Appropriateness of Hysterectomy as Treatment for Benign Gynecological Conditions.

Objective: To assess the appropriateness of hysterectomies performed at a large tertiary health system using the 1997 RAND appropriateness classification system and an updated algorithm. Design: We abstracted structured and unstructured data from electronic medical records on patient demographics, primary indication(s) for hysterectomy, diagnosis codes associated with the hysterectomy, previous treatments, and laboratory results. Subjects: Patients aged 18-44 years. Exposure: Receipt of hysterectomy for benign and nonobstetric conditions from October 2014 to December 2017. Main Outcome Measures: Using these data, we provided a RAND-based (dichotomous: inappropriate/appropriate) and Wright-based (3-level: inappropriate/ambiguous/appropriate) appropriateness rating and characterized missing information patterns associated with inappropriate ratings. Results: We analyzed 1,829 hysterectomies across 30 nonmutually exclusive primary indications for surgery. Nearly a third (32.8%) of surgeries had only one primary indication for surgery. Using the RAND-based classifier, 31.3% of hysterectomies were rated as appropriate and 68.7% as inappropriate. Using the Wright-based algorithm, 58.1% of hysterectomies were rated as appropriate, 15.7% as ambiguous, and 26.2% as inappropriate. Missing information on diagnostic procedures was the most common characteristic related to both RAND-based (46.1%) and Wright-based (51.2%) inappropriate ratings. Conclusions: The 1997 RAND classification lacked guidance for several contemporary indications, including gender-affirming care. RAND also has an outdated requirement for diagnostic surgeries such as laparoscopies, which have decreased in practice as diagnostic imaging has improved. Sensitivity analyses suggest that inappropriate surgeries cannot all be attributed to bias from missing electronic medical record data. Accurately documenting care delivery for benign gynecological conditions is key to ensuring quality and equity in gynecological care.

Endometrial Thickness as Diagnostic Triage for Endometrial Cancer Among Black Individuals.

Importance: Poor performance of the transvaginal ultrasonography triage strategy has been suggested as a contributor to racial disparity between Black individuals and White individuals in endometrial cancer (EC) stage at diagnosis in population-level simulation analyses. Objectives: To examine the false-negative probability using ultrasonography-measured endometrial thickness (ET) thresholds as triage for EC diagnosis among Black individuals and assess whether known risk factors of EC modify ET triage performance. Design, Setting, and Participants: This retrospective diagnostic study of merged abstracted electronic health record data and secondary administrative data (January 1, 2014, to December 31, 2020) from the Guidelines for Transvaginal Ultrasound in the Detection of Early Endometrial Cancer sample assessed Black individuals who underwent hysterectomy in a 10-hospital academic-affiliated health care system and affiliated outpatient practices. Data analysis was performed from January 31, 2023, to November 30, 2023. Exposure: Pelvic ultrasonography within 24 months before hysterectomy. Main Outcome and Measures: Ultrasonography performed before hysterectomy as well as demographic and clinical data on symptom presentation, endometrial characterization, and final EC diagnosis were abstracted. Endometrial thickness thresholds were examined for accuracy in ruling out EC diagnosis by using sensitivity, specificity, and negative predictive value. False-negative probability was defined as 1 - sensitivity. Accuracy measures were stratified by risk factors for EC and by factors hypothesized to influence ET measurement quality. Results: A total of 1494 individuals with a uterus (median [IQR] age, 46.1 [41.1-54.0] years) comprised the sample, and 210 had EC. Fibroids (1167 [78.1%]), vaginal bleeding (1067 [71.4%]), and pelvic pain (857 [57.4%]) were the most common presenting diagnoses within 30 days of ultrasonography. Applying the less than 5-mm ET threshold, there was an 11.4% probability that someone with EC would be classified as not having EC (n = 24). At the 4-mm (cumulative) threshold, the probability was 9.5%, and at 3 mm, it was 3.8%. False-negative probability at the 5-mm threshold was similar among EC risk factor groups: postmenopausal bleeding (12.4%; 95% CI, 7.8%-18.5%), body mass index greater than 40 (9.3%; 95% CI, 3.1%-20.3%); and age 50 years or older (12.8%; 95% CI, 8.4%-18.5%). False-negative probability was also similar among those with fibroids on ultrasonography (11.8%; 95% CI, 6.9%-18.4%) but higher in the setting of reported partial ET visibility (26.1%; 95% CI, 10.2%-48.4%) and pelvic pain (14.5%; 95% CI, 7.7%-23.9%). Conclusion and Relevance: These findings suggest that the transvaginal ultrasonography triage strategy is not reliable among Black adults at risk for EC. In the presence of postmenopausal bleeding, tissue sampling is strongly recommended.

