Diagnostic Experiences of Black and White Patients with Uterine Cancer: A Qualitative Study

Abstract

Objective:

To explore patient experiences with the diagnosis process for uterine cancer and the perceived barriers that may affect early diagnosis and racial disparities in stage at diagnosis.

Methods:

We conducted semi-structured interviews to ascertain the diagnostic journey of 11 non-Hispanic Black (“Black”) and 11 non-Hispanic White (“White”) patients who were diagnosed with uterine cancer in the past six months. All interviews were audio-recorded, professionally transcribed, and analyzed using thematic analysis. Findings were presented to patients and community advocates for critical review and feedback before being finalized.

Results:

Respondents had a median age of 64 years. Thirteen (59.1%) had stage I tumor, whereas nine (40.9%) had stage II-IV disease. Respondents were attentive to their symptoms but unaware that they could indicate uterine cancer. This was compounded by women’s conditioned acceptance of discomfort and disconnection from gynecological care after reproductive age. Respondents often viewed racial disparities in diagnosis through other social determinants of health, including gender, age, and healthcare access. These overlapping social experiences, coupled with respondents’ concentration on recovery, may mask their perceptions about systemic racism. Although few respondents noted negative experiences in their own evaluations leading to the diagnosis of uterine cancer, Black respondents often described how previous discriminatory experiences informed a wariness of healthcare systems.

Conclusion:

Lack of public awareness of uterine cancer, gendered expectations for discomfort, and disconnection from gynecologic care all interfered with early diagnosis of uterine cancer. Discriminatory experiences in prior healthcare further complicate Black patients’ engagement with the healthcare system.

Graphical Abstract

INTRODUCTION

Uterine cancer is one of the most common cancers among women in the U.S. (1) The incidence has increased annually for nearly 20 years (2) and is projected to continue to rise over the next decade. With this increase persists a large racial disparity in uterine cancer mortality, with a two-fold higher death rate among Black patients compared with other racial or ethnic groups (3). A major contributor to the higher mortality rate among Black patients is their more advanced stage at diagnosis (4). Roughly two-thirds of uterine cancer patients from other racial or ethnic groups were diagnosed when their cancers were at a localized stage, while only 55% of Black patients received diagnoses at localized stages (3).

Several studies have identified clinical factors that may contribute to this disparity. One study (5) showed that Black patients are less likely than White patients to present with abnormal uterine bleeding – a primary symptom of uterine cancer and often a signal for further testing (6). Another study (7) suggested that when undergoing diagnostic evaluation, the use of transvaginal ultrasound with a threshold endometrial thickness – a standard first-line diagnostic evaluation – could miss more cases of uterine cancer among Black patients than White patients due to their higher prevalence of non-endometrioid types of uterine cancer and fibroids.

Even among patients who do present with abnormal bleeding, Black patients are less likely than White patients to receive guideline-concordant diagnostic procedures (8, 9). Research has also demonstrated that the timing and delivery of clinical care for Black patients with gynecologic cancers is affected by negative interactions with healthcare providers, differential diagnoses of prior or concurrent reproductive conditions, and generational loss of family health information (10-14). Recent work by Doll et al. (15) proposes that these socio-cultural experiences contribute to a vulnerability of care that delays or circumvents patients from receiving their cancer diagnoses.

Few studies describe patients’ understanding of the cumulative factors that affect early diagnosis of uterine cancer or the quality and equity of the diagnostic process. Through qualitative interviews, this study explored patients’ perspectives on their diagnostic journey for uterine cancer and compared the experiences between Black and White patients.

METHODS

Patient Sample and Recruitment

We recruited study respondents from a university-affiliated tertiary care center located in the northeastern U.S. Patients were eligible for this study if they met the following criteria: 1) were 18 years of age or older, 2) were non-Hispanic Black (“Black”) or non-Hispanic White (“White”), 3) were diagnosed with uterine cancer within the past six months (including both endometrial carcinoma and uterine sarcoma), 4) did not have a previous cancer diagnosis, and 5) were English-speaking. Potentially eligible patients were identified from gynecologic oncology tumor board listings. Clinicians at affiliated gynecologic oncology clinics were also informed of the eligibility criteria and could directly refer patients to the study. In all instances, patients’ clinical providers made the initial contact to inform patients of the availability of this study and inquire about their interest in participation.

