Women who have typically undergo a non-invasive procedure — a transvaginal ultrasound — to look for signs of uterine cancer. But research suggests that test misses far more cancers in Black women compared to white women. Black people with uteruses are more likely to develop endometrial cancer, and recent studies suggest that may be a factor.
They're also , making early detection all the more crucial. (Endometrial cancer is a type of uterine cancer, the explains, although the terms are often used interchangeably.) But the current guidelines that doctors and radiologists use to interpret transvaginal ultrasounds simply aren't as effective for this group, experts say, meaning the test misses signs of cancer in Black women.
That may be leading to delayed diagnoses among Black women — who are already more likely to develop aggressive forms of endometrial cancer. "One thing is clear across the board: Unfortunately, Black women are more likely to die of endometrial cancer," Dr. Onyinye D.
Balogun, radiation oncologist at NewYork-Presbyterian Brooklyn Methodist Hospital, tells TODAY.com. White women with endometrial cancer have a five-year survival rate of 84%, she says, but the same figure for Black women is only 62%.
That trend persists even when controlling for access to health care and insurance coverage, Dr. Kemi Doll, gynecologic oncologist and associate professor in the department of obstetrics and gynecology at the University of Washington, tells TODAY.com.
showed that "Black women were less likely to get appropriate biopsies and ultrasounds," she explains. But even when they did get that care, they were more likely to be diagnosed at later cancer stages and . "That led to the question of, Wait, have we actually assessed if the ultrasounds are working the way they're supposed to?" she says.
"I had to question whether the medical care setup itself was equitable and was accurate." In a study published in June in , Doll and her team investigated exactly that question. The team looked at the effectiveness of the current transvaginal ultrasound guidelines among Black patients.
When a postmenopausal patient comes in with abnormal bleeding, the first step is a transvaginal ultrasound, a non-invasive test that can rule out the need for further testing. Transvaginal ultrasounds are used to help diagnose or rule out many other conditions, such as ovarian cysts and uterine polyps, the says. If the provider is looking to rule out endometrial cancer, they will use the ultrasound to measure a patient's endometrial stripe, a band of tissue that lines the uterus.
According to guidelines set by the , if a patient's endometrial stripe is 4 mm thick or less, endometrial cancer can usually be ruled out. "When you're no longer menstruating, the thickness of the endometrial stripe should be more or less stable," Balogun explains. If the tissue appears to be getting thicker, that could indicate the presence of endometrial cancer.
And the patient will go on to get a more invasive test, such as a biopsy, to examine the tissue. But in the new study, which included data for about 1,500 Black patients, more than 11% of those with endometrial cancer (24 of 210 people) had endometrial thickness measurements that fell within the normal limit. The work builds on Doll's previous study, published in 2021 in .
For that work, the team used a simulated cohort of 370,000 Black and white patients. They found the current 4 mm guideline would detect fewer than half of endometrial cancer patients in Black women compared to nearly 88% in white women. Together, Doll's work suggests that the current cutoff "is not the right threshold when it comes to all women," Balogun says.
And it may be leading to missed cancers, later diagnoses and worse outcomes in Black women specifically. A transvaginal ultrasound is "a nice option" to help people avoid unnecessary biopsies, Dr. Kimberly Gecsi, chief medical officer in the department of obstetrics and gynecology at the Medical College of Wisconsin and ACOG member, tells TODAY.
com. "However, this study shows that that's not a reasonable strategy in our Black patients," says Gecsi, who flagged the new study to a committee of ACOG experts for review. "ACOG is planning to review the recent study findings that suggest the use of transvaginal ultrasound for detection of endometrial cancer in Black individuals may be unreliable," the organization tells TODAY.
com in a statement. “(The findings are) really significant because an entire treatment paradigm was developed for all people based on studies that weren’t performed in all people,” Dr. Stephanie V.
Blank, director of gynecologic oncology for the Mount Sinai Health System, tells TODAY.com. "A lot of the standards we created in medicine are based on the Caucasian population," Balogun agrees.
These particular guidelines were "based on large studies that took place in , and ," Blank explains, which did not include many Black participants. "This is a really good example of why we need to make sure that we are being very inclusive..
