The more you know: Association between endometrial cancer knowledge and guideline concordant practice patterns in response to abnormal bleeding among first-line providers in a national survey (574)

Abstract

<b>Objectives:</b> Provider uncertainty about appropriate diagnostic work-up of initial endometrial cancer (EC) symptoms may be a factor in racial inequities in EC care and outcomes. We evaluated the relationship between provider knowledge of EC and reported practice patterns in a nationally representative survey of first-line providers for initial EC symptoms. <b>Methods:</b> We mailed 1,637 surveys to physicians (MD/DOs, <i>n</i> = 1,316) and nurse practitioners (NPs, <i>n</i> = 321) sampled from professional societies' mailing lists (OBGYN, emergency medicine (EM), family medicine/primary care (FM), and internal medicine (IM)). An initial 10% pilot mailing was used to ascertain response rates by region, with the subsequent 90% over-targeted to lower response regions. The survey contained provider demographic, practice setting, and EC knowledge questions along with four case vignettes, which varied by patient ultrasound findings, age, bleeding symptoms, and comorbid conditions. We assessed for significant differences in knowledge and practice patterns by provider characteristics with bivariate testing. We then constructed a knowledge score (-1-10) and used Poisson regression to calculate prevalence ratios (PR) for the association between knowledge and reported practice patterns. <b>Results:</b> Of 559 returned surveys, 531 met inclusion criteria (response rate=38%). Most respondents were female (65%), 40-59 years (55%), and White (79%). Most (73%) had no university affiliation, and 77% reported at least a weekly frequency of seeing Black women; 58% were OBGYN, 25% FM, 12% EM, and 10% IM. Less than half of all respondents (48%) correctly identified EC as being more common than both ovarian and cervical cancer, and fewer (35%) identified the correct decade of median age of EC diagnosis (60-70). Non-guidelineconcordant management answers ranged from 5 to 75% by case and specialty. For example, for a 55-year-old with abnormal bleeding and an 8mm ES, many chose to observe and wait for repeated bleeding (OBGYN 12%, Family Med 25%, EM 45%, and IM 35%). For a 70-year- old with PMB, 5% of OBGYNs, 12% of EM, 16% of FM, and 22% of IM respondents failed to choose TVUS, EMB, or D&C as the appropriate next step. Those with knowledge scores above the median (6, IQR: 4-7) (<i>n</i>=205) were statistically significantly more likely to select any guideline-concordant option for two of the cases (PRs: 1.28-1.36) and to choose endometrial biopsy, specifically (PRs:1.34-1.47). <b>Conclusions:</b> In a national provider survey across specialties and training backgrounds where initial EC symptoms are likely to be disclosed, most respondents lacked basic knowledge about the commonality of EC and important risk factors. Most did not recommend endometrial biopsy as an initial diagnostic step, and a significant proportion reported non-guideline concordant practices. The association of EC knowledge with correct care recommendations indicates the importance of a targeted national education and training effort for first-line providers as EC incidence continues to rise.