We called interested patients to provide more detailed information about the study and perform a brief phone screening to confirm eligibility. Patients who met all eligibility criteria were scheduled for interviews at their convenience. The interview was conducted via a secure, password-protected conferencing platform. Patients could choose to call or log into the platform online. Before the interview, patients received a study packet by mail or email containing an information sheet about the study, telephone and login instructions, and a draft questionnaire for them to preview. Verbal consent was obtained at the beginning of each interview. After the interview, each respondent received a $50 gift card in appreciation of their time.

Data Collection

Interviewers (MCB, EI) used a semi-structured guide (see Appendix A) to elicit respondents’ experiences leading up to their uterine cancer diagnosis (e.g., symptom onset and recognition, symptom reporting and care seeking, diagnostic tests received) and their perceptions about whether race influenced their diagnostic experience. Both interviewers were trained in qualitative methods. The interview guide was developed using previous literature (10, 14, 16-18) and refined with feedback from Black and White cancer survivors (19). At the end of each interview, we also gathered respondents’ feedback on a draft questionnaire (e.g. clarity and scope of draft survey questions) to inform a subsequent survey study on the same topic. (Those findings are not covered in this manuscript.)

We conducted one-on-one interviews from April 2022 through July 2023. Each interview lasted no more than 90 minutes and was audio-recorded, professionally transcribed, cleaned, and de-identified (20). The interviewers wrote field notes to capture environmental details and reflect critically on data collection and analysis (19). This study was reviewed and approved by the Institutional Review Boards at Yale University and Columbia University.

Data Analysis

We used thematic analysis to analyze the interview data (20, 21). Two researchers (MCB, EI) independently coded transcripts using a codebook aligned to the National Institute of Minority Health and Health Disparities Research Framework (22), which incorporates a life course perspective on factors influencing health and healthcare. They met regularly with a third team member (XX) to compare code applications, resolve differences or discrepancies, refine the codebook, and discuss emergent themes (23). They wrote notes to document their progress and used qualitative software to manage the data (NVivo, Lumivero, Denver, CO) (21).

Preliminary findings were presented to patients and community advocates for their critical review and feedback (19, 21). Patient reviewers included Black and White gynecological cancer survivors identified through a local community research fellowship, a local patient support group, and study team contacts. The community advocate reviewers were members of the study institution’s cancer center community advisory board. Reviewers’ reflections and recommendations were incorporated into the final analysis.

RESULTS

We completed interviews with 22 patients, including 11 Black patients and 11 White patients (median age: 64 years). Characteristics of interview respondents are summarized in Table 1. Thirteen respondents (59.1%) had stage I diagnosis, while nine (40.9%) had stages II-IV disease.

Table 1:

Respondent characteristics (n=22)

Characteristic	N (%)
Age, in years
<55	4 (18.2%)
55-64	7 (31.8%)
≥65	11 (50.0%)
Race and ethnicity
Non-Hispanic Black	11 (50.0%)
Non-Hispanic White	11 (50.0%)
Cancer stage
I	13 (59.1%)
II-IV	9 (40.9%)
Histologic subtype
Endometrioid carcinoma	10 (45.5%)
Non-endometrioid carcinoma	9 (40.9%)
Sarcoma/other	3 (13.6%)
Insurance status
Medicare or Medicaida	11 (50.0%)
Private insurance	11 (50.0%)
Marital status
Single	6 (27.3%)
Divorced, separated, or widowed	9 (40.9%)
Married	7 (31.8%)
Education
High school diploma	3 (13.6%)
Some college or Associate’s degree	7 (31.8%)
Bachelor’s degree	7 (31.8%)
Master’s degree	5 (22.7%)
Frequency of physical exam prior to uterine cancer diagnosis
≥Twice per year	6 (27.3%)
Every two years - annually	11 (50.0%)
None or no regular check up	5 (22.7%)

Percentages may not add up to 100% due to rounding.

^aMedicaid and Medicare insurance were combined to protect patient confidentiality and avoid reporting small numbers.

We identified three themes in the data. First, respondents were attentive to their symptoms but did not recognize that they could indicate cancer. Second, patients’ responses to those symptoms were informed by assumptions and prior healthcare experiences related to gender and age. For Black patients, this also included racially discriminatory experiences. Finally, respondents discussed the discomfort acknowledging racial disparities, particularly as they navigated their cancer diagnosis and treatment.

