrasonography (11.8%; 95% CI, 6.9%-18.4%) but higher in the setting of reported partial ET visibility (26.1%; 95% CI, 10.2%-48.4%) and pelvic pain (14.5%; 95% CI, 7.7%-23.9%).
Conclusion and Relevance
These findings suggest that the transvaginal ultrasonography triage strategy is not reliable among black adults at risk for EC. In the presence of postmenopausal bleeding, tissue sampling is strongly recommended.
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