.in our research," Gecsi says. "We had really good data that showed that transvaginal ultrasound is an appropriate triage strategy — until we went and said, Okay, what about in this specific population?" And there are some factors unique to Black patients that may make transvaginal ultrasounds less useful for them.
First, Black women are more likely to get that are harder to see on scans. These cancers, called non-endometrioid cancers, are not hormonally driven, Doll explains. And they tend to not create the same "global thickening" of the endometrial lining that more common cancer types do, she says.
That makes these types of tumors easy to miss on an ultrasound. The other issue is uterine fibroids, which are a type of growth that develops in the uterus, the Mayo Clinic says. Fibroids are common and most never become cancerous, but they can cause discomfort as well as heavy, irregular bleeding.
"What's different is that that start earlier in life, grow larger and last longer," Doll explains. Fibroids can distort the endometrial tissue, Blank says, making it harder to see other changes on an ultrasound, thus masking signs of cancer. “Regardless of race, if you know you have large fibroids or fibroids in the past that have persisted, (transvaginal ultrasound) is not a great technique for you,” Doll says.
“It’s just that Black women are way more likely to be in that group.” But fibroids may also play a more complex role here, too, Doll says. Her work found that, because Black women are more likely to have persistent irregular bleeding as a result of long-lasting fibroids, bleeding after menopause .
"People just have learned to accept because of fibroids," Blank says. That makes it harder to know when bleeding warrants a trip to the doctor, she says. But, Doll adds, even doctors in her study brushed off Black patients' concerns as, "Oh, well, that's probably your fibroid," when they did come to the office.
Again, the result is a delay in care that could detect endometrial cancer. "The onus falls on the health care professional," Balogun says. "I know we're all stressed, we all have so much on our plates.
But the first responsibility is on the physician." That means taking the time to "tailor your care," she says. Not every Black patient will have a fibroid that distorts the endometrial tissue, but what this research does is remind providers to take a step back.
"Please take into consideration who the patient is and what their background is when making clinical decisions," Balogun says, "and don't just use this number across the board." Doll wants primary care doctors be on "high alert" for postmenopausal bleeding and encourages them to start asking about it specifically during appointments. "And when Black women come in with bleeding symptoms, really take that seriously and make sure you've ruled out endometrial cancer," she says.
Abnormal bleeding, including postmenopausal bleeding, is the major red flag symptom for endometrial cancer. Other symptoms can include pelvic pain or heaviness and losing weight without trying, the explains. Doll's latest research suggests that it may be best for Black patients to skip the ultrasound step altogether and go straight to a tissue biopsy.
It's a more invasive and uncomfortable procedure, which is "not ideal," Doll says. But because Black women are at the highest risk of dying of this disease, if they are presenting with a symptom of cancer, "we need to be sure and give you the most accurate test," she says. Blank tells TODAY.
com that she's already adjusted her thinking. "I have a much lower threshold to to biopsy all patients, but especially Black women," she says. "We know Black women with endometrial cancer do worse than white women, and if part of it is delayed diagnoses, let's let's fix that," Blank continues.
"Let's do everything we can. Let's get rid of these structural (barriers) and give patients the care they deserve." While the main responsibility for proper care rests with the provider, Balogun says, there are helpful ways .
First, the experts agree, patients need to recognize that postmenopausal bleeding should be taken seriously. "The vast majority of the time, we can effectively rule out endometrial cancer," Gecsi says. "But it's not a symptom that that you want to ignore.
It's a symptom that you definitely want to talk with your doctor about." During a doctor's appointment, Balogun recommends having a friend or family member with you to be a "second pair of ears." They can help advocate for you and take notes just in case.
And they can even join in the conversation via phone call or Zoom, she says. And if you feel your doctor really isn't listening to you, consider getting a second opinion or go somewhere else, the experts agree. "If something doesn't seem right to a patient, that person should tell their doctor," Blank says.
"And if the doctor dismisses it, they might need to find another doctor." Additionally, Gecsi encourages people to participate in research. Doing so is "critical," she says, to make sure that studies include a wide variety of patient types.
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