Attentive to Symptoms But Unsure of Cause

Respondents had little to no awareness of uterine cancer before their diagnosis. They generally had not discussed it with clinicians or seen it represented in public health campaigns. One patient shared, “I never, never read about it, studied about it, or tried to know about it.… I didn’t know it was such a thing.⁰¹” Another respondent admitted, “even now, my mind’s eye had to do the separation. There is uterine cancer. There is cervical cancer. There is ovarian cancer. I had it all grouped into one.⁰²”

Respondents were attentive to their symptoms, recognizing that something was wrong, but not suspecting cancer. Many attributed gynecological symptoms – including unexpected bleeding – to familiar causes, including fibroids, strain from physical activity, or incomplete menopause. One respondent shared, “when the bleeding happened I didn’t know what the heck was going on with the bleeding. I just thought man, maybe I’m not menopausal just yet. I just thought I was having late-stage spotty period.⁰³” Another patient explained, “all that time, I thought that the heavy bleeding was the fibroids, the pee leaks was the fibroids, the discomfort during the menstrual was the fibroids, the protruding of my belly was the fibroids.⁰⁴” Other study patients described how easy it could be to overlook non-specific symptoms like bloating and discomfort because they could be associated with other conditions or organ systems. “I did have a symptom that I missed, the bloating.…But women bloat all the time⁰⁵” said one respondent.

The quality of the communication with the clinician mattered as well, especially when respondents were unsure about the purpose or interpretation of various testing cascades. One respondent pointed out that patients are often advised that abnormal findings can be acceptable in the absence of other warning signs, saying, “[the doctor] took a Pap smear first. And the pap smear revealed something was not right.…She did the biopsy. Meanwhile she told me that usually it’s nothing to worry about.…I had a few abnormal Pap smears but each time.…my primary doctor would tell me.…sometimes it can be this, sometimes it can be there. But not to worry about it. If I don’t have any pain or if I don’t have any bleeding or anything like that.⁰⁶” When discussing genetic screening, another respondent shared “I had done genetic testing [for another cancer].… And I thought, ‘Well, I’ve already done the testing.’ I came out clear with all of that.…no one ever said that to me when I did my testing like, ‘You’re good for all of these cancers but there are other cancers that you could get.’⁰⁷”

This lack of awareness contributed to respondents feeling guilt or self-blame, particularly for patients who had noticed changes but did not immediately question or report them. “It was also my fault, too… I didn’t realize that a foul-smelling discharge could be an indication of uterine cancer. I never had that before so, I just kind of dealt with it. It would wax and wane,⁰⁸” said one respondent. Another patient shared, “when I first saw that first bleeding, I wish I had gone right then, instead of waiting another month before, and then having the clots passing.⁰⁹” Two respondents gave examples of personal decisions relating to race and age that they worried may have unintentionally increased their risk for developing uterine cancer. One patient said, “I was taking those supplements and I know those put me at risk.…I was going with bioidentical hormones, thinking that it was a better route. I look back and I should’ve just dealt with the stupid hot flashes.¹⁰” Another respondent shared, “I started doing relaxers for a few years and now, there’s commercials out there about ‘oh, if you’ve used a straightening agent or relaxed with these chemicals on your hair, that could lead to cancer’.…I’m like, ‘did I do this to myself?’.…that opens up a whole other conversation about what it’s like to be a Black woman in America and to be accepted.¹¹”

Responses to Symptom Informed by Prior Experiences with Sexism, Ageism, and Racism

As they shared their paths to diagnosis, respondents reflected on how lifetime experiences with gender, age, and race affected their care. They discussed how women are conditioned from adolescence to accept painful periods, disruptive hormonal changes, and an unpredictable menopause. One respondent shared, “having mild cramping and spotting has been part of my life since I was 14 years old.…I think early diagnosis is affected because we tend to just power through stuff. We just go ‘oh, feeling a little cramping.…let me get through it, let me just deal with it.’¹¹” Another respondent observed, “there’s an expectation when it comes to your female anatomy that you’ve got to expect pain… I don’t think you get the same thing when somebody says I’ve got a heart palpitation.⁰⁵”

