Role of bleeding recognition and evaluation in Black-White disparities in endometrial cancer

• Published in: American journal of obstetrics and gynecology 2018-12, Vol.219 (6), p.593.e1-593.e14
• Main Authors: Doll, Kemi M., Khor, Sara, Odem-Davis, Katherine, He, Hao, Wolff, Erika M., Flum, David R., Ramsey, Scott D., Goff, Barbara A.
• Format: Article
• Language: English
• Subjects: African-Americans; Aged; Black People; endometrial cancer; Endometrial Neoplasms - complications; Endometrial Neoplasms - diagnosis; Endometrial Neoplasms - epidemiology; Endometrial Neoplasms - ethnology; Female; health care disparities; Healthcare Disparities; Humans; Logistic Models; postmenopausal bleeding; Postmenopause; Practice Guidelines as Topic; racial health disparities; Risk Factors; SEER Program; Socioeconomic Factors; Surveillance, Epidemiology, and End Results–Medicare; United States - epidemiology; Uterine Hemorrhage - diagnosis; Uterine Hemorrhage - ethnology; Uterine Hemorrhage - etiology; White People; Women's Health Services - standards
• ISSN: 0002-9378; 1097-6868; 1097-6868
• DOI: 10.1016/j.ajog.2018.09.040

Advanced stage at diagnosis is an independent, unexplained contributor to racial disparity in endometrial cancer. We sought to investigate whether, prior to diagnosis, provider recognition of the cardinal symptom of endometrial cancer, postmenopausal bleeding, differs by patient race. Black and White women diagnosed with endometrial cancer (2001 through 2011) from Surveillance, Epidemiology, and End Results–Medicare who had at least 2 years of claims prior to diagnosis were identified. Bleeding diagnoses along with procedures done prior to diagnosis were captured via claims data. Multinomial logistic regression was used to evaluate the association of race with diagnostic workup and multivariate models built to determine the association of appropriate diagnostic procedures with stage at diagnosis. In all, 4354 White and 537 Black women diagnosed with endometrial cancer were included. Compared to White women, Black women were less likely to have guideline-concordant care: postmenopausal bleeding and appropriate diagnostic evaluation (70% vs 79%, P < .001), with adjusted relative risk ratios of 1.12–1.73 for different nonguideline-concordant pathways: bleeding without diagnostic procedures, alternative bleeding descriptions, and neither bleeding nor procedures. These pathways were associated with higher odds of advanced stage at diagnosis (adjusted odds ratio, 1.90–2.88). The lack of recognition and evaluation of postmenopausal bleeding is associated with advanced stage at diagnosis in endometrial cancer. Older Black women are at highest risk for the most aggressive histology types, yet they are less likely to have guideline-concordant evaluation of vaginal bleeding. Efforts aimed at improving recognition–among patients and providers–of postmenopausal bleeding in Black women could substantially reduce disparities in endometrial cancer.