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Invited Commentary
July 15, 2021

A Race-Conscious Analysis of the Use of Transvaginal Ultrasonography in the Evaluation of Postmenopausal Bleeding

Author Affiliations
  • 1Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, New York
  • 2Department of Obstetrics & Gynecology, Washington University School of Medicine in St Louis, St Louis, Missouri
JAMA Oncol. 2021;7(8):1165-1166. doi:10.1001/jamaoncol.2021.1681

Endometrial cancer (EC) is one of the few cancers with an overall increasing incidence in the US.1 Postmenopausal bleeding, which is experienced by approximately 90% of women diagnosed with EC, is a sensitive symptomatic marker for diagnostic testing.2 Current guidelines for diagnostic testing include transvaginal ultrasonography (TVUS) to measure endometrial thickness (ET), with greater than 4 mm used as a trigger for endometrial sampling.2 Endometrial cancer inequities in delayed diagnosis and excess mortality persist for Black women. Black women with EC have a 90% higher 5-year mortality compared with White women.1 Independent of insurance and access to health care, Black women are more likely to be diagnosed with advanced-stage disease and with high-risk, poor prognostic, nonendometrioid EC. In this issue of JAMA Oncology, Doll et al3 summarize the evidence that nonendometrioid EC is less likely to be identified by TVUS ET measurements and that uterine fibroids can distort the endometrium lining and limit accurate ET measurements. Given the high prevalence of nonendometrioid EC and fibroids among Black women, the role of TVUS as a primary diagnostic test may not be adequate. The authors hypothesize that current TVUS guidelines for postmenopausal bleeding may have worse performance when applied to Black women and, as a result, contribute to ongoing racial inequity in EC outcomes.

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    1 Comment for this article
    Race Conscious Analysis
    Daniel Krell, M.D. | Retired PCP
    Given the recognition that "race" is a social construct, rather than a biological classification, it feels redundant -- and even racist -- in this study and many others that analyze medical dynamics in the context of race and identify differences in responses to diagnostic and therapeutic interventions. Most of the studies conclude that socioeconomic factors are ultimately the cause(s) of the racial disparities. Are these studies persisting because the authors want to strengthen arguments to make our society and health care system more equitable? Or do they persist because of an expectation/hope that real, actionable, "racial," biologic differences will be revealed by another study? We are more alike than we are different. Genetic and phenotypic traits often show greater variability within races than they do between races. Epigenetic differences often correlate with geographic differences, and mixtures of populations, rather than race

    There needs to be a leap to making equitable health care and socioeconomic factors the primary goals, rather than repeatedly exploring health/medical issues that, predictably, will affect one or more "races" differently from other "races." Otherwise, the persistent testing serves to avoid discussion of "race" being a social construct, and the need to address those socioeconomic issues that negatively impact people's lives.