Access to Primary Care and Its Impact on Endometrial Cancer Diagnosis

Alexander J. Fife, MD

Delays in the diagnosis and treatment of endometrial cancer remain a significant concern, particularly for patients without an established outpatient primary care provider or obstetrician-gynecologist (OB-GYN). According to Alexander J. Fife, MD, a recent study shed light on this issue.

“Systemically, patients without a primary care relationship are more likely to present with higher stage disease. Minority women, in particular, are more likely to live in areas with a shortage of primary care physicians, leading to decreased access to primary care and healthcare in general,” Fife, clinical instructor at Rutgers New Jersey Medical School, told Targeted OncologyTM, in an interview.

A total of 484 patients with endometrioid endometrial cancer who presented with postmenopausal bleeding at a diverse, urban medical center between 2006 and 2018 were included in the study. The median time from the onset of symptoms to treatment was found to be 4 months (interquartile range, 2-8 months). Despite the delays, the majority of patients (88.6%) were diagnosed with stage I disease, indicating that early-stage endometrial cancer remains common at diagnosis.

However, the study revealed that the patients who had not seen a primary care physician or OB-GYN in the year prior to symptom onset were more likely to experience significant delays in their care. The delay in treatment was notably higher among these patients (27.7%) compared with those with established care (14.3%). These delays correlated with a higher likelihood of extrauterine disease at diagnosis, with 20.2% of those without recent primary care visits presenting with more advanced disease, vs 4.9% of those with established care.

The study also highlighted racial and ethnic disparities in care, with Black and Hispanic patients found to be more likely to experience significant delays from initial biopsy to diagnosis. Overall, this may contribute to worse outcomes for these groups of patients.

In the interview, Alexander J. Fife, MD, discussed the challenges of diagnosing endometrial cancer, highlighting delays in care, particularly for patients without primary care access.

Gynecologic cancer illustration: © Crystal Light - stock.adobe.com

Targeted Oncology: Can you discuss the rationale behind this research?

Fife: Coming from North Dakota, the delays to care were a common topic that came up. Classically, the study that people talked about a lot was patients with stroke symptoms get tPA. There is a time-based treatment from the onset of symptoms until people are supposed to be treated, usually about 6 hours. So, my thoughts on delays to care and interest in delays to care came, stemming from that, where if someone is 4 hours from a stroke center, how do you improve access to getting that in? After I finished medical school in North Dakota, I moved to the Bronx for residency where it switched a little bit from geographic barriers to a little bit more like systemic and social barriers to care. As a resident, I met a lot of patients who expressed a lot of frustration with the healthcare system, and difficulty getting appointments to be evaluated. Some of those patients spawned the idea to start looking into this for the study.

What were the methods and designs used?

This study was a retrospective chart review, where we went back into patient charts and collected information from the history portion of the notes. We defined a few variables, starting with focusing on patients with postmenopausal bleeding, which allowed us to assess the temporal relationship between symptom onset and treatment. Postmenopausal bleeding is the number 1 symptom of endometrial cancer, so we looked at when patients became symptomatic, when they saw a doctor, when they got diagnosed, and when they received treatment. We also focused on healthcare access and patients' relationship to the healthcare system. We reviewed whether patients had seen a primary care physician or a general OB-GYN in the year before their symptoms started. Patients with an established relationship with outpatient care were those who had seen a doctor, while patients who had not seen a doctor in multiple years or only came through the emergency room were defined as not having an established healthcare relationship.

Given the findings of the study, what are the biggest factors contributing to delays in diagnosing and treating endometrial cancer, especially for those in underserved communities?

We found that the primary delay came from the time between symptom onset and initial evaluation by a physician, especially in patients without an established relationship with a primary care physician. These patients had higher stage disease at presentation. Looking at other outcome data, we found that Black women were more likely to experience delays from their first endometrial biopsy to diagnosis. Patients with preoperative biopsies showing endometrial hyperplasia also experienced delays in diagnosis.

Factors contributing to delay [have been] identified in the literature, [including] difficulty making appointments, fear of a cancer diagnosis, and fear of wasting a doctor's time. Systemic barriers, especially in underserved populations, also play a role. Uninsured or underinsured patients are more likely to face these barriers. Studies have shown that [Medicaid] expansion has led to earlier stage diagnoses and more timely treatment in patients with gynecologic cancers, not just endometrial cancer.

