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Ursula A. Matulonis, MD: Hello. I'm Dr Ursula Matulonis. Welcome to season two of the Medscape InDiscussion: Endometrial Cancer podcast series. Today, we'll discuss health disparities in endometrial cancer. I want to introduce my guest, Dr Eloise Chapman-Davis.
Dr Chapman-Davis is division director of gynecologic oncology at the NewYork-Presbyterian Hospital, Weill Cornell Medical College. She serves as the co-chair of the Meyer Cancer Center gynecologic oncology disease management team. She is an associate professor of obstetrics and gynecology at Weill Cornell Medicine and is the associate director of DEI (diversity, equity, and inclusion) for the Meyer Cancer Center.
I first met Eloise when she was doing her residency in obstetrics and gynecology at the Brigham and Women's Hospital. I always knew she was going to be a star, so it's great to see her career really soar. Dr Chapman is actively involved in clinical and translational research, evaluating gynecologic cancer outcomes through clinical trial development, and has an emphasis on healthcare disparities. Dr Chapman-Davis, welcome to the Medscape InDiscussion: Endometrial Cancer podcast.
Eloise Chapman-Davis, MD: Thank you so much, Dr Matulonis. I'm so excited to be able to participate in this podcast and discuss a topic that is clearly near and dear to my heart as it relates to healthcare disparities in gynecologic oncology.
Matulonis: It's a real pleasure and honor to have you here today. As you know, the 2025 US cancer statistics were recently published in CA: A Cancer Journal for Clinicians. The statistics for uterine cancer continue to worsen, especially for Black women. The only cancer for which survival has decreased over the past four decades is uterine cancer, and this cancer is now the fifth most common cause of cancer death for women. Uterine cancer also has the largest Black-White mortality disparity, with a 5-year relative survival rate of 63% for Black women vs 84% for White women. Black women are one half as likely as White women to receive guideline-concordant diagnostic procedures for the workup and diagnosis of uterine cancer, and we'll talk about that a little bit later.
You've written extensively on disparities observed in the many aspects of uterine cancer. You were the senior author of an article entitled "An Intervention-Based Approach to Achieve Racial Equity in Gynecologic Oncology," which was published in Obstetrics & Gynecology in 2023. In this review, you set out to highlight evidence-based interventions from both inside gynecologic oncology and outside of gynecologic oncology to alleviate disparity. Can you tell us about some of those interventions that you think can alleviate disparities, what's worked, and what hasn't worked, perhaps, both inside and outside of gynecologic oncology?
Chapman-Davis: I would just like to start by saying that this is an unfortunate situation that we're in because we've known that racial disparities and outcomes have existed, especially in endometrial cancer, for over the past two decades. This isn't new information, but I think as we continue to see this gap widen, it's important that we start to think about all the causes that are making this continue to happen, some of which may be biologic, but a lot of which are also rooted in societal drivers, things in terms of community interactions with people.
One of the things that we wanted to bring across is that a multidisciplinary approach has to be taken to change or make a real effect in closing this disparity gap. Some of the things that we think about are at which point can all of these disparities exist — one, as it relates to access. Access is a big problem, and it's not just for communities of color but in a lot of areas where people have lower socioeconomic status and other drivers in terms of social determinants of health. When we think about where you live, the neighborhoods that you live in, the people that you have access to, talking about transportation, food, poverty, it all sort of mixes together. It can cause a problem of why people may not want to show up. Insurance definitely plays a role. But when we look at a lot of these disparities, a lot of women have insurance. And unfortunately, with endometrial uterine cancer, there is an actual symptom. I think that if people have a symptom, the increase in educational awareness is also something else that we need to push in many communities because some may have to decide between putting food on their table and going to the doctor because they saw a spot of blood. Some women may feel that that is not something alarming. In certain communities, it may actually even be considered a normal finding. Oh, they thought my period had come back and may not have taken these symptoms as seriously. One of the main things we need to do in terms of interventions, and they've had studies looking at this, is the role of the patient navigator, as well as the role of having more community outreach and community partnership through organizations that increase advocacy and awareness.