This expectation for discomfort led respondents to weigh the duration and degree of symptoms when deciding to seek care. One patient described how she was not worried until her bleeding worsened, noting, “the bleeding ultimately, it wasn’t stopping me from doing stuff. You know, it wasn’t that bad.…I was still very active; I was running, I was working out.¹²” Another respondent reflected on her experience, saying “It wasn’t real bad, like red blood or bleeding in the commode, or nothing like that. It was just a little wipe of blood. So I didn’t really think that it was anything serious. I really didn’t.⁰⁶”

At the time of their diagnosis, nearly half of our respondents (n=10, 45.4%) were disconnected from gynecological care and more than 20% (n=5) did not attend annual preventative care visits. One respondent explained “I had a doctor, but I had not been to my GYN in over seven years.… I had no problems. I was not sexually active. I was not worried about it.⁰²” These respondents had to find gynecological providers willing to promptly accept new, older patients. One respondent recalled, “they said, ‘Well, we’re not taking any new patients,’ and that’s how they answered me.…’We’re only taking patients that are dealing with having babies or getting some kind of help trying to have babies.’⁴⁴” Several respondents relied on younger family members to help find practitioners who could quickly see them, like one respondent who shared, “[my daughter] told this place that ‘my mother needed to see a doctor because she’s 70 years old and she’s bleeding’.¹⁵”

For Black respondents, issues around gender and age were magnified by discriminatory experiences in health care. Some patients described early encounters that fostered longstanding mistrust, like one respondent whose physician recommended a hysterectomy during her child-bearing years. She noted, “if I wasn’t Black and if I wasn’t so young he might not have dared to try such a serious surgery on me when it wasn’t absolutely necessary.¹³” Other respondents recounted current incidents happening alongside their cancer diagnoses. “When I really think about it, I feel like I experienced some kind of medical apartheid,” said one respondent. “I don’t think they were really taking what I was saying about the [non-cancer] pain seriously.⁰³” These experiences were in direct contrast to comments from White respondents, who held more innate trust in the healthcare system. One White respondent explained, “if you’re in some kind of pain or you feel some discomfort, I think you’ve got to go to the doctor. That’s something my mother drilled in me from the time I was very little.¹⁴”

Respondents described how active support from primary care and gynecological providers facilitated prompt appointments and testing. One respondent shared, “because I was already in the practice and my OB-GYN saw the breakthrough bleeding and he just started fast-tracking me through the process…his patient navigator was like, ‘oh, he wants to get you in really quick.⁰³” Another respondent noted “the thing that moved my progress along was the fact that I had established healthcare relationships. Would the other women have those?⁰⁵”

Similarly, many respondents were heartened by relationships with clinicians whom they felt listened to them, recognized their experiences, and advocated for them. These clinicians were often female and/or persons of color. Their commitment to act, to be “very attentive to everything that I say,⁰²” and to “treat you like my sister and like a family member¹²” built patients’ confidence in the quality and safety of their care.

Acknowledging Discomfort with Disparities

When asked whether race impacted their cancer journey, initially respondents tended to suggest that racial disparities result from access barriers like insurance coverage or provider availability. Some also suggested that personal responsibility, rather than race, may be a factor as well, like one respondent who said, “we do have busy lives, so you’re the last one you’re the last one to take care of yourself.¹⁶” As the interviews progressed, though, respondents considered moments when they wondered whether access barriers masked experiences of racism or discrimination. Their observations came from waiting room encounters, support groups, and personal reflections.

“Some people, I’m amazed at how long they have to wait to have their surgery performed. Some people have to wait months. I don’t know why that it is.…I had mine within ten days of me being diagnosed…But I’m not a doctor.…I don’t know if the wait affects anything or the outcome.¹⁷”

“I hate to think race was having anything to do with it, but I feel like I did get some preferential treatment because of my standing, being educated, white, and a nurse.…I don’t know if I were in a different situation, how long that appointment would take. But in my case, it literally was 24 hours.⁰⁸”

“I don’t think I ever felt like I was getting less than because of race. …when I got there and you’re looking around the waiting room.…what I kept questioning was are you guys sure you got the right information? Like was there a mix up? Because I feel like … there was not another Black face in the room the two times that I was there.¹¹”

During these reflections, respondents shared that it was difficult to consider questions around discrimination or bias while enduring cancer surgery and treatment. Many were focused on maintaining a positive outlook during their recovery. One respondent said, “I just kept it simple.…Not that I didn’t want to hear what other people had to say. I just wanted to know what was happening to me…I didn’t want to be bogged down with other information. I just really wanted to be focused on getting healthy and getting through this.¹²” Another patient said, “I hate to think that, but I don’t know if that was the case.…I was told that a couple times, ‘don’t worry about it. Don’t worry it’s not a big deal unless it gets worse.’.…And I hate to think that it was race. But I don’t know. I really don’t know.⁰⁶”

