When Racial Bias Is Embedded in Medical Norms: How Physicians Can Approach Patients’ Uterine Cancer Risk and Care

Three new ACOG resources are designed to help obstetrician–gynecologists provide optimal care in the context of dramatic disparities in uterine cancer outcomes. Uterine cancer, mostly endometrial, is the most common gynecologic cancer in the United States. Its incidence and mortality rates are increasing, with substantial disparities documented over decades—disparities that are targeted in a new CME course, literature review, and research presentation. The resources spotlight ways that false assumptions about race have been incorporated into medical literature and clinical standards, with bleak consequences for communities of color. For example, Black women are twice as likely as white women to die from uterine cancer—one of the largest outcome gaps in cancer treatment.

The new resources capture current insights about uterine cancer, identify some of the modifiable factors that contribute to disparities, and help physicians and other clinicians avoid inadvertent bias in diagnostic and treatment procedures. ACOG Lead for Equity Transformation Jennifer Villavicencio, MD, MPP, FACOG, says, "We recognize that as obstetrician–gynecologists, we are part of a system that perpetuates racial inequities and that our guidelines may be based on data that is flawed. ACOG has a responsibility to call this out and work with humility and accountability to correct these flaws, with the ultimate goal of decreasing health inequities."

The below key takeaways from the evolving science of uterine cancer are drawn from these ACOG resources:

• A free CME-accredited online course is the next eModule in ACOG's series on breast and gynecologic cancers, developed through a CDC partnership. The eModule summarizes relevant literature and existing recommendations and guides clinicians in identifying and modifying risk factors for uterine cancer, determining effective methods for early diagnosis, and summarizing key health disparities. It offers up to seven free CME credits.
• Obstetrics & Gynecology’s Health Disparities in Uterine Cancer: Report from the Uterine Cancer Evidence Review Conference is the evidence summary of the literature review of health disparities and inequities related to uterine cancer, by Sara Whetstone, MD, MHS, FACOG, et al. The literature review of disparities emerged from the Uterine Cancer Evidence Review Conference ACOG convened as a step toward developing evidence-based educational materials.
• At ACOG's 2022 Annual Clinical & Scientific Meeting, Kemi M. Doll, MD, MSCR, FACOG, gave The John and Marney Mathers Lecture: A Race-Conscious Approach to Investigation and Intervention of Endometrial Cancer Inequity. This lecture is part of a package of on-demand 2022 Annual Meeting content, offering 58 CME credit hours.

Key Takeaways on Uterine Cancer Disparities

The Green Journal’s literature review and the CME eModule confirmed stark, ongoing disparities, including:

• Black women have a higher incidence of uterine cancer than white women; earlier studies did not adjust for the higher hysterectomy rate among Black women, underestimating their true incidence.
• Black women with uterine cancer have substantially higher mortality rates and worse survival rates than women of any other race or ethnicity. Black and Hispanic women are much less likely than white women to receive guideline-concordant care.
• These disparities have persisted without change since studies from more than 25 years ago.

Key Takeaways on Medical Literature as a Contributing Factor

"The findings of our review highlight key obligations for us as health care professionals and researchers," the literature review on health disparities concludes. "Many of the disparities … are modifiable. However, we found no published studies of interventions to reduce racial disparities in uterine cancer care." At ACOG's 2022 Annual Clinical & Scientific Meeting, Dr. Doll highlighted opportunities for more equitable clinical approaches. These include:

• Postmenopausal bleeding is a common early symptom of endometrial cancer. For Black women, who have higher rates of fibroids and irregular menstrual cycles, unusual bleeding has been normalized among patients and health care professionals. Although Black women are at greatest risk for aggressive histologic subtypes, they are less likely than other women to have bleeding categorized as postmenopausal, for that bleeding to be documented at all, and to receive appropriate diagnostic procedures. This is significantly associated with advanced stage at diagnosis. It is a key opportunity for clinical intervention.
• Transvaginal ultrasound is recommended for screening symptomatic women. If endometrial thickness is less than 4 millimeters, a biopsy can be avoided for most women without persistent or recurrent uterine bleeding. These guidelines, however, are based in certain assumptions—such as a low-risk population—that do not apply across the board, says Dr. Doll, and were developed without sufficient data on Black women and other minority patient communities. "Let's study these women," says Dr. Doll. "We want to bring the same level of rigor, a scientific process that includes this community's voice, so we don't repeat the cycle."

A Collective Responsibility

Longstanding passivity about racial disparities has rested on assumptions, without evidence, of biological or genetic causes. “[T]his distracts from addressing the structural forces and inequities that affect uterine cancer outcomes,” according to the literature review on health disparities, a point also emphasized in the CME eModule.

The events of the last few years have increased recognition that such disparities are unacceptable and require new research and clinical approaches. "We have an obligation to work to overhaul currently unjust systems that perpetuate unacceptable racial inequities in health outcomes," says ACOG's statement on racism in obstetrics and gynecology.

Dr. Doll credits Black women's advocacy on maternal mortality for generating more meaningful discussion of Black women’s reproductive health. "This includes thinking about endometrial cancer as a product of the reproductive life course instead of as a 'cancer problem,'" she says. "We have this entire story of Black women from prepuberty to postmenopause, and we can see the path and what links their health problems together. This gives us new questions around endometrial cancer."

About this Series

This is the first piece of a two-part series on racial disparities in uterine cancer diagnosis, treatment, and outcomes. See PART II: What the Science of Uterine Cancer Reveals about Medical Racism.

Free CME eModule

Take ACOG's free, CME-accredited online course, Prevention and Early Diagnosis of Uterine Cancer, to learn more about managing your patients' unique risk for uterine cancer.