Study Protocol for the Social Interventions for Support During Treatment for Endometrial Cancer and Recurrence (SISTER) study: a community engaged national randomized trial.

Aim: Social isolation in cancer patients is correlated with prognosis and is a potential mediator of treatment completion. Black women with endometrial cancer (EC) are at increased risk for social isolation when compared with White patients. We developed the Social Interventions for Support during Treatment for Endometrial Cancer and Recurrence (SISTER) study to compare and evaluate interventions to address social isolation among Black women with high-risk EC in USA. The primary objective of the SISTER study is to determine whether virtual support interventions improve treatment completion compared with Enhanced Usual Care. Secondary objectives include comparing effectiveness virtual evidence-based interventions and evaluating barriers and facilitators to social support delivery. Patients & methods: This is a multi-site prospective, open-label, community-engaged randomized controlled trial, consisting of three intervention arms: enhanced usual care, facilitated support group and one-to-one peer support. Primary outcome will be measured using relative dose. Qualitative semi-structured interviews will be conducted with a subset of participants to contextualize the relative degree or lack thereof of social isolation, over time. Data analysis: Primary analysis will be based on an intent-to-treat analysis. Multivariable analysis will be performed to determine the effect of the intervention on the primary and secondary outcomes of interest, relative dose and social isolation score. Semi-structured interviews will be qualitatively analyzed using inductive and deductive approaches of content analysis. Discussion/conclusion: Endometrial cancer mortality disproportionately affects Black women, and social isolation contributes to this disparity. The SISTER study aims to identify whether and to what extent differing social support vehicles improve key outcomes for Black women in the United States with high-risk EC. Clinical Trial Registration: NCT04930159 (ClinicalTrials.gov).

The Carolina hysterectomy cohort (CHC): a novel case series of reproductive-aged hysterectomy patients across 10 hospitals in the US south.

BACKGROUND: Hysterectomy is a common surgery among reproductive-aged U.S. patients, with rates highest among Black patients in the South. There is limited insight on causes of these racial differences. In the U.S., electronic medical records (EMR) data can offer richer detail on factors driving surgical decision-making among reproductive-aged populations than insurance claims-based data. Our objective in this cohort profile paper is to describe the Carolina Hysterectomy Cohort (CHC), a large EMR-based case-series of premenopausal hysterectomy patients in the U.S. South, supplemented with census and surgeon licensing data. To demonstrate one strength of the data, we evaluate whether patient and surgeon characteristics differ by insurance payor type. METHODS: We used structured and abstracted EMR data to identify and characterize patients aged 18-44 years who received hysterectomies for non-cancerous conditions between 10/02/2014-12/31/2017 in a large health care system comprised of 10 hospitals in North Carolina. We used Chi-squared and Kruskal Wallis tests to compare whether patients' socio-demographic and relevant clinical characteristics, and surgeon characteristics differed by patient insurance payor (public, private, uninsured). RESULTS: Of 1857 patients (including 55% non-Hispanic White, 30% non-Hispanic Black, 9% Hispanic), 75% were privately-insured, 17% were publicly-insured, and 7% were uninsured. Menorrhagia was more prevalent among the publicly-insured (74% vs 68% overall). Fibroids were more prevalent among the privately-insured (62%) and the uninsured (68%). Most privately insured patients were treated at non-academic hospitals (65%) whereas most publicly insured and uninsured patients were treated at academic centers (66 and 86%, respectively). Publicly insured and uninsured patients had higher median bleeding (public: 7.0, uninsured: 9.0, private: 5.0) and pain (public: 6.0, uninsured: 6.0, private: 3.0) symptom scores than the privately insured. There were no statistical differences in surgeon characteristics by payor groups. CONCLUSION: This novel study design, a large EMR-based case series of hysterectomies linked to physician licensing data and manually abstracted data from unstructured clinical notes, enabled identification and characterization of a diverse reproductive-aged patient population more comprehensively than claims data would allow. In subsequent phases of this research, the CHC will leverage these rich clinical data to investigate multilevel drivers of hysterectomy in an ethnoracially, economically, and clinically diverse series of hysterectomy patients.

