Estimated Performance of Transvaginal Ultrasonography for Evaluation of Postmenopausal Bleeding in a Simulated Cohort of Black and White Women in the US

Abstract

IMPORTANCEBlack women in the US with endometrial cancer (EC) are more likely to be diagnosed with advanced-stage disease independent of insured status and histologic type. The most common way of diagnosing EC at early stages is through screening of people with postmenopausal bleeding to detect endometrial thickness (ET). This approach may disproportionately underperform in Black women secondary to a higher prevalence of fibroids and nonendometrioid EC in this population, both of which affect the quality of ET measurement.OBJECTIVE To compare the performance of recommended transvaginal ultrasonography (TVUS) ET thresholds as a screening method to prompt endometrial biopsy by race in a simulated cohort of symptomatic women. DESIGN, SETTING, AND PARTICIPANTSIn a simulated retrospective cohort study, based on data from Surveillance, Epidemiology, and End Results (SEER) national cancer registry 2012-2016; the US census; and published estimates of ET distribution and fibroid prevalence, diagnostic test characteristics of the 3-mm or more, 4-mm or more, and 5-mm or more ET thresholds for biopsy to capture EC diagnoses were calculated. The simulated cohort was constructed from February 2, 2020 (date of access to SEER data), to August 31, 2020. Analysis occurred from September 30, 2020, to March 30, 2021, including the primary analysis and the sensitivity calculations. MAIN OUTCOMES AND MEASURESThe main outcome measured was accuracy of the TVUS ET threshold to accurately identify cases of EC, measured by sensitivity, negative predictive value, and area under the curve (AUC).RESULTS A total of 367 073 simulated Black and White women with postmenopausal bleeding were evaluated, including 36 708 with EC. Among Black women, the currently recommended 4-mm or greater ET threshold prompted biopsy for fewer than half of EC cases (sensitivity, 47.5%; 95% CI, 46.0%-49.0%); of women referred for biopsy, 13.1% were EC cases (positive predictive value, 13.1%; 95% CI, 12.5%-13.6%). The AUC for the 4-mm or more threshold was 0.57 (95% CI, 0.56-0.57). In contrast, among the White women, the 4-mm or more threshold led to biopsy for most with EC (sensitivity, 87.9%; 95% CI, 87.6%-88.3%). Of those referred for biopsy, 14.6% had EC (positive predictive value, 14.6%; 95% CI, 14.4%-14.7%); AUC was 0.73 (95% CI, 0.73-0.74). The same variations held for the 3-mm or more and 5-mm or more ET thresholds: sensitivity, positive predictive value, and AUC were consistently lower for Black women than White women. CONCLUSIONS AND RELEVANCEThe findings of this simulated cohort study suggest that use of ET as measured by TVUS to determine the need for EC diagnostic testing in symptomatic women may exacerbate racial disparities in EC stage at diagnosis. In simulated data, TVUS ET screening missed almost 5 times more cases of EC among Black women vs White women owing to the greater prevalence of fibroids and nonendometrioid histologic type in Black women.

A Simple Cervicovaginal Epigenetic Test for Screening and Rapid Triage of Women With Suspected Endometrial Cancer: Validation in Several Cohort and Case/Control Sets

“…Women who might benefit most from the WID-qEC in the near future might be (1) women presenting with abnormal bleeding or other symptoms suggestive of ECs undergoing triage for malignancies, in particular those for whom currently available tests (eg, ultrasound) are less reliable. 8 For example, although the number of non-White women in our settings was low, the performance of the WID-qEC to detect EC was similar in White and non-White women; and (2) women at high risk of developing EC. The WID-qEC exhibited a high NPV in all settings.…”

HE4 as a Biomarker for Endometrial Cancer

“…These studies suggest that the incorporation of serum HE4 into algorithms that include factors, such as endometrial thickening, age, menopausal status and BMI, could improve the accuracy of serum HE4 for distinguishing EC from benign endometrial conditions, with REM and REM-B showing the most promising results. A recent study showed that the optimum cut-off for endometrial thickness on TVUS may vary according to race, which may need to be considered in algorithms that include TVUS [ 120 ].…”

British Gynaecological Cancer Society (BGCS) uterine cancer guidelines: Recommendations for practice

“…A simulated retrospective cohort study, from the Surveillance, Epidemiology and End Results (SEER) data, demonstrated a sensitivity of 47.5% (95% CI 46.0 to 49%) using a cut off of ≥4 mm in black women, compared to a sensitivity of 87.9% (95% CI 87.6 to 88.3%) in white women. [85] Poorer diagnostic test performance of TVS in black women was consistent when using a ≥3 mm or ≥5 mm cut off.…”