Cedars-Sinai Investigators Find Black Women With Low-Risk Disease Are Less Likely Than White Women to Receive Lifesaving Hysterectomies, and Less Likely to Survive Their Cancer
Investigators from Cedars-Sinai Cancer found that Black women with a low-risk form of endometrial cancer were less likely than white women with the same cancer to have a hysterectomy, and less likely to survive their cancer. The study, published in the peer-reviewed journal Gynecologic Oncology, concluded that further research is needed to clarify the reasons for this disparity.
Kristin Taylor, MD
“We’ve known for years that Black women with endometrial cancer have lower survival rates than white women, largely because they are more likely to have an aggressive subtype and to be diagnosed at an advanced stage,” said Kristin Taylor, MD, assistant professor of Obstetrics and Gynecology at Cedars-Sinai and lead author of the study. “But our study found this disparity persists even when we compare patients with the lowest-risk form diagnosed at the earliest possible stage.”
Taylor and fellow investigators reviewed data on more than 23,000 Black and white women from the National Cancer Institute’s SEER database, which collects data from registries in 18 geographic areas in the U.S. All of the patients had the earliest-stage, least-aggressive endometrial cancer—a type called stage 1A low-grade endometrioid endometrial carcinoma.
“Low-grade endometrioid tumors account for about 80% of endometrial cancers, and most of these are stage 1 at diagnosis,” said Taylor. “For these patients, standard treatment is hysterectomy, and many should be cured without the need for radiation or chemotherapy.”
The SEER data showed that the vast majority of patients, both Black and white, were treated with hysterectomy and had high overall survival rates. However, while just 1% of white women did not receive hysterectomies, 3% of Black women in the study didn’t receive this lifesaving surgery.
“We had hoped that when we looked only at the lowest-risk patients, the disparity between Black and white women would disappear, but it did not,” Taylor said. “It’s disappointing.”
Residing in the South, being insured with Medicaid, and residing in a county with low median income were also associated with not receiving surgery.
Study investigators said doctors might recommend against hysterectomy for women—both Black and white—with underlying health conditions that increase risk of surgical complications. Doctors might also offer women of childbearing age a fertility-sparing hormone treatment that lets them temporarily postpone surgery, Taylor said.
However, a slightly higher—though not statistically significant—number of Black women than white women refused surgery when their doctors recommended it, the study found.
“Although there was no data collected on the reason for refusal,” Taylor said, “there is likely an element of mistrust of the medical community that contributes to this difference.”
One factor that might help account for this disparity is structural racism, Taylor said. She pointed to historical policies that caused more Black people to be of lower socioeconomic status, and thus more likely to be uninsured or underinsured and have less access to quality healthcare. She also noted prior medical experimentation on Black people (e.g., the Tuskegee syphilis study) as recently as a few decades ago.
“Even though they might not always be in our conscious memory, I think that the downstream effects of those insults from decades ago get passed on culturally, particularly in the South. Among my own family, I see geographical differences in how members perceive their relationships with their doctors,” said Taylor, who was born in the South but grew up in Illinois.
Taylor said that further studies should be conducted to delve into the roles of these social factors.
“Disparities in survival that persist even among patients with the same stage and subtype of cancer must be investigated and addressed,” said Dan Theodorescu, MD, PhD, director of Cedars-Sinai Cancer and the PHASE One Distinguished Chair. “Dr. Taylor’s work is an example of the many ways investigators at Cedars-Sinai Cancer are working to understand these disparities and bring the highest level of care to all of the diverse patient groups we serve.”
Going forward, Taylor and team plan to address some limitations of the current study by looking at a different dataset.
“One major limitation with the SEER database is that socioeconomic factors are recorded at the county level, which is so broad,” Taylor said. “We're essentially repeating this study using the California Cancer Registry, which gives information including median income, education level, insurance status, primary language and immigration status at the neighborhood level. We'll have a much richer, more granular view of the lives of these patients, which should be really informative.”
Another planned study goes in a completely different direction.
“Some data suggest that there are different genetic pathways, even within this narrow subset of tumors, that could be driving disparities between outcomes in Black and white women,” Taylor said. “We’re hoping to develop models in the lab derived from the tumors of Black and white women with this subtype of cancer to look for biologic differences that could help inform treatments for each population.”