Key points:
- Black women have a higher risk of advanced stage uterine cancer and have a higher mortality rate when compared to white women.
- A study in the US has found that Black women are at a higher risk of receiving a false negative transvaginal (TV) ultrasound due to the higher prevalence of fibroids and non-endometroid high-risk endometrial cancer in this population.
- Due to the risk of a false negative TV ultrasound in Black women, consider a repeat ultrasound if their symptoms, change, worsen, or do not settle.
- Consider advice from gynaecology if a Black woman has a negative or inconclusive TV ultrasound, but you have a high index of suspicion for uterine cancer.
- Educate patients with pre-existing benign gynaecology conditions such as fibroids, to have a low threshold to see a clinician if their usual symptoms change.
Uterine cancer is the most common gynaecological cancer in the UK and often cases are diagnosed at an early stage. However, figures published by the Office for National Statistics, have shown that between 2017 and 2019, uterine cancer mortality rates in Black women, were twice as high when compared to white women.
Another analysis published in BMJ open, revealed that Caribbean and African women are more than twice as likely to be diagnosed with uterine cancer at a late stage.
Cancer research UK’s 5-year survival statistics for stages of uterine cancer between 2013-2017:
- Stage 1 – More than 90%
- Stage 2 – Around 75%
- Stage 3 – Almost 50%
- Stage 4 – 15%
The most common symptom of uterine cancer is post-menopausal bleeding. However, other symptoms include post-coital bleeding, intermenstrual bleeding, pelvic pain, abnormal discharge, menorrhagia and haematuria.
An article by Ester Moss et al. (2023) highlights the growing awareness regarding the significance of prostate cancer in Black men. However, uterine cancer in Black women has received less attention in the UK, and there is an urgent need to raise awareness.
Potential pitfalls: TV US and endometrial thickness in black women
Black women have a higher risk of a false negative TV ultrasound. A US study in JAMA oncology has found that assessing endometrial thickness with a TV ultrasound, missed four times more cases of endometrial cancer in Black women compared to white women.
This discrepancy is felt to be related to the greater prevalence of fibroids in Black women, as well as the non-endometroid high risk endometrial cancer, which may cause less thickening of the womb.
For patients presenting with post-menopausal bleeding, current guidance in the UK suggests that an endometrial thickness of > 4mm on TV ultrasound requires further endometrial assessment (biopsy and/or hysteroscopy).
However, given the above findings from JAMA oncology, an endometrial cancer diagnosis in a Black women could be missed based on this protocol. In the US, Dr Kemi Doll is carrying out a study to redefine the appropriate measurement thresholds for the diagnosis of endometrial cancer in Black women.
Helpful hints: A low threshold for re-investigation and tissue sampling
- Given the risk of a false negative TV ultrasound in Black women, consider a repeat ultrasound if the patients bleeding symptoms do not settle, worsen, or change.
- If you have a high index of suspicion for uterine cancer despite a normal ultrasound, consider seeking advice from gynaecology.
- In cases of Black women with concerning abnormal bleeding in the perimenopause, consider seeking advice from gynaecology regarding a direct referral for endometrial tissue sampling.
- For patients with pre-existing benign gynaecological conditions, such as fibroids, it’s important to provide clear education and advise them to seek medical attention promptly if they notice any changes in their usual symptoms.
Practice takeaway:
The ‘You Need to Know’ campaign specifically targets Black and Asian women and aims to raise awareness of uterine cancer. Click on this link for resources for patients and healthcare professionals.