Regarding Black women and delays in diagnosis, the number of affected patients was relatively small—around 19 or 20—but studies have shown that Black women are more likely to receive non–guideline-concordant care in the evaluation of their postmenopausal bleeding. For example, ultrasounds measuring endometrial thickness are recommended, and patients with a thickness of 4 mm or less are considered low risk for malignancy. However, more research has come out that Black women are more likely to experience false negatives with these ultrasound findings, with an eightfold increase in false negative rates compared to the general population. Even when following guidelines, Black women are more likely to have a delayed diagnosis.

A lot of future efforts should be directed on expedited repeat endometrial sampling for these patients, treating endometrial hyperplasia, and closer follow-up for those with initially negative workups or ultrasounds, particularly Black women who are at higher risk for false negatives.

What specific interventions could be implemented at the primary care level to improve timely referral diagnosis for patients with suspected endometrial cancer?

I think the biggest intervention comes before patients are even seeing the primary care doctor; it is expanding access to primary care and getting more doctors to go into primary care. Again, there have been more incentives. A lot of medical schools have started offering expedited 3-year programs to increase the number of people entering primary care. Expanding NP and PA programs can also help address the primary care physician shortage. Increasing access and availability in primary care is going to be the biggest thing. And before the primary care level, community-level interventions are important. We need to encourage people to see doctors not only when they are sick, but also for age-based screenings and early interventions.

Once patients are seeing a primary care physician, there needs to be patient education. Studies show as many as 44% of patients are unaware that postmenopausal bleeding is a symptom of cancer. Educating patients about cancer signs is essential, so they know to make an appointment and get evaluated if they experience symptoms like postmenopausal bleeding.

Regarding the workup for malignancy, there needs to be a broader understanding that the traditional ultrasound cutoff of 4 mm for endometrial thickness may lead to an underdiagnosis of endometrial cancer.

How can collaboration between specialists and general practitioners for early detection be improved?

Medicine is and always will be face-to-face. Even with things like telemedicine, we are still looking at a patient and talking to them. Since I have moved to Rutgers, it is easy for me to refer patients because I know the GYN oncologists. It is much easier for me to be able to pick up my phone and text a colleague or a friend about a patient. I want to refer [patients], and just getting to meet each other, knowing our specialists, and knowing our colleagues in other specialties will make life so much easier.

Are there any social or cultural factors that might contribute to delays in seeking care for endometrial cancer symptoms?

Some studies have identified difficulty in making appointments in fear of an oncologic diagnosis or fears of wasting a doctor's time. Uninsured underinsured patients have increasing difficulty getting access to medical care. It was not something that was addressed in our study, but there have been concerns about the trust in the healthcare system from minority women. Any time trust is broken, it takes time to build that trust back. That is going to happen one interaction at a time, as well as through improving the numbers of underrepresented minorities in medicine.

What are some potential explanations for the disparities and delays based on race and ethnicity? What strategies can be implemented to ensure equitable access and timely care for all patients?

A lot of it comes down to the risk factors present, whether biologic or related to systemic issues. As we discussed, Black women are more likely to have false negative results on initial workup, including ultrasound screening. They are also more likely to have aggressive histologies and higher stage disease at presentation. Systemically, patients without a primary care relationship are more likely to present with higher stage disease. Minority women, in particular, are more likely to live in areas with a shortage of primary care physicians, leading to decreased access to primary care and healthcare in general.

What are some promising new tools that could help potentially improve early detection and diagnosis of endometrial cancer?

I think just about every field right now comes down to artificial intelligence, whether it is medicine, tech, or anything else. We know that screening and prophylactic surgery benefit patients with known genetic malignancy or familial cancer syndromes, like BRCA mutations or Lynch syndrome. However, screening everyone and doing prophylactic surgery for everyone would not be helpful. Using advanced technology to assess patients with certain risk factors could help determine who might benefit from advanced screening or prophylactic surgery, even if they do not have familial genetic cancer syndrome but have other risk factors that increase their risk for malignancy.

REFERENCE:

Fife AJ, Najor AJ, Aspir TB, et al. Reduced healthcare access contributes to delay of care in endometrial cancer. Gynecol Oncol. 2024;182:115-120. doi:10.1016/j.ygyno.2024.01.010