Transvaginal ultrasonography unreliable in identifying endometrial cancer for Black women

Key takeaways:

• Transvaginal ultrasonography below 5 mm led to misclassification of Black women with endometrial cancer.
• Women with partially visible endometrial thickness or pelvic pain had higher false-negative probabilities.

Transvaginal ultrasonography triage resulted in misclassification for more than one in 10 Black women, suggesting it is not a reliable strategy to identify Black women at risk for endometrial cancer, according to a diagnostic study.

Current guidelines recommend that women presenting with postmenopausal bleeding undergo pelvic transvaginal ultrasonography, and diagnostic endometrial tissue sampling is warranted for women with an endometrial thickness of 4 mm or greater.

“However, insured Black patients with endometrial cancer are less likely to receive endometrial biopsy after presenting with postmenopausal bleeding; they have reported undergoing ultrasonography with initially reassuring results; and a previous simulation study using population estimates suggested that the transvaginal ultrasonography triage approach may miss cases of endometrial cancer among Black individuals due to their greater prevalence of fibroids and nonendometrioid histologic types,” Kemi M. Doll, MD, MSCR, gynecologic oncologist in the department of obstetrics and gynecology at the Fred Hutchinson Cancer Center at the University of Washington, and colleagues wrote in JAMA Oncology.

Doll and 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 women underwent hysterectomy from 2014 to 2020.

Primary outcomes included ultrasonography performed before hysterectomy, demographic and clinical data on symptom presentation, endometrial characterization and final endometrial cancer diagnosis.

Overall, 210 women 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 were 3.8% with the 3 mm endometrial thickness threshold, 9.5% with the 4 mm threshold and 11.4% with the 5 mm threshold. Endometrial cancer risk factors had similar false-negative probabilities at the 5 mm threshold, with 12.4% for postmenopausal bleeding, 9.3% for BMI greater than 40 kg/m² and 12.8% for age 50 years or older.

False-negative probabilities for Black women with fibroids identified via pelvic ultrasonography ranged from 4.4% with the 3 mm threshold to 11.8% in the 5 mm threshold. Black women with partially visible endometrial thickness and/or pelvic pain had higher false-negative probabilities with 3 mm and 5 mm thresholds, ranging from 13% to 26.1% and 4.8% to 14.5%, respectively.

“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, tissue sampling is strongly recommended.”