By Kiara Doyal, Seattle Medium
According to Dr. Kemi Doll, a gynecologic oncologist at the University of Washington School of Medicine and Fred Hutchinson Cancer Center, endometrial cancer (EC), a disease that occurs when cells in the lining of the uterus (endometrium) grow uncontrollably, is on the rise, especially among Black women.
“EC has had one of the worst racial disparities in all of U.S. cancers for decades. It is the most common gynecologic cancer in the U.S. as well. It is four times more common than cervical cancer, and twice as common as ovarian cancer,” said Doll. “We are just now talking about it, but the higher mortality for Black women is not new.”
Transvaginal ultrasounds, a type of imaging test that uses sound waves to create pictures of the inside of the pelvis and one of the most common types of ultrasounds, are used to measure the thickness of the endometrium to determine whether a biopsy needs to be performed to confirm the diagnosis of EC. Unfortunately, this screening method is failing Black women worldwide as they are not reliable for checking for EC. A normal endometrial thickness is usually less than 4 millimeters in postmenopausal women. A thicker endometrium can cause concern for the presence of abnormal cells or tumors, which is an indicator of EC.
According to Doll, if the thickness of the endometrium is under 4 millimeters, then the tissue biopsy may not be performed, and it may be assumed that the patient is cancer-free. However, Doll warns that this protocol can be deadly for Black patients.
“In our study of 1400 Black individuals, all of whom underwent hysterectomy, we looked back at the ultrasound results before surgery. We found that for those 210 individuals with EC, there was a significant 9.6% of people who had endometrial thickness measurements below the 4mm threshold,” says Doll. “This threshold is supposed to determine who is at risk of EC and needs a biopsy to make the diagnosis. However, we found that it was not accurate and using such a measurement would miss cases.”
Due to the unreliability of transvaginal ultrasounds in catching EC in Black women, noticing and addressing symptoms early on and seeking a prompt evaluation with a gynecologist is something Doll believes is the best chance for Black women to catch the disease in its earliest stage, as many Black women are more likely to be diagnosed in later stages of the disease.
“I believe that there are many reasons as to why Black women are diagnosed in the later stages of EC,” says Doll. “These reasons could be delays in diagnosis from women not realizing their symptoms are a sign of cancer, dismissal in healthcare settings from providers either not knowing about EC or misattributing symptoms to other gynecologic conditions, having more aggressive types of EC that spread faster, and social and environmental factors that delay care generally.”
“Detecting endometrial cancer early is extremely important because treatment is more likely to be effective when it’s started before the cancer spreads outside the uterus,” says Dr. Whitney Robinson, a PhD-trained researcher in the Department of Obstetrics and Gynecology. “For endometrial cancers that are treated at this early stage, 95% of patients are still alive five years after diagnosis.”
However, early detection can be difficult because identifying symptoms of EC may be challenging for some. Postmenopausal bleeding, after a period of no bleeding for six months to a year, can be alarming to older Black women and can be a primary indicator of EC. Other signs of EC may include pelvic pain, bloating, and urinary symptoms.
“In the event that an older Black woman over the age of 45 or postmenopausal has new spotting after you think you are done with your periods, or for younger women with very heavy and irregular periods and risk factors for EC including obesity, diabetes, and a long history of irregular cycles, they should always be ruled out for EC,” said Doll.
As Black women already face poorer quality healthcare interactions and potential dismissal of symptoms, Doll believes that as a community we need to be informed about the signs of EC and the required testing to rule it out, like a tissue biopsy.
Doll also noted that a tissue biopsy is a much better tool for detection than a transvaginal ultrasound.
“What we found in real-world clinical scenarios is that [transvaginal ultrasounds] are just not accurate enough to be safely employed as a strategy among Black people. Whereas, a tissue biopsy is conclusive,” said Doll.
According to a study published in the Journal of Clinical Oncology in 2019, Black women have a higher risk of having a false-negative transvaginal ultrasound than white women. This means that their endometrial thickness is measured as normal, even though they have EC.
“This study only included Black women,” said Doll. “In prior work, we hypothesized that the difference in fibroids prevalence and the higher rate of non-endometrioid type EC in Black women affects the accuracy of using endometrial thickness as a sign of cancer.”
Doll stressed that Black women are not more at risk for EC compared to other ethnicities but are more likely to die from EC due to late diagnosis, more aggressive EC types that are difficult to treat, and the host of other downstream effects of being a marginalized and oppressed population in U.S. society.
“With death rates from endometrial cancer twice as high in Black women in the U.S. than other racial and ethnic groups, improving early detection and access to high-quality treatment are important priorities,” said Robinson. “Moving forward, I would like to see more research and more attention drawn to EC,” said Doll. “I would love to see a diagnostic process that is risk-based, and even the development of a screening tool so we can catch EC before it starts.”