I think this is something that's newer to the cancer community. Patient navigation has been around for a very long time, but not in terms of thinking about early detection. When people present to the emergency room and are found to have a symptom, they get discharged and told to follow up with the doctor. How did they get there? Who should they call? Is this an emergent appointment, or is this an appointment I need to wait a month to follow up on? Once you get that appointment, is there someone who's making sure that you got there, making sure that you've done all the screening and the workup that you needed?
They have shown this in many studies, even having patient navigators in emergency rooms to help patients. They've seen this in cervical cancer screening and breast cancer screening, making sure that patients are followed to the rule, from screening to biopsy to being in the hands of an oncologist before they step away.
The nice thing about these patient navigators is that there's a real role of having what we call lay navigators — people from the communities that a lot of these patients are in, people they trust, people who may speak the language. We've seen this in studies in patients who speak Mandarin Chinese, and in certain areas where they may not trust the providers that they're with. When we talk about some of the Black and Hispanic communities, we are in the same situation, where there are clearly some racial biases that occur. There are a lot of people who think that this is not something that healthcare providers really understand, nor try to understand — why a patient may not show up or a reason for them missing an appointment.
Those patient navigators really help to figure out that sometimes the patient just needed someone to watch their kid or they couldn't miss work. It doesn't mean they don't care about themselves, but they just need another sort of push to help that move through. So that's just one example.
As we think about community partnerships and advocacy, a lot of patient education is very important. As physicians, if we collaborate with our community partners and cohorts, a lot of patients will show up. Whether it's faith-based organizations such as churches, whether it's barbershops, whether it's areas in their communities where people feel safe and they gather already, are also really good places to target to have this increased education and awareness about symptoms and things that people maybe don't feel comfortable talking to their family about. But being able to talk about it amongst their peers and with people who look like them is really important.
Matulonis: Those are all incredibly insightful comments that are really spot-on. Federal funding for uterine cancer is about $15 million per year, and it ends up being one of the lowest-funded cancers. The funding is especially low given the number of uterine cancer cases diagnosed per year, which is just around 70,000. We've just talked about the dropping survival rate. Other cancer groups, such as breast cancer, have really gotten the word out about understanding what symptoms might be happening and different types of treatments. How do you think we get the word out on uterine cancer to increase awareness, education, and understanding of this cancer in different populations? Obviously, the strategies may be different for different populations, but what are your general thoughts on that subject?
Chapman-Davis: As we think about getting the word out, what we don't do as well as our breast cancer colleagues is that we don't start with our survivors. We don't utilize our endometrial cancer survivors as much. We have such a plethora of endometrial cancer survivors, being the most common cancer that we treat. And actually, if you detect it early, it's pretty curable. We actually have a much higher population of survivors than, say, in ovarian cancer or even our other cervical cancer colleagues. And so we have people from a variety of communities who can speak to their journey. I think we are only now tapping into those groups of people.
We have collective groups, like ECANA, which is the Endometrial Cancer Action Network for African-Americans and was created by one of our own colleagues, Dr Kemi Doll. She saw that this was a niche that was needed and that there were tons of African American women who've had this cancer.
One of the things we know is that this cancer is very much rooted in obesity and diabetes, things that are very treatable comorbidities that are also very common across multiple racial and ethnic groups. So just like we target smoking to lung cancer, we're also understanding some of these things that really affect a lot of our racial and ethnic groups in a higher proportion than others. Number one, it's very important for people to see that this is linked to developing endometrial cancer.
And number two is understanding that specifically in the African American community, they're more at risk of having the more high-risk and more aggressive type of cancers — that has to be put front and center. I think it's said more appropriately through the survivors who've been through that and who thought [their symptoms were nothing to be concerned about]. This will help this population understand that, no, we have high-grade, worst-performing types of cancers. We are actually the ones that really need to know about this as soon as possible to have any long-term survival.
