AMETHIST@Penn Implementation Science Center Headed by LDI Senior Fellows
Racial Disparities in Endometrial Cancer Mortality
Black Women Dying More Often From Early-Stage Cancers
Systemic racism is a pervasive cause of health disparities, and race-related disparities within gynecologic cancers are no exception. Consider this: Black women with endometrial cancer have nearly twice the risk of dying as white women with endometrial cancer. The disparity in outcomes can be attributed partly to more aggressive forms of endometrial cancer and other biological considerations among Black women, but many social factors affecting access to health care play a vital role as well.
Gynecologic oncologists can help reduce these disparities by providing leadership and collaborating with medical specialists, scientists, social and health policy experts, patients, and the community at large to mitigate the impact of these social factors. One of the ways we can do that is through research studies that reveal where gaps in cancer care occur.
We recently conducted research to determine whether Black women with endometrial cancer are more likely to die from the cancer itself, an outcome called “cancer-specific survival,” as opposed to dying from all causes, an outcome called “overall survival” that may be driven by a multitude of factors beyond the cancer itself, including other health conditions and social circumstances. As we reported in Gynecologic Oncology Reports, we found that Black women with endometrial cancer have an increased risk of death directly related to their endometrial cancer compared to white women, regardless of the stage and type of the cancer.
The disparities were greatest for Black women diagnosed with early-stage cancers. This is important given that most women with endometrial cancer are diagnosed in the early stage. For the same cancer at the same stage, Black women were still more likely to die due to their endometrial cancer.
The question is why? For insight, we specifically compared women with the same stage at diagnosis, all of whom underwent primary surgical management and adjusted for receipt of adjuvant treatment. This study design allowed us to consider how race plays a role not in screening or diagnosis (issues that have been addressed in previous studies) but in downstream care for these patients.
Differences in cancer biology may explain some outcomes, but these differences are clearly not the whole story. Black women potentially experience more delays in diagnosis and barriers to treatment. They may also be less likely to receive standard of care therapies and have less access to social and health resources. After surgery, the care they receive—or do not receive—may perpetuate these disparities. Furthermore, since clinical trials lack diversity and have historically underrepresented Black women, their findings may not show the effect of systemic therapies in Black women.
The Amenability Index theorizes that the greatest disparities occur in conditions that are the most amenable to intervention, and has specifically been applied to gynecologic cancers as described by Kemi Doll (2018). It asserts that socioeconomic status continues to be associated with mortality because higher socioeconomic status individuals have more flexible resources, including knowledge, money, power, and social connections. These flexible resources likely play a significant role in the persistent disparities we see in outcomes and present a more pervasive issue that may continue to make resolving these disparities difficult.
So where do we go from here? Our study and others like it highlight the need to continually evaluate how we provide care beyond surgical management for early-stage endometrial cancer and address systemic issues across the entire medical system that lead to disparities in outcomes.
We need to recognize the disparities that are leading to Black women dying more quickly and frequently from all stages and types of endometrial cancer. To curtail the rising incidence and worsening mortality rates that Black women are facing, we need to allocate resources—research funding, time, education, and effort—from all stakeholders, including health providers, policymakers, community, and patient networks. We need to recruit and support underrepresented minorities in clinical trials intentionally. We need to seek therapies that help improve outcomes for Black women after surgical management, especially in the setting of recurrence.
There is no single clear answer to solve this problem. However, if we continue to work to develop interventions across the spectrum of cancer care, we can hopefully develop a multimodal approach to help Black women with endometrial cancer live longer and live better.
The study, Disparities in Cancer-Specific and Overall Survival in Black Women with Endometrial Cancer: A Medicare-SEER study, was published in the April 2022 issue of Gynecologic Oncology Reports. Authors include Daniel H. Saris, Anna Jo Bodurtha Smith, Colleen Brensinger, Sarah H. Kim, Ashley F. Haggerty, Nawar Latif, Lori Cory, Robert L. Giuntoli, Mark A. Morgan, Lilie L. Lin, and Emily M. Ko.
Daniel Saris, MD
Resident, Obstetrics and Gynecology, Pennsylvania Hospital
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