Objectives: Both the incidence and outcomes of endometrial cancer are adversely impacted by multiple socioeconomic and other factors associated with access to care. To better understand how women with undiagnosed endometrial cancer can be engaged earlier, we undertook a retrospective cohort study to evaluate patterns of care for women presenting to a high-volume Emergency Department with abnormal uterine bleeding (AUB).
Methods: After obtaining IRB approval, all women presenting to a safety-net quaternary medical center between 1/1/2014 and 12/31/2019 with abnormal uterine bleeding were identified by querying the institutional Clarity database. Potential subjects age <40 years, pregnant, previously diagnosed with gynecologic cancer or who had undergone hysterectomy or pelvic radiotherapy were then excluded. Statistical significance was assessed either a Student's t-test or Wilcoxon-Mann-Whitney test for continuous variables and chi-square or Fisher's exact tests for categorical variables.
Results: A total of 492 women (mean age: 50.9±10.6 years; mean BMI of 32.8±10.0) were evaluated for AUB. Of these, 171 (34.8%) self-identified as African-American and 122 (24.8%) as Hispanic. Spanish was the preferred language for 73 (14.8%). Payor status was documented as ‘unfunded’ for 265 subjects (53.9%) and Medicare for 43 (8.7%). Evidence of commercial insurance (HMO/PPO) was documented for 134 (27%). Most women (n=455; 92.4%) underwent pelvic examination by either an emergency physician (59.6%), a gynecologist (5.9%) or both (27%). Many also received a pelvic ultrasound (n=388; 78.8%). However, only a modest number of subjects (n=87; 17.7%) underwent endometrial biopsy. Premenopausal subjects (n=350) were more likely to be evaluated with a wet prep (66.3% vs 55.9%). However, no differences in the proportion of pre- and postmenopausal subjects (n=118) who underwent a pelvic examination or received a pelvic ultrasound or an endometrial biopsy (17.7 % vs 16.9%) were observed. Of note, median endometrial thickness measured sonographically for postmenopausal subjects was 8.7 mm (IQR: 5.0-13.0). A full menstrual history documented much less frequently for Hispanic women (57.4%) than non-Hispanic African-American (48.5%) or Caucasian (38.2%) women (p=0.04). Menstrual history was much more likely to be documented as date of last menstrual period (LMP) only for women with BMI>40 (40.0%) than women with BMI<30 (23.3%) or 3040 were also more likely to undergo pelvic ultrasound as part of their clinical evaluation (p=0.02). No other associations between patterns of care and body mass index, race or ethnicity were identified. Patterns of care did not appear to depend on the time of day at which patients presented for care.
Conclusions: Endometrial biopsy was not performed for many of the women experiencing postmenopausal vaginal bleeding in this study, despite frequent sonographic evidence of abnormal endometrial thickness and a lack of health care funding. Developing strategies to address this pattern of care may help to lessen the impact of access disparities that contribute to adverse endometrial cancer outcomes.