Also, we need to get the message out to our colleagues and all of our providers that these differences exist, whether those are physicians or nurse practitioners, because a lot of gynecologic care now is handled by PAs and nurse practitioners, not just our subspecialists. When they specifically meet a Black woman and are thinking about screening or ultrasounds, we need to biopsy patients. If a Black patient has fibroids, do not feel comfortable saying, "Oh, the bleeding is from the fibroid. We'll just follow it; it's not anything to be concerned about." But actually think the opposite; be hyperconcerned about a Black woman with fibroids because you should not feel reassured by their ultrasound with a thin stripe. In fact, they should go straight to biopsy no matter what you think. So, having the providers have the education on their side is important because there are racial differences. There are unconscious biases that we may all have, and everything should not be tailored to one-size-fits-all. Yes, there are certain comorbidities that you see as relates to endometrial cancers, but there are other higher-risk comorbidities that you'll see in certain racial and ethnic groups that you may take for granted. We need to be aware of that as we're counseling patients and making our own decisions.
One way to help address some of those biases is to try to focus on standardized diagnostic pathways — making sure that we have really early guidelines and clinical decision‒support systems. They do a lot of this for breast cancer, where you have straight pathways to say, "This is what you need to do no matter what," which helps with increasing competence and to ensure that providers will follow these guideline-recommended diagnostic procedures to reduce the variability that we see in care.
Matulonis: Picking up on that statement that you made about the need for strict guideline-recommended care for our patients with uterine cancer: You and others have written about the disparities in treatment and diagnosis of Black patients and White patients. There was an article in the Journal of the National Cancer Institute back in 2023 from Jason Wright and some of his colleagues, using Medicaid databases, with really astonishing findings, showing that Black patients were more likely than White patients to experience delayed diagnosis and not to receive guideline-recommended diagnostic procedures. And then, even when they did receive recommended diagnostic procedures, Black women were more likely than White women to experience a delay in time to the first diagnostic procedure. Really remarkable. How do you begin to solve these problems? What measures do you think will help to make this better?
Chapman-Davis: Well, I think there's a lot that goes into that. It's not like one step is going to fix everything. Addressing some of these implicit biases that people may have that lead to some of these disparities and timeframe to healthcare delivery, and using things like the electronic health records to flag and track patients to make sure they have timely follow up — these will help.
That takes it a little bit out of the provider's hands. But also important is having some sort of reoccurring system to try to get the patients to come back. The other thing that may relate to that is, honestly, as a person of color myself, I do see a lot of patients who've come for second opinions on things that you would say, "Why are you not getting treated for this?" This is a clear diagnosis, but there is an inherent delay in their treatment. Sometimes the conversation is about whether the patient trusts the provider. Some of the conversations are that the providers were either very dismissive to the patient's concerns or didn't address it at all and said, "This is the recommendation; take it or leave it" and did not want to understand what the patient's concerns were, coming at them in a way that appeared more hostile, where it seems like, "Oh, well, you're just refusing care," when that wasn't necessarily the case. I do think some of that has to do with increasing cultural competence across providers.
One other thing that can help with that is increasing the representation of Black professionals in the gynecologic oncology workforce and healthcare leadership roles. I do think fostering cultural sensitivity in care delivery is important, and I think that spans across all racial and ethnic groups. If a patient is not responsive to you, it may not be that they don't care about their health but that there's something that concerns them and they may not know how to express it in a way that they think you care or where they will feel heard or listened to.
I think that can sometimes play a role. People want to feel comfortable and confident with their provider. I definitely have heard the opposite, where people have felt dismissed. Going back to bias, a patient will say, "I've been bleeding, bleeding, bleeding, bleeding, and no one recommended that I get a biopsy." They will be told that they have fibroids, they have endometriosis, or there are other reasons for their bleeding, and it has been going on for months. Whereas someone else, maybe from a different, affluent racial-ethnic group, could have a spot of blood, and in two seconds they will get a biopsy, and then someone's calling me on their phone to get them on the table within a week.
I know we all have those patients as well. But I think we as providers have to make sure that our access to care is open to all and not limit it to just the people who have access. I think that if we know, especially for certain populations that have poor-risk histology and high-risk disease, we should be doing our best to get those patients in right away. I think that we also have to do a better job as providers.
