Facilitators and Barriers to Acceptability of a Biopsy-First Approach in the Diagnostic Evaluation for Endometrial Cancer Among Black Women.

Abstract

Background: Black people in the U.S. with endometrial cancer have a 5-year mortality rate that is more than twice that of white patients. This disparity is driven, in part, by Black individuals' higher likelihood of advanced-stage diagnosis. Transvaginal ultrasound (TVUS)- as a triage tool for referral to tissue sampling - underperforms among Black women. In this context, tissue sampling as an early step to rule out endometrial cancer for symptomatic Black patients may improve timely diagnosis of endometrial cancer. Patient acceptability of biopsy as a priority test is necessary to ensure success of this clinical approach. Yet, little is known about the perspective of Black women on biopsy in the diagnostic work-up for endometrial cancer.

Objective: The goal of this qualitative study was to identify facilitators and barriers to acceptability of a biopsy-first approach to rule out endometrial cancer among cisgender Black women.

Study design: In this community-engaged qualitative study, three focus groups were conducted among self-identified cisgender Black women at risk for endometrial cancer. Convenience sampling was carried out using social media and newsletter networks. A focus group guide was developed based on the Theory of Planned Behavior and contained questions about past experiences, initial impressions of a biopsy-first approach, an educational presentation, and final thoughts about a biopsy-first approach. Transcripts of focus group recordings were coded using a combined inductive and deductive approach, and analyzed using directed and thematic content analysis.

Results: Twenty-five women participated in focus groups (Table 1), with 6-10 participants per group. Participants initially expressed understandable apprehension and rejection of biopsy-first approach to symptom presentation, informed by concerning past experiences and awareness of medical racism. Yet, by the end of the focus groups, there was overall acceptability of biopsy as a priority test to rule out endometrial cancer. Barriers of biopsy acceptability include negative past experiences, including mismatch of pain expectations with actual experiences, and known incidents of medical racism. Facilitators of biopsy acceptability included: 1) fostering patient-provider trust through explicit acknowledgement of medical racism, sharing information, personalized recommendations, and racial concordance in care; and 2) health education about racial disparities in endometrial cancer, the biopsy procedure, physical risks of forgoing biopsy, emotional benefits of biopsy, and the range of possible pain experiences.

Conclusions: This qualitative study describes Black cisgender women's perspectives on biopsy as a first-line approach in evaluating abnormal bleeding as a tool to rule out endometrial cancer in this population. We find that a patient-centered communication approach that incorporates trust-building, shared decision-making and education may be most successful when recommending biopsy. These findings can inform culturally-competent clinical guideline development and public health education to ultimately improve timely diagnosis - and ultimately survival - of endometrial cancer among Black women.