Black women less likely to receive lifesaving hysterectomies for endometrial cancer
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Compared with white women, Black women with a low-risk form of endometrial cancer less frequently received a hysterectomy and had lower survival rates, according to research conducted at Cedars-Sinai Cancer Center.
The study, published in Gynecologic Oncology, reviewed data on more than 23,000 Black and white women from NCI’s SEER database. All individuals included in the analysis had stage IA low-grade endometrioid endometrial carcinoma.
“When treating gynecologic cancers, there is not always the opportunity for a cure, but this one usually presents very early and is the most treatable,” Kristin N. Taylor, MD, assistant professor of obstetrics and gynecology at Cedars-Sinai and lead author of the study, told Healio. “I think for oncologists, really making sure patients have a full understanding of that and emphasizing the likelihood of cure is important. When patients receive a cancer diagnosis, they often feel helpless and disempowered, but this is one gynecologic cancer where surgery truly is a game changer.”
Taylor spoke with Healio about her study’s findings, the potential factors driving this disparity and her future plans for this research.
Healio: What inspired you to study these racial disparities in low-risk endometrial cancer?
Taylor: We know that Black women are more likely to have aggressive subtypes of endometrial cancer — collectively called type 2 endometrial cancers — which are anything other than the low-grade endometrioid histology, and account for about 20% of all endometrial cancers. For reasons that are still not quite fully understood, Black women are more likely to have these subtypes and experience decreased survival. That’s certainly part of the disparity in outcomes, but irrespective of the histologic type, we do see that Black women are also more likely to have a more advanced stage at the time of diagnosis. This often So, often, what we’re left doing with studies looking at survival is to account for those differences in histology and stage statistically. I wanted to look only at patients with the earliest stage disease and the more favorable histology and see whether the disparity would go away.
Healio: How did you conduct the study?
Taylor: We used the SEER database, which allows us to look at this on a population level. We chose patients with stage IA grade 1 or 2 endometroid endometrial adenocarcinoma diagnosed between 2010 and 2016. It was limited to Black and white women, because that is where we’ve seen the starkest disparities historically. We looked at survival outcomes and treatment received, what type of surgery was done, and adjuvant treatment such as chemotherapy and radiation therapy, as well as other demographic factors. We also examined individual demographic factors and county-level socioeconomic status.
Healio: What did you find?
Taylor: This is the first study to my knowledge that looked at disparities in treatment and survival exclusively within this favorable group. The most notable finding was a survival difference by race. Although outcomes were very good in both groups, the 5-year relative survival for white women was estimated at 100% vs. 95% for Black women. We saw something very similar for cancer-specific survival.
We also found that most patients did have a hysterectomy and, not surprisingly, receipt of hysterectomy was found to be predictive of vastly improved survival. Consistent with prior studies, the rate differed by race, with 98.5% of white women and 96.3% of Black women having undergone surgery. This sounds very similar but is different enough that we see that race does end up being predictive of having surgery, and receipt of hysterectomy appears to play a significant role in the survival disparity.
Healio: What do you think is driving this disparity?
Taylor: It’s a bit of speculation, just because the SEER database couldn’t really equip us to drill down into the specific reasons for that. In terms of hysterectomy rates, there may be differences in how frequently providers recommend hysterectomy due to implicit bias, or the likelihood that the patient agrees to hysterectomy due to historically rooted mistrust of the medical community among Black women. On a population level, there are higher rates of uninsurance or underinsurance that can result in less access to quality care with more rigorous standard-of-care recommendations.
Healio: What can oncologists do to help improve this situation?
Taylor: One interesting thing we gleaned from the results was that most people who didn’t have hysterectomy did this because they were recommended not to have surgery. We couldn’t see the reasons for this, but those rates were similar between Black and white women.
I would say it’s critical to make sure that a gynecologic oncologist is involved in the patient’s care and able to make a determination whether the patient is a candidate for hysterectomy. If so, we must emphasize to patients how important that treatment is for their survival.
Healio: Is there anything else you’d like to mention?
Taylor: The study does have a limitation in that we’re looking very coarsely at race, but not at ethnicity or ancestry. We’re comparing Black vs. white, but these are very heterogeneous groups — both biologically and socioeconomically.
We are in the process of doing another study using the California Cancer Registry that we’re hoping can give much more granular data in terms of ethnicity, immigration status and socioeconomic status. I think those data will give us richer information on who patients are in terms of ancestry, where they come from and their different exposures. We also just received a grant to look more into the biologic differences between the two groups, specifically, to develop lab models derived from patient tumors of Black women vs. white women to look at the genetic differences, even within histologic subtypes. This could shed light on whether pathophysiology is mediating some of the differences in outcomes that we see.
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Kristin N. Taylor, MD, can be reached at Samuel Oschin Cancer Center, 127 S. San Vicente Blvd., Pavilion, 7th Floor, Los Angeles, CA 90048; email: kristin.taylor@cshs.org.
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