This is the second piece of a two-part series on racial disparities in uterine cancer diagnosis, treatment, and outcomes. See Part I: When Racial Bias Is Embedded in Medical Norms: How Physicians Can Approach Patients’ Uterine Cancer Risk and Care.
Major disparities in uterine cancer outcomes, targeted in new ACOG resources, are highlighting ways that racism is embedded in medical research and the resulting clinical guidelines. The disparities in uterine cancer experiences have endured over several decades. Uterine cancer disparities serve as a case study with substantial implications for obstetrician–gynecologists and patients as they work to provide and receive optimal care. Addressing the disparities underlines the complexity and importance of health equity work, a point implicit in a new ACOG CME eModule, a literature review in Obstetrics & Gynecology, and a research presentation at ACOG's 2022 Annual Clinical & Scientific Meeting.
In a video that forms part of ACOG's new multimedia CME eModule on uterine cancer, Sara Whetstone, MD, MHS, FACOG, says, "The questions in the literature often center around 'What's wrong with people of this race or ethnicity?'" Dr. Whetstone is lead author of the literature review on health disparities in uterine cancer and associate professor of obstetrics, gynecology, and gynecologic surgery at the University of California San Francisco. She says researchers should instead ask, "How does marginalization, lack of resources, lack of power and privilege, translate to different health outcomes and experiences for patients?"
For Kemi M. Doll, MD, MSCR, FACOG, associate professor in the University of Washington School of Medicine division of gynecologic oncology, this line of inquiry includes, "How is racial identity operating in a health care setting? What do the levers of power and influence look like? Why would a college-educated Black woman hesitate to talk with a physician about symptoms of her reproductive organs?"
Understanding these social-behavioral components is a prerequisite to equitable patient care and requires that the science of health equity is sufficiently valued, Dr. Doll says. "Walking through health inequities, pulling out their mechanisms and how they overlap, is the same kind of work we do to understand immunotherapy and molecular signatures of disease," she says. Dr. Doll delivered The John and Marney Mathers Lecture at ACOG's 2022 Annual Clinical & Scientific Meeting, 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.
Endometrial cancer provides a compelling example of medical racism hiding in plain sight. "We know Black women have more fibroids, and we know they are more likely to have the kinds of endometrial cancer that do not always cause thickness measured on ultrasound. So how did we come up with a diagnostic strategy based on a test—transvaginal ultrasound—that’s so differentially impactful?" asks Dr. Doll. "Naturally, as researchers, we might look at who's doing the worst, who's dying from this disease, then figure out the guidelines. But that is not what happened here. An effect of systemic racism is seen in the fact that our goal was avoiding biopsies in the population of convenience, the majority, rather than the group most at risk." Similarly, the limitations of the data are difficult to dispute. "When we demonstrate that the guidelines are based on studies out of Scandinavia, Italy, and Hong Kong and largely exclude or fail to report on women with fibroids, it's easy to see that's not objective," Dr. Doll says.
In a joint statement with other medical societies, ACOG acknowledges the persistence of racism in medicine: "Racism continues to be prevalent in research, in its conduct as well as its scholarship and publication." ACOG is committed to mitigating these inequities and reducing the impact racism has on scholarship and clinical care. This includes actions such as convening expert review and input and supporting ongoing research and collaborations that seek to address flawed research and practice.
Dr. Doll's clinical research aims to identify risk factors for Black women. Her process involves Black survivors of endometrial cancer. Their experiences point to numerous opportunities for intervention, which she discusses in her ACOG Annual Meeting lecture, available on demand. In the CME eModule, Dr. Whetstone points out that uterine cancer outcomes among populations that are systemically disadvantaged by their sexual orientation, gender identity, rural geography, or other marginalized identities are also missing from the literature.
Free CME e-Module
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.