"I Wasn't Presented With Options": Perspectives of Black Veterans Receiving Care for Uterine Fibroids in the Veterans Health Administration.

INTRODUCTION: Black women with uterine fibroids experience greater symptom severity and worse treatment outcomes compared with their White counterparts. Black veterans who use Veterans Health Administration (VA) health care experience similar disparities. This study investigated the experiences of Black veterans receiving care for uterine fibroids at VA. METHODS: We identified Black veterans aged 18 to 54 years with newly diagnosed symptomatic uterine fibroids between the fiscal years 2010 and 2012 using VA medical record data, and we recruited participants for interviews in 2021. We used purposive sampling by the last recorded fibroid treatment in the data (categorized as hysterectomy, other uterine-sparing treatments, and medication only/no treatment) to ensure diversity of treatment experiences. In-depth semistructured interviews were conducted to gather rich narratives of veterans' uterine fibroid care experiences. Transcribed interviews were analyzed using content analysis. RESULTS: Twenty Black veterans completed interviews. Key themes that emerged included the amplified impact of severe fibroid symptoms in male-dominated military culture; the presence of multilevel barriers, from individual to health care system factors, that delayed access to high-quality treatment; insufficient treatments offered; experiences of interpersonal racism and provider bias; and the impact of fertility loss related to fibroids on mental health and intimate relationships. Veterans with positive experiences stressed the importance of finding a trustworthy provider and self-advocacy. CONCLUSIONS: System-level interventions, such as race-conscious and person-centered care training, are needed to improve care experiences and outcomes of Black veterans with fibroids.

Endometrial Cancer and Reproductive Justice.

Endometrial cancer (EC) is the most common gynecologic cancer in the United States. Black individuals with EC have had a more than 90% higher 5-year mortality risk than White people while being subject to lower quality care across the entire disease process. In this commentary, I offer the perspective that EC is part of the reproductive justice movement, as a representation of threat to reproductive health independent of childbearing. With this work, I want to place EC squarely among the discursive arguments that reproductive justice makes in the interconnectedness of fertility, reproductive health, parenthood, and, ultimately, life.

Endometrial Cancer Knowledge and Guideline-Concordant Practice Patterns Among First-Line Providers.

Background: Provider uncertainty about the appropriate guideline-concordant evaluation of endometrial cancer (EC) symptoms may be a factor in racial inequities in EC. To evaluate the relationship between EC knowledge and reported practice patterns in a nationally representative survey of first-line providers for initial EC symptoms. Materials and Methods: This was a mailed cross-sectional survey of physicians and nurse practitioners from professional organization roster of providers from Obstetrics and Gynecology (OBGYN), Family Medicine, Internal Medicine, and Emergency Medicine. It queried demographics, practice characteristics, EC knowledge, and guideline-concordant practice patterns via three case vignettes. Regions of low response were retargeted to ensure strong representation among providers caring for Black women patients. EC knowledge was analyzed via a composite score (range: -3 to 10, with higher scores representing more EC knowledge), and adjusted prevalence ratios (PRs) used to test the association between knowledge and reported practice patterns. Results: Among 531 returned surveys (response rate = 38%), OBGYN had highest (53%) frequency of >6 (median) EC knowledge score, and Emergency Medicine had the lowest (15%) (p < 0.001). Nonguideline-concordant practice patterns were reported in 14%, 41%, and 35% of the three EC cases presented. Providers with knowledge >6, (n = 205) were significantly more likely to report guideline-concordant care on case vignettes (PR 1.28-1.36). Conclusions: In a national survey of multi-specialty backgrounds, there were basic knowledge gaps about EC and EC risk factors among providers, and a sizeable proportion reported nonguideline concordant practices. These findings indicate the importance of targeted education and training for first-line providers, as EC incidence rises.

Participation of Patients With Limited English Proficiency in Gynecologic Oncology Clinical Trials.

