Transvaginal ultrasonography has been found unreliable in identifying endometrial cancer among Black women, with more than one in ten cases misclassified, according to a diagnostic study. This raises concerns about the current reliance on this diagnostic method for Black women at risk for endometrial cancer.
Current Guidelines and Practices
Current medical guidelines recommend that women experiencing postmenopausal bleeding should undergo pelvic transvaginal ultrasonography. If the endometrial thickness measures 4 mm or greater, diagnostic endometrial tissue sampling is warranted.
However, evidence suggests a disparity in the diagnostic process for Black women. “Insured Black patients with endometrial cancer are less likely to receive endometrial biopsy after presenting with postmenopausal bleeding. Many report undergoing ultrasonography with initially reassuring results,” stated Kemi M. Doll, MD, MSCR, a gynecologic oncologist at the Fred Hutchinson Cancer Center at the University of Washington, and her colleagues in JAMA Oncology. A previous simulation study using population estimates indicated that the transvaginal ultrasonography triage might miss cases of endometrial cancer among Black individuals due to a higher prevalence of fibroids and nonendometrioid histologic types.
Study Findings
Doll and her colleagues conducted a retrospective diagnostic study using merged abstracted electronic health record data and secondary administrative data from 1,494 Black women (median age, 46.1 years) from the GUIDE-EC sample. All the women underwent hysterectomy between 2014 and 2020.
The primary outcomes examined were ultrasonography performed before hysterectomy, demographic and clinical data on symptom presentation, endometrial characterization, and final endometrial cancer diagnosis. Of the 1,494 women studied, 210 had endometrial cancer. The most common presenting diagnoses within 30 days of vaginal ultrasonography were fibroids (78.1%), vaginal bleeding (71.4%), and pelvic pain (57.4%).
False-Negative Probabilities
The study revealed significant false-negative probabilities associated with different endometrial thickness thresholds:
3.8% with the 3 mm threshold
9.5% with the 4 mm threshold
11.4% with the 5 mm threshold
Endometrial cancer risk factors had similar false-negative probabilities at the 5 mm threshold:
12.4% for postmenopausal bleeding
9.3% for a BMI greater than 40 kg/m²
12.8% for age 50 years or older
For Black women with fibroids identified via pelvic ultrasonography, false-negative probabilities ranged from 4.4% with the 3 mm threshold to 11.8% with the 5 mm threshold. Those with partially visible endometrial thickness and/or pelvic pain had even higher false-negative probabilities, ranging from 13% to 26.1% at the 3 mm threshold and 4.8% to 14.5% at the 5 mm threshold.
Implications for Clinical Practice
“These findings suggest that the transvaginal ultrasonography triage strategy is not reliable among Black adults at risk for endometrial cancer,” the researchers wrote. In the presence of postmenopausal bleeding, the study strongly recommends tissue sampling rather than relying solely on ultrasonography.
Conclusion
The study underscores the need for improved diagnostic approaches for Black women at risk for endometrial cancer. Given the higher false-negative rates associated with transvaginal ultrasonography, especially in the presence of fibroids and other complicating factors, it is crucial for healthcare providers to consider alternative or additional diagnostic methods to ensure accurate detection and timely treatment of endometrial cancer in this population.