Matulonis: Those are all amazing points. You've also written about the lack of clinical trial participation of Black patients and that Black patients remain systematically understudied in clinical trials. In one of your reviews, you called out KEYNOTE-775, which compared the standard chemotherapy vs the combination of pembrolizumab and lenvatinib in metastatic endometrial cancer, and you pointed out that only 3.7% of study participants were Black. You also mentioned that it was a global trial and that there were no sites in Africa that had participated in the trial. So, what do you think are or will be effective strategies to enroll Black women in endometrial cancer trials?
Chapman-Davis: I think that this is a long-standing problem, and it starts back with what we do with our inclusion criteria. So if you are excluding people who may have some of the comorbidities because you want the healthiest population, then, in essence, you're going to decrease the amount of patients who are from certain racial or ethnic groups that would be included.
For instance, if people have a history of HIV, or have a certain BMI, or are diabetics but are controlled. In America, obesity is one of the biggest problems that we have. There are many patients who are going to have all of these complications, so that is more real-world information on how that drug is going to really interact in everybody. Excluding certain populations that may have certain high-risk comorbidities also leads to having some problems with clinical trial enrollment. The other major thing is being able to get access to these trials where people are at. You can't expect all the trials to be at Memorial Sloan Kettering and have people who live far away in certain areas of Brooklyn feel comfortable coming to this trial.
I think if your patient population has a certain population is higher risk and a certain racial or ethnic group, then when you make these trials, you should make every effort to have representation of the percentage of those people from that racial-ethnic group who have that cancer. If that means you need to set up those trials in the community hospital, then that makes more sense. Now, I understand that you may not have all the support you need, but part of the goal with these trials through pharmaceutical companies is that they should help to facilitate that.
If that means that they need to pay for somebody to be there, to have these trials open up closer to home, that's important. Other things in terms of advocating for the patient experience are that there are a lot of things you have to do to stay in a trial — meaning that there are multiple appointments you have to go to for multiple scans. A lot of these are not standard trial scans and imaging. For a lot of people, it's a lot to come to multiple appointments — for example, if you are a single mother, the primary caregiver and working person, and you don't have transportation. So, it's things as simple as providing transportation and thinking about why patients should just volunteer their time without any remuneration. Yes, they may be helping themselves, but they're also helping other people, and they also have to live in the situation that they're in. So, for a lot of people, these ideas of the social determinants of health really become critical, even over their own personal health.
I think that the people who create these trials have to understand that if you want these populations to participate, you have to do things to make it easier for them, outside of saying, "We're trying to do this to help save your life." A lot of people live day to day, and the day-to-day things that they need to do to survive are not necessarily coming to the hospital for multiple appointments.
Those are things that we need to think about and put it back on the companies that are running these trials to help what's needed to increase participation.
Matulonis: I totally agree with you. Congratulations on all your leadership positions at Weill Cornell. As a leader, you had some control, if not a lot of control, over some of the programs and initiatives that you're working on at Weill Cornell. So, tell us about some of those programs that you're working on to reduce the many disparities that we've talked about today related to uterine cancer diagnosis and treatment.
Chapman-Davis: The nice thing about being in a system like NewYork-Presbyterian is that it's not just Weill Cornell Medicine. We expand out to NewYork-Presbyterian Queens and Brooklyn Methodist Hospital. Queens has the most diverse population in the United States. Brooklyn has a very large African American community that we outreach. So, at the Meyer Cancer Center, we have a really fantastic office of community outreach and engagement. Being on the board of the executive council of the cancer center myself, we make sure that some of our strategic priorities are based on the disparities that are in our catchment area. Uterine cancer and cervical cancer are some of the biggest disparities within our catchment area. And so that's a major focus for us in terms of access for clinical trials — increase in enrollment specifically around minority communities, which means opening trials in Brooklyn, and making sure that whatever we have at our site at Cornell, we have as the same opportunities in both Queens and Brooklyn.