BACKGROUND: Significant disparities exist in recruitment of minorities to clinical trials, with much of the prior literature focused on race/ethnicity only. Limited English proficiency (LEP) is a known barrier in healthcare that may also drive disparities in trial enrollment. We sought to determine participation rates in gynecologic oncology trials among patients with LEP and to explore barriers to their participation. METHODS: In a retrospective cohort study, electronic health record data from >2,700 patients treated over 2 years at one academic gynecologic oncology practice were abstracted and the primary exposure of having LEP was identified. The primary outcome was enrollment in a clinical trial. Demographic, financial, clinical, and healthcare access-related covariates were also abstracted and considered as potential confounders in a multivariable logistic regression model. Age, race, ethnicity, and insurance status were further examined for evidence of effect modification. In addition, a survey was administered to all gynecologic oncology research staff and gynecologic oncology providers (n=25) to assess barriers to research participation among patients with LEP. RESULTS: Clinical trial enrollment was 7.5% among fluent English speakers and 2.2% among patients with LEP (risk ratio, 0.29; 95% CI, 0.11-0.78; P=.007), and remained significantly lower in patients with LEP after adjusting for the identified confounders of Hispanic ethnicity and insurance payer (odds ratio, 0.34; 95% CI, 0.12-0.97; P=.043). There was a trend toward race and LEP interaction: Asian patients were equally likely to participate in research regardless of language fluency, whereas White and Black patients with LEP were less likely to participate than non-LEP patients in both groups (P=.07). Providers reported that the most significant barriers to enrollment of patients with LEP in research were unavailability of translated consent forms and increased time needed to enroll patients. CONCLUSIONS: Patients with LEP were 3.4 times less likely to participate in gynecologic oncology trials than fluent English speakers. De-aggregation of race, ethnicity, and language proficiency yielded important information about enrollment disparities. These findings offer avenues for future interventions to correct disparities.

Uterine lavage identifies cancer mutations and increased TP53 somatic mutation burden in individuals with ovarian cancer.

Current screening methods for ovarian cancer (OC) have failed to demonstrate a significant reduction in mortality. Uterine lavage combined with TP53 ultra-deep sequencing for the detection of disseminated OC cells has emerged as a promising tool, but this approach has not been tested for early-stage disease or non-serous histologies. In addition, lavages carry multiple background mutations, the significance of which is poorly understood. Uterine lavage was collected preoperatively in 34 patients undergoing surgery for suspected ovarian malignancy including 14 patients with benign disease and 20 patients with OC (6 non-serous and 14 high grade serous-like (serous)). Ultra-deep duplex sequencing (~3000x) with a panel of common OC genes identified the tumor mutation in 33% of non-serous (all early stage) and in 79% of serous cancers (including four early stage). In addition, all lavages carried multiple somatic mutations (average of 25 mutations per lavage), more than half of which corresponded to common cancer driver mutations. Driver mutations in KRAS, PIK3CA, PTEN, PPP2R1A and ARID1A presented as larger clones than non-driver mutations and with similar frequency in lavages from patients with and without OC, indicating prevalent somatic evolution in all patients. Driver TP53 mutations, however, presented as significantly larger clones and with higher frequency in lavages from individuals with OC, suggesting that TP53-specific clonal expansions are linked to ovarian cancer development. Our results demonstrate that lavages capture cancer cells, even from early-stage cancers, as well as other clonal expansions and support further exploration of TP53 mutation burden as a potential OC risk factor.

More than treatment refusal: a National Cancer Database analysis of adjuvant treatment refusal and racial survival disparities among women with endometrial cancer.