A few respondents questioned whether it was appropriate to ask whether race impacted care, while others wondered why this disparity was not receiving more attention. One respondent cited the enrollment differences in a study she found examining an aggressive type of uterine cancer, saying “there were like 782 White women and like 14 Black women.…How is that a fair study?.…There’s your disparity right there.¹⁰” Another patient captured many respondents’ sentiments when she shared, “it seemed like we had escaped this racism thing. We knew it was still out there, but it felt like it was something that was in the past that was escaped. I’m saying all of this to say that that may be the same thing in the medical field. It may be something that is not obvious, but it could be something that is very subtle.⁰⁴”

Throughout their diagnostic journeys, many respondents said they talked more openly with family members and friends about their symptoms and their care, trying to break generational silences on gynecological conditions and help identify familial risks. This was especially important to Black respondents, who said they planned on encouraging and advising other Black women on how to seek medical care in spite of any hesitation or mistrust. One respondent described telling her clients, “just go and get checked out about anything that’s going on with you. When you feel signs, there’s signs for a reason.…Any kind of sign you get, go check it out about diagnosing it.¹⁵” Another respondent felt like her cancer journey created an opportunity for her to make a difference for others, saying “I want to be a mentor. Because I know how to talk to people, I know how to comfort people, and that was my faith.¹⁸”

DISCUSSION

The process of diagnosing a disease involves complex and evolving appraisal by patients and clinicians, as well as interactions between them and with various aspects of the healthcare system (24). Our interview data captured multiple factors in this process and demonstrate how the lack of public awareness about uterine cancer, coupled with gendered expectations for discomfort and disconnection from gynecological care, interfered with the diagnosis of uterine cancer. The findings also indicate how discriminatory experiences related to gender, age, and race affect patients’ interactions with the healthcare system. Within our study, Black and White patients often traveled the same diagnostic paths, but Black patients’ discriminatory experiences within the healthcare system compounded each barrier and could potentially increase their vulnerability to care (15).

Like many cancer studies (25), our data collection focused on patient-driven activities associated with the appraisal and help-seeking intervals of the Walter Pathway to Treatment (26). Our thematic findings cut across the many levels (individual, interpersonal, community, and societal) and domains (behavioral, sociocultural environment, and health care system) of influence identified in the NIMHD Minority Health and Health Disparities Research Framework (22). They build on previous research (27, 28) to illustrate how experiences that feel singular to patientsreflect manifold systemic issues around trust, community outreach, and access to specialty care (9). One unique strength of our study is our collaboration with cancer patients and patient advocates for critical review of the study design, data collection instruments, and research findings. Their suggestions for the interview guide helped ensure the questions were clear and relevant. They affirmed our thematic findings, describing them as heartbreaking and familiar, and encouraged our team to consider action-driven efforts to improve early diagnosis.

Despite initiatives aimed to increase population awareness about uterine cancer, such as the Inside Knowledge About Gynecologic Cancer campaign by the Centers for Disease Control and Prevention (29, 30), virtually all respondents in our study reported little or no awareness of uterine cancer symptoms or risk factors. Ironically, this void is somewhat filled by news reports on potentially carcinogenic hair care products and television commercials for class-action lawsuits (31-33). Without standard screening, the early diagnosis of uterine cancer is heavily dependent on patient initiative. Yet our findings affirm previous research identifying a lack of information as a primary contributor to delays in diagnosis (10, 15). There is an urgent need to improve the reach and efficacy of public health campaigns for uterine cancer.

