Ultrasound-based versus immediate biopsy-based management of postmenopausal bleeding in non-Hispanic Black and non-Hispanic White individuals.

BACKGROUND: Ultrasound-based evaluation of endometrial thickness to rule out endometrial cancer in patients with postmenopausal bleeding (PMB) is not sufficiently validated in the non-Hispanic Black (NHB) population. Differences in ultrasound performance between NHB and non-Hispanic White (NHW) patients may contribute to documented disparities in cancer-associated survival. METHODS: We developed a decision-tree model, informed by literature and institutional data, comparing an immediate biopsy-based strategy (BBS) to an ultrasound-based strategy (UBS) to evaluate PMB in NHB and NHW patients. Primary outcomes were the probability of a missed cancer diagnosis and incremental biopsies per additional cancer detected. Fibroid prevalence, endometrial visibility, and race were modeled using institutional patient-level data. Prompt endometrial sampling following abnormal ultrasound (perfect follow-up) was assumed; institutionally observed follow-up rates were alternatively modeled. RESULTS: In a simulated cohort of 10,000 patients with PMB, UBS missed 109 (95 % prediction interval (PI) 85-159) cancer diagnoses compared to 70 missed for BBS. Compared to UBS, BBS resulted in 123 (95 % PI 45-265) biopsies/additional cancer detected for NHB and 155 (95 % PI 47-398) for NHW. Under observed follow-up rates, BBS resulted in 33 (95 % PI 26-38) biopsies/additional cancer detected for NHB and 44 (95 % PI 30-54) for NHW. NHB derived higher value (fewer biopsies/additional cancer detected) from BBS than NHW, particularly with fibroids present. CONCLUSION: BBS has higher value compared to UBS under observed/imperfect levels of follow-up and enhanced value when fibroids are present and among NHB patients. These results suggest that endometrial sampling should be offered at time of initial evaluation for PMB.

Duke Scholars

Author Laura Jean Havrilesky Obstetrics and Gynecology, Gynecologic Oncology

Author Evan Robert Myers Obstetrics and Gynecology, Women's Community & Population He ...