BACKGROUND: Disparities in adjuvant treatment between Black and White women with endometrial cancer exist and contribute to worse outcomes among Black women. However, factors leading to disparate treatment receipt are understudied. OBJECTIVE: We examined whether patient refusal of adjuvant treatment (chemotherapy or radiation) differed between Black and White women and whether treatment refusal mediated racial disparities in survival among women with endometrial cancer. STUDY DESIGN: We used the National Cancer Database, a hospital-based cancer registry, to identify non-Hispanic Black and non-Hispanic White women diagnosed with endometrial cancer from 2004 to 2016 who either received or refused recommended radiation or chemotherapy. We used logistic regression to estimate multivariable-adjusted odds ratios and 95% confidence intervals for associations between race and treatment refusal. We also examined predictors of treatment refusal in race-specific models. Accelerated failure time models were used to estimate absolute differences in overall survival by race. We used causal mediation analysis to estimate the proportion of racial differences in overall survival attributable to racial differences in adjuvant treatment refusal. We considered the overall study population and strata defined by histology, and adjusted for sociodemographic, tumor, and facility characteristics. RESULTS: Our analysis included 75,447 endometrial cancer patients recommended to receive radiation and 60,187 endometrial cancer patients recommended to receive chemotherapy, among which 6.4% and 11.4% refused treatment, respectively. Among Black women recommended for radiation or chemotherapy, 6.4% and 9.6% refused, respectively. Among White women recommended for radiation or chemotherapy, 6.4% and 11.8% refused, respectively. After adjusting for sociodemographic variables, facility characteristics, and tumor characteristics, Black women were more likely to refuse chemotherapy than White women (adjusted odds ratio, 1.26; 95% confidence interval, 1.15-1.37), but no difference in radiation refusal was observed (adjusted odds ratio, 1.00; 95% confidence interval, 0.91-1.11). Some predictors of radiation refusal varied by race, namely income, education, histology, stage, and chemotherapy receipt (P interactions<.05), whereas predictors of chemotherapy refusal were generally similar between Black and White women. Among women recommended for radiation, Black women survived an average of 4.3 years shorter than White women, which did not seem attributable to differences in radiation refusal. Among women recommended for chemotherapy, Black women survived an average of 3.2 years shorter than White women of which 1.9 months (4.9%) could potentially be attributed to differences in chemotherapy refusal. CONCLUSION: We observed differences in chemotherapy refusal by race, and those differences may be responsible for up to about 2 months of the overall 3.2-year survival disparity between White and Black women. Radiation refusal did not explain any of the 4.3-year disparity among women recommended for radiation. Treatment refusal accounts for, at most, a small fraction of the total racial disparity in endometrial cancer survival. Although a better understanding of the reasons for patient treatment refusal and subsequent intervention may help improve outcomes for some women, other causes of disparate outcomes, particularly those reflecting the social determinants of health, must be investigated.

Uterine Weight as a Modifier of Black/White Racial Disparities in Minimally Invasive Hysterectomy Among Veterans with Fibroids in the Veterans Health Administration.

Introduction: Uterine fibroids are the most common indication for hysterectomy. Minimally invasive hysterectomy (MIH) confers lower risk of complications and shorter recovery than open surgical procedures; however, it is more challenging to perform with larger fibroids. There are racialized differences in fibroid size and MIH rates. We examined the role of uterine size in black-white differences in MIH among Veterans in the Department of Veterans Affairs (VA). Methods: Using VA clinical and administrative data, we conducted a cross-sectional study among black and white Veterans with fibroids who underwent hysterectomy between 2012 and 2014. We abstracted postoperative uterine weight from pathology reports as a proxy for uterine size. We used a generalized linear model to estimate the association between race and MIH and tested an interaction between race and postoperative uterine weight (≤250 g vs. >250 g). We estimated adjusted marginal effects for racial differences in MIH by postoperative uterine weight. Results: The sample included 732 Veterans (60% black, 40% white). Postoperative uterine weight modified the association of race and MIH (p for interaction=0.05). Black Veterans with postoperative uterine weight ≤250 g had a nearly 12-percentage point decrease in MIH compared to white Veterans (95% CI -23.1 to -0.5), with no difference by race among those with postoperative uterine weight >250 g. Discussion: The racial disparity among Veterans with small fibroids who should be candidates for MIH underscores the role of other determinants beyond uterine size. To eliminate disparities in MIH, research focused on experiences of black Veterans, including pathways to treatment and provider-patient interactions, is needed.

A Race-Conscious Approach Toward Research on Racial Inequities in Palliative Care.

Racial inequities in palliative and end-of-life care have been well-documented for many years. This inequity is long-standing and resistant to many intervention efforts. One reason for this may be that research in racial inequity in palliative care, and the interventions developed, do not account for the effects of race and the everyday racism that patients of color experience while navigating the healthcare system. Public Health Critical Race Praxis (PHCRP) offers researchers new routes of inquiry to broaden the scope of research priorities in palliative care and improving racial outcomes through a novel conceptual framework and methodology. PHCRP, based off critical race theory (CRT), contains 10 principles within four foci to guide researchers toward a more race conscious approach for the generation of research questions, research processes, and development of interventions targeting racial inequities.

A conceptual model of vulnerability to care delay among women at risk for endometrial cancer.

