‘Concerning error rate’: Study questions viability of TVUS triage strategy

Black patients presenting with postmenopausal bleeding (PMB) should undergo endometrial biopsy to avoid missing endometrial cancer.This is because the current approach of using transvaginal ultrasonography to help determine who should undergo biopsy is not reliable for this population, according to a study in JAMA Oncology.PMB is a common symptom of endometrial cancer. Currently, some guidelines suggest that individuals presenting with PMB should undergo pelvic transvaginal ultrasonography (TVUS) as a triage approach to determine who should continue on to biopsy. Guidelines suggest that those with an endometrial thickness (ET) measurement of 4 mm or greater should continue on to undergo diagnostic endometrial tissue sampling, while those whose endometrial thickness is less than 4mm reportedly don’t need further testing, the paper said. But studies have shown that Black “patients with endometrial cancer are less likely to receive endometrial biopsy after presenting with PMB; they have reported undergoing ultrasonography with initially reassuring results.” And one study suggested that TVUS may miss endometrial cancer in Black individuals because this population has a greater prevalence of fibroids and nonendometrioid histologic types, the authors said.A further issue is that endometrial cancer is on the rise, especially in the Black population who are often diagnosed at later stages. The Guidelines for Transvaginal Ultrasound in the Detection of Early Endometrial Cancer (GUIDE-EC) project was conducted to study the diagnostic accuracy, healthcare delivery, and quality of care for Black individuals with endometrial cancer, and to look at false negatives from TVUS.The retrospective study used clinical data from a large academic medical health system in the U.S. Endometrial thickness was determined from pelvic ultrasonographic reports and physician notes. A total of 1,494 Black individuals who underwent pelvic ultrasonography and hysterectomy were included in the analyses. They had a mean age of 46.1 years; 210 had endometrial cancer and 1,284 did not have endometrial cancer.If was found that 24 cases of endometrial cancer were below the 5-mm threshold that would trigger a biopsy, resulting in 11.4% of endometrial cancer cases likely misclassified.“This is a concerning error rate for a triage strategy that would terminate further workup and provide false reassurance to both patients and physicians. This result contributes to an increasing body of work questioning the wisdom of the TVUS triage strategy,” the paper said.The researchers also found that that 9.5% of the cancers in Black women were detected below the threshold of 4 millimeters. False negatives were also more likely if the visualization of endometrial thickness from the images was partial, or if fibroids were present. Another factor that can add to false negatives is patients who have increased discomfort with the vaginal ultrasonography probe which can lead to technicians conducting a shorter, lower-quality study.“Use of TVUS to assess need for endometrial biopsy among Black individuals at risk for (endometrial cancer) is not a reliable triage strategy. In the presence of concerning symptoms, we recommend tissue sampling,” the authors concluded.This research is “super important”, according to Dr. Jessica McAlpine, a professor of obstetrics and gynecology at the University of British Columbia—not part of the study.“I would never just be reassured by ultrasound and always seek tissue if there is PMP bleeding,” she told the Medical Post in an email. She emphasized that “anyone with PMB should have an endometrial tissue biopsy. One should never be reassured by ultrasound findings.”Ultrasound should be considered an adjunct test and does not replace tissue sampling. “Unfortunately, many people are falsely reassured by ultrasound,” she said.This is true for all patients, regardless of ethnicity or race. She noted that there may be differences in Black women, many of whom may be more likely to have a thin endometrial lining. Also, a greater proportion of Black women are more likely to have an increased risk for subtypes of endometrial cancer where there can be thin or atrophic linings that are not estrogen driven.

‘Concerning error rate’: Study questions viability of TVUS triage strategy

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