Some of the other opportunities that we've been working on include doing a lot of community engagement. We have a very active community advisory board made up of members of the community. A lot of them have even been on our research projects from the very beginning, trying to understand and hear the voice of the community, which I think is very important.
One of the previous projects they worked on was trying to educate the community about what clinical trials are, so that if they hear about clinical trials, the response won't be, "I'm not your guinea pig. I heard what they did back in the day to our folks." We help them understand what a phase 1 trial is, what's phase 2, what's phase 3. This was a funded project that involved community providers and physicians, various medical oncologists, and gynecologic oncologists. They had a lecture series to also teach community healthcare workers how to explain it in a good way to the community, and they really saw a "pre-" and "post-" — how much people understood about clinical trials in general and whether this would make them more open to hear more about it. It did show a positive outcome. So, bringing in more of the community outreach is important.
Some of the other projects that I'm working on have to do with increasing patient education. I focused on a project called MedExplain. It was called the PALS program, or patient-activated learning system, where we created culturally competent videos to make things very simple about what to expect. My major priority initially started with cervical cancer, and we found some really good responses from that. We're also trying to focus on creating more videos that are culturally competent around signs and symptoms of endometrial cancer, not only just understanding the importance of follow-up from abnormal Pap smears.
And then, finally, we're thinking about biology; clearly that has to play some sort of role in all of this, right? I'm not saying all of this is social or access to care, even unconscious bias and racism. There are other things that are playing a role, and for us to better understand what they are, we need to get tissue. We need to get genetics. We need to get molecular testing, and we need to get that specifically on women of color. So part of the project that I've been working on is with our friends who do a lot of molecular and genomic testing, to talk about the ancestry of Black women who have these high grades, specifically in endometrial cancer, and looking to see if we can do a deep dive to figure out if there are certain things going on in this population compared with our Caucasian counterparts.
So we're trying to attack it in different ways. But I hope everyone understood from this podcast that there isn't a one-stop fix; if we all work together and look at it from different pathways, we may be able to do something to close this gap in a more meaningful way.
Matulonis: That's great. It's really impressive, as is the breadth and depth of the work that you're doing. Any other research projects at Weill Cornell that really excite you? And do you have any last comments for our audience?
Chapman-Davis: I think it's really important to make sure that you, as physicians who are in control of what happens to your patients, hold your institutions accountable for regularly reporting the disparities and healthcare outcomes, because you need to know what's happening here in your own institution and your communities. That will really help push them to help improve equity. These initiatives can be continuously monitored for quality improvement, focusing on what is specifically needed in your institution to help close the gaps in inequity in cancer care.
I'm excited to be in a place where I'm able to get access to so many different patients across different spans to be able to understand how these cancers will change over time, and also see the access to all of these new, innovative treatments that are out there and how they will affect all these different racial-ethnic groups. As we look at the clinical trials as they are right now, we have a way to really try to expand and change the outlook by getting more in-depth into all these different racial-ethnic groups and communities.
Matulonis: Eloise, I really want to thank you so much for being here today and describing the work that you're doing. Today, we've talked to Dr Chapman-Davis about disparities in uterine cancer. We've talked about what can be done to overcome disparities, thinking about how to increase clinical trial enrollment of Black women, and also what Dr Chapman-Davis and her colleagues at Weill Cornell are doing to overcome disparities.
Thank you for tuning in. Please take a moment to download the Medscape app to listen and subscribe to this podcast series on endometrial cancer. This is Dr Ursula Matulonis for the Medscape InDiscussion: Endometrial Cancer podcast.
Listen to additional seasons of this podcast.
Resources
An Intervention-Based Approach to Achieve Racial Equity in Gynecologic Oncology
Patient Navigation in Cancer Treatment: A Systematic Review
Racial Disparities in Diagnostic Evaluation of Uterine Cancer Among Medicaid Beneficiaries
Lenvatinib Plus Pembrolizumab for Advanced Endometrial Cancer
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Endometrial Cancer Disparities: Improving Black Women's Access to Care and Trials - Medscape - Feb 13, 2025.
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