OBJECTIVE: Care delay may allow for cancer progression prior to treatment initiation. However, in endometrial cancer, quantitative data to support this hypothesis is mixed. Factors that cuase delay prior to clinical presentation are present among Black women, however the whether and how they present among White women, and thus how they may drive racial disparity is unknown. METHODS: In this qualitative study, from June 2019 to March 2020, we conducted in-depth semi-structured interviews among 17 White women with EC (34-73 years), living in the Northwest (11), West (2), Midwest (1), Southwest (1), and Northeast (2) U.S. regions, including six with high-risk and/or advanced stage endometrial cancer. An exploratory and descriptive content analysis was performed using iterative rounds of inductive coding, case summaries, and additional interviews to confirm emergent themes, followed by synthetic analysis of themes from a prior qualitative study conducted among Black women, which we analyzed for overlap and distinctions. RESULTS: There were critical points of overlap and distinction between Black and White women in four delay factors identified: menopause and endometrial cancer knowledge, prior negative healthcare experiences, prior/concurrent reproductive conditions, and healthcare provider response. Conceptualizing the care journey as a circular path demonstrates the potential for accumulation of delay that is dependent on underlying risk. CONCLUSION: We have identified four areas of vulnerability that are often unrecognized and difficult to assess in quantitative investigations of overall quality and co-occurring disparities in endometrial cancer care. With the addition of epidemiologic risk, we present a unified model of vulnerability to care delay in endometrial cancer that can be applied to future quantitative studies and ongoing clinical care.

Development of an algorithm to assess unmeasured symptom severity in gynecologic care.

BACKGROUND: Healthcare disparities research is often limited by incomplete accounting for differences in health status by populations. In the United States, hysterectomy shows marked variation by race and geography, but it is difficult to understand what factors cause these variations without accounting for differences in the severity of gynecologic symptoms that drive the decision-making for hysterectomy. OBJECTIVE: This study aimed to demonstrate a method for using electronic health record-derived data to create composite symptom severity indices to more fully capture relevant markers that influence the decision for hysterectomy. STUDY DESIGN: This was a retrospective cohort study of 1993 women who underwent hysterectomy between April 4, 2014, and December 31, 2017, from 10 hospitals and >100 outpatient clinics in North Carolina. Electronic health record data, including billing, pharmacy, laboratory data, and free-text notes, were used to identify markers of 3 common indications for hysterectomy: bulk symptoms (pressure from uterine enlargement), vaginal bleeding, and pelvic pain. To develop weighted symptom indices, we finalized a scoring algorithm based on the relationship of each marker to an objective measure, in combination with clinical expertise, with the goal of composite symptom severity indices that had sufficient variation to be useful in comparing different patient groups and allow discrimination among severe symptoms of bulk, bleeding, or pain. RESULTS: The ranges of symptom severity scores varied across the 3 indices, including composite bulk score (0-14), vaginal bleeding score (0-44), and pain score (0-30). The mean values of each composite symptom severity index were greater for those who had diagnostic codes for vaginal bleeding, bulk symptoms, or pelvic pain, respectively. However, each index demonstrated a variation across the entire group of hysterectomy cases and identified symptoms that ranged in severity among those with and without the target diagnostic codes. CONCLUSION: Leveraging multisource data to create composite symptom severity indices provided greater discriminatory power to assess common gynecologic indications for hysterectomy. These methods can improve the understanding in healthcare use in the setting of long-standing inequities and be applied across populations to account for previously unexplained variations across race, geography, and other social indicators.

Estimated Performance of Transvaginal Ultrasonography for Evaluation of Postmenopausal Bleeding in a Simulated Cohort of Black and White Women in the US.

