A patient-centered approach that incorporates trust-building, shared decision-making, and education may increase acceptance of early endometrial biopsy and improve timely diagnosis of endometrial cancer (EC) among Black women, according to a recent study published in the American Journal of Obstetrics & Gynecology.1
EC remains the most common gynecologic malignancy in the United States, with Black individuals experiencing more than twice the 5-year mortality of White patients. Advanced-stage diagnosis contributes substantially to this disparity, and there are currently no routine screening tests for early detection.2
Key takeaways:
- A patient-centered, biopsy-first approach may increase timely detection of endometrial cancer among symptomatic Black women.
- Acceptance of biopsy is strongly influenced by provider trust, racial concordance, and acknowledgment of medical racism.
- Detailed information on procedure risks, accuracy, and potential outcomes facilitates patient acceptance and shared decision-making.
- Anxiety, dehumanization, and prior negative encounters with gynecologic procedures contribute to initial reluctance toward biopsy-first strategies.
- Most participants preferred a more accurate, invasive test over a less invasive, less accurate test when provided with context, personalized rationale, and comprehensive information.
Standard clinical guidelines recommend using postmenopausal or abnormal uterine bleeding to initiate diagnostic evaluation, with transvaginal ultrasound (TVUS) frequently employed as a triage tool.1 However, emerging evidence indicates that TVUS may underperform in Black patients, raising questions about the acceptability and feasibility of a biopsy-first approach.
Study design and participant characteristics
A qualitative study explored perspectives of Black cisgender women regarding early endometrial biopsy as a first-line diagnostic strategy. The study recruited 25 participants across 3 focus groups from April to June 2023.
Recruitment and facilitation were conducted in partnership with 2 Black EC survivors and Epoch Tribe, a Black woman–led nonprofit organization in North Carolina. Eligible participants were aged 35 years or older, identified as Black or African American, and retained a uterus. Participants aged 35 to 49 years reported prior episodes of abnormal uterine bleeding.
Focus groups were structured around 4 components: previous experiences with uterine procedures, initial impressions of a biopsy-first approach, an educational presentation on EC, and final impressions of biopsy-first acceptability. Focus groups were recorded, transcribed, and analyzed using directed and thematic content analysis.
Experiences with uterine procedures
Participants described prior uterine procedures, including TVUS and biopsy, as sources of fear, anxiety, and dehumanization. Experiences of pain often exceeded provider descriptions, and participants reported feeling dismissed or compared to animals. One participant described this as,
“I think that we, as women of color, are completely dismissed. Not even an afterthought, a forethought, an in-between thought when it comes to us being humans. Because they treat animals that undergo research better than they treat us. Especially when it comes to our femininity, our feminine parts. It's to be so quick to say, let's do a biopsy. They wanna take from us-constantly take from us. And then not give us all that information.”
Initial impressions of biopsy-first
Initial attitudes toward biopsy-first were generally unfavorable, reflecting skepticism tied to experiences of medical racism and lack of personalized rationale. Participants emphasized the need for detailed information regarding the necessity of the procedure. One participant stated,
“I would not consider that. I would ask questions. I would need some data, some blood tests. It’s an intrusive procedure. Is that important? Because there's a reason why they're doing it.”
When asked to choose between a less invasive, less accurate test and a more invasive, more accurate test, most participants expressed conditional acceptance of the latter, driven by a desire for diagnostic clarity. Participants highlighted the importance of thorough information sharing, including discussion of procedural risks, potential pain experiences, and individualized health indicators. One participant explained,
“If I go straight to the…more invasive approach, I would want to know what are the indicators that lead up to it. Talk to me about my hormone levels and my blood cell levels, like there's a reason why that's going to be the best decision….I'm not Henrietta Lacks, you know, you're not going to be using me to just find stuff.”
Key components for biopsy-first acceptability
Physicians can improve acceptance of early biopsy by focusing on:
- Informed choice through comprehensive, transparent education on EC and biopsy risks.
- Shared decision-making allowing patients to participate in selecting their diagnostic pathway.
- Provider trust, strengthened by acknowledgment of medical racism, individualized recommendations, and racial concordance in care.
- Pain management and realistic expectations, including discussion of potential discomfort and emotional considerations.
- Detailed rationale for biopsy, including physiological indicators, procedural benefits, and accuracy compared with TVUS.
Final impressions and provider trust
Following an educational presentation, all participants expressed acceptance of a biopsy-first approach, contingent upon trust and informed choice. One participant noted,
“If my medical provider looked like me. That's what would make me go with the first test, if I felt I trusted my doctor, and that my doctor actually likes Black people, and likes me.”
These findings suggest that incorporating trust-building, patient-centered education, and shared decision-making into clinical encounters may enhance acceptability of early endometrial biopsy among symptomatic Black women. Clinicians are encouraged to address prior negative experiences, provide detailed information on the procedure and potential outcomes, and explicitly acknowledge the impact of medical racism.
References
- Alson JG, Orellana M, Robinson WR, et al. Facilitators and barriers to acceptability of a biopsy-first approach in the diagnostic evaluation for endometrial cancer among Black women. Am J Obstet Gynecol. 2025;233:294.e1-11. doi:10.1016/j.ajog.2025.03.012
- Doll KM, Khor S, Odem-Davis K, et al. Role of bleeding recognition and evaluation in Black-White disparities in endometrial cancer. Am J Obstet Gynecol. 2018;219(6):593.e1-593.e14. doi:10.1016/j.ajog.2018.09.040