IMPORTANCE: Black women in the US with endometrial cancer (EC) are more likely to be diagnosed with advanced-stage disease independent of insured status and histologic type. The most common way of diagnosing EC at early stages is through screening of people with postmenopausal bleeding to detect endometrial thickness (ET). This approach may disproportionately underperform in Black women secondary to a higher prevalence of fibroids and nonendometrioid EC in this population, both of which affect the quality of ET measurement. OBJECTIVE: To compare the performance of recommended transvaginal ultrasonography (TVUS) ET thresholds as a screening method to prompt endometrial biopsy by race in a simulated cohort of symptomatic women. DESIGN, SETTING, AND PARTICIPANTS: In a simulated retrospective cohort study, based on data from Surveillance, Epidemiology, and End Results (SEER) national cancer registry 2012-2016; the US census; and published estimates of ET distribution and fibroid prevalence, diagnostic test characteristics of the 3-mm or more, 4-mm or more, and 5-mm or more ET thresholds for biopsy to capture EC diagnoses were calculated. The simulated cohort was constructed from February 2, 2020 (date of access to SEER data), to August 31, 2020. Analysis occurred from September 30, 2020, to March 30, 2021, including the primary analysis and the sensitivity calculations. MAIN OUTCOMES AND MEASURES: The main outcome measured was accuracy of the TVUS ET threshold to accurately identify cases of EC, measured by sensitivity, negative predictive value, and area under the curve (AUC). RESULTS: A total of 367 073 simulated Black and White women with postmenopausal bleeding were evaluated, including 36 708 with EC. Among Black women, the currently recommended 4-mm or greater ET threshold prompted biopsy for fewer than half of EC cases (sensitivity, 47.5%; 95% CI, 46.0%-49.0%); of women referred for biopsy, 13.1% were EC cases (positive predictive value, 13.1%; 95% CI, 12.5%-13.6%). The AUC for the 4-mm or more threshold was 0.57 (95% CI, 0.56-0.57). In contrast, among the White women, the 4-mm or more threshold led to biopsy for most with EC (sensitivity, 87.9%; 95% CI, 87.6%-88.3%). Of those referred for biopsy, 14.6% had EC (positive predictive value, 14.6%; 95% CI, 14.4%-14.7%); AUC was 0.73 (95% CI, 0.73-0.74). The same variations held for the 3-mm or more and 5-mm or more ET thresholds: sensitivity, positive predictive value, and AUC were consistently lower for Black women than White women. CONCLUSIONS AND RELEVANCE: The findings of this simulated cohort study suggest that use of ET as measured by TVUS to determine the need for EC diagnostic testing in symptomatic women may exacerbate racial disparities in EC stage at diagnosis. In simulated data, TVUS ET screening missed almost 5 times more cases of EC among Black women vs White women owing to the greater prevalence of fibroids and nonendometrioid histologic type in Black women.

Changing trends in Black-White racial differences in surgical menopause: a population-based study.

BACKGROUND: Bilateral oophorectomy before menopause, or surgical menopause, is associated with negative health outcomes, including an increased risk for stroke and other cardiovascular outcomes; however, surgical menopause also dramatically reduces ovarian cancer incidence and mortality rates. Because there are competing positive and negative sequelae associated with surgical menopause, clinical guidelines have not been definitive. Previous research indicates that White women have higher rates of surgical menopause than other racial groups. However, previous studies may have underestimated the rates of surgical menopause among Black women. Furthermore, clinical practice has changed dramatically in the past 15 years, and there are no population-based studies in which more recent data were used. Tracking actual racial differences among women with surgical menopause is important for ensuring equity in gynecologic care. OBJECTIVE: This population-based surveillance study evaluated racial differences in the rates of surgical menopause in all inpatient and outpatient settings in a large, racially diverse US state with historically high rates of hysterectomy. STUDY DESIGN: We evaluated all inpatient and outpatient surgeries in North Carolina from 2011 to 2014 for patients aged between 20 and 44 years. Surgical menopause was defined as a bilateral oophorectomy, with or without an accompanying hysterectomy, among North Carolina residents. International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes were used to identify inpatient and outpatient procedures, respectively, and diagnostic indications. We estimated age-, race-, and ethnicity-specific rates of surgical menopause using county-specific population estimates based on the 2010 United States census. We used Poisson regression with deviance-adjusted residuals to estimate the incidence rate ratios in the entire state population. We tested changes in surgery rates over time (reference year, 2011), differences by setting (reference, inpatient), and differences by race and ethnicity (reference, non-Hispanic White). We then described the surgery rates between non-Hispanic White and non-Hispanic Black patients. RESULTS: Between 2011 and 2014, 11,502 surgical menopause procedures for benign indications were performed in North Carolina among reproductive-aged residents. Most (95%) of these surgeries occurred concomitant with a hysterectomy. Over the 4-year study period, there was a 39% reduction in inpatient surgeries (incidence rate ratio, 0.61) and a 100% increase in outpatient surgeries (incidence rate ratio, 2.0). Restricting the analysis to surgeries among non-Hispanic White and Black patients, the increase in outpatient surgeries was significantly higher among non-Hispanic Black women (P<.01) for year-race interaction (reference, 2011 and non-Hispanic White). The overall rates of bilateral oophorectomy for non-Hispanic Black women rose more quickly than for non-Hispanic White women (P<.01). In 2011, the rate of surgical menopause was greater among White women than among Black women (17.7 vs 13.2 per 10,000 women). By 2014, the racial trends were reversed (rate, 24.8 per 10,000 for non-Hispanic White women and 28.4 per 10,000 for non-Hispanic Black women). CONCLUSION: Our findings suggest that the rates of surgical menopause increased in North Carolina in the early 2010s, especially among non-Hispanic Black women. By 2014, the rates of surgical menopause among non-Hispanic Black women had surpassed that of non-Hispanic White women. Given the long-term health consequences associated with surgical menopause, we propose potential drivers for the racially-patterned increases in the application of bilateral oophorectomy before the age of 45 years.

Characterization of the Early Years of Bevacizumab Use for First-Line Treatment of Ovarian Cancer in the United States.

PURPOSE: To quantify early dissemination patterns, factors influencing use, and costs of bevacizumab (BEV) for the treatment of newly diagnosed ovarian cancer (OC) in the United States before its regulatory approval for this indication (off-label use). METHODS: We identified women 18-65 years of age with newly diagnosed OC treated with surgery and platinum-based chemotherapy from 2008 to 2016 through the MarketScan database (N = 8,109). The proportion of women receiving BEV over time was calculated, multivariate logistic regression used to determine factors associated with BEV use, and total costs per cycle of chemotherapy with and without BEV abstracted. RESULTS: BEV utilization rose 1.8-fold during the study period, from 4.1% (2008) to 7.4 % (2016). BEV was used with non-platinum/taxane regimens over a third of the time (37.2%). Physician specialty (medical oncology v gyn oncology) and geography (southeast region) were significantly associated with higher rates of use. Clinical factors associated with BEV use were metastatic disease and presence of ascites. The median cost of one cycle of platinum/taxane chemotherapy plus BEV was $10,897 in US dollars (USD) (interquartile range $7,573-$18,133 USD), compared with $1,629 USD (interquartile range, $683.0-$4,461 USD) for platinum/taxane alone. CONCLUSION: Off-label use of BEV for newly diagnosed OC was rare (< 10%), but doubled following presentation of phase II and III data at international meetings. Both clinical (ascites, metastatic disease, and age) and nonclinical (specialty and region) factors were associated with BEV use, and its use was accompanied by a six-fold increase in the cost of one cycle of treatment.

Incorporating Measures of Structural Racism into Population Studies of Reproductive Health in the United States: A Narrative Review.

Purpose: Black women in the United States face poor outcomes across reproductive health measures-from pregnancy outcomes to gynecologic cancers. Racial health inequities are attributable to systemic racism, but few population studies of reproductive health outcomes integrate upstream measures of systemic racism, and those who do are limited to maternal and infant health outcomes. Advances in understanding and intervening on the pathway from racism to reproductive health outcomes are limited by a paucity of methodological guidance toward this end. We aim to fill this gap by identifying quantitative measures of systemic racism that are salient across reproductive health outcomes. Methods: We conducted a review of literature from 2000 to 2019 to identify studies that use quantitative measures of exposure to systemic racism in population reproductive health studies. We analyzed the catalog of literature to identify cohesive domains and measures that integrate data across domains. For each domain, we contextualize its use within population health research, describe metrics currently in use, and present opportunities for their application to reproductive health research. Results: We identified four domains of systemic racism that may affect reproductive health outcomes: (1) civil rights laws and legal racial discrimination, (2) residential segregation and housing discrimination, (3) police violence, and (4) mass incarceration. Multiple quantitative measures are available for each domain. In addition, a multidimensional measure exists and additional domains of systemic racism are salient for future development into distinct measures. Conclusion: There are quantitative measures of systemic racism available for incorporation into population studies of reproductive health that investigate hypotheses, including and beyond those related to maternal and infant health. There are also promising areas for future measure development, such as the child welfare system and intersectionality. Incorporating such measures is critical for appropriate assessment of and intervention in racial inequities in reproductive health outcomes.