Since most uterine cancer patients are at post-menopausal ages, their healthcare perceptions are shaped by the cumulative and often overlapping lifetime impact of many sociocultural forces. Educational efforts that apply an intersectional (34) approach that acknowledges these factors and incorporates them into tailored interventions and campaigns (25, 35-38) may prove more effective than general messaging, particularly given the subtlety of discrimination in health care (39). In our study, many respondents were eager to share their cancer stories with friends, family members, and their wider communities to break down body taboos or stigmas, offer vital preventative information, and reduce current health disparities. The use of trusted messengers, which can be an effective approach to overcoming mistrust and reaching diverse patient populations (40), may be especially impactful for Black patients, who reported years of racially discriminatory experiences in healthcare settings. Importantly, this patient-centered strategy emphasizes directly addressing factors that contribute to patient hesitation or exclusion, including stigma, discrimination, and fear (26). In addition, clinic-based approaches, such as adoption of proactive screening questionnaires or prompts during patient visits to elicit symptoms, may mitigate patients’ lack of awareness and engage providers in facilitating timely specialty care access for older patients. Likewise, efforts to improve clinician training and patient-clinician communication may help avoid dismissive responses to patients’ reports of pelvic pain or non-specific symptoms and avoid providing ambiguous guidance around abnormal test results and associated monitoring or follow-up care.

Our finding that patients often found rapport with female clinicians and clinicians of color reiterate the importance of a diverse healthcare workforce and trusted community outreach. A nationally representative 2023 Survey on Racism, Discrimination, and Health (39) reported that more than one in five Black adults were treated unfairly by their healthcare provider because of their racial or ethnic background within the past year. In addition, among Black adults who used healthcare in the past three years, 60% reported that at least some of the time, they prepared for possible insults from healthcare providers or a need to take care with their appearance to avoid being treated unfairly during healthcare visits (33). The national survey found more positive interactions between patients and providers when they had a shared racial and ethnic background (33), which aligns with our results indicating that respondents felt more assured when treated by female physicians and/or physicians of color. Hiring and retaining providers who share racial and ethnic backgrounds with patients and building strong local support networks were among the mitigation strategies identified (39) for healthcare institutions to address disparities.

The qualitative data elicited from Black and White patients with uterine cancer provided nuanced information about the sociocultural aspects of patients’ experience that cannot be measured from other data sources. The uncertainty in their responses regarding disparity may reflect several critical research issues to consider. To reduce recall bias, our study interviewed patients within six months after their uterine cancer diagnosis. Many patients were still undergoing active treatment which may have lessened their attention to systemic issues, like healthcare disparity, while living amidst the crisis of cancer. Patients’ reflections regarding disparity might shift over time after they were farther removed from the shock of diagnosis. Future studies assessing patient perspectives after a longer follow-up may provide additional insights. Researchers may also structure conversations about racial disparities differently. Our study respondents were asked a direct question about how race affected their diagnostic experience during the interview. This item was typically met with brief responses but followed with further reflection towards the end of the interview. We recognize that a less direct approach may foster more or different types of discussion (e.g., asking patients to speak generally rather than to their own experiences, or providing patients with a case study or example for reflection).

We recognize other limitations of our study as well. All respondents were recruited from a single tertiary healthcare center located in the Northeast. The data may not reflect patients’ experiences at smaller facilities or institutions elsewhere in the country. Likewise, 54.5% of our respondents had at least a bachelor’s degree, compared to 39.0% of women age 25 or older in the general U.S. population (41), and all respondents in our study were insured. Hence, our data may disproportionately reflect the experiences of patients with higher socioeconomic status, rather than the broader uterine cancer patient population. Our study focused on patients’ perspectives, but providers also play an important role in early diagnosis of uterine cancer (e.g., use of guideline-recommended diagnostic procedures) (8, 9). Future qualitative research ascertaining influencing factors from providers’ perspective would also be insightful. We concur with Najor et al (2023) (25) that it would be advantageous to methodically track time elapses during patient pathways to treatment, as we noticed that our respondents had personalized senses of what is considered a timely response to symptoms, ranging from days to weeks to months. Finally, when arranging interviews, we prioritized respondents’ scheduling convenience over pairing the race between respondent and interviewer. Therefore, some Black respondents were interviewed by a White researcher and some White respondents were interviewed by a Black researcher. These discordances may have affected respondents’ comfort or willingness to share their perspectives.

As uterine cancer incidence continues to increase (42), so must efforts to improve patient outcomes and promote health equity. This study revealed lack of information among patients about uterine cancer and showed how their responses to symptoms and healthcare settings are impacted by cumulative lifetime experience from sexism, ageism, and racism. Efforts to reduce racial disparity in uterine cancer stage at diagnosis should directly address the lack of awareness while acknowledging the overlapping social forces related to individual identities that contribute to patients’ experiences, especially those of older Black female patients.

HIGHLIGHTS.

• Patients were attentive to their symptoms but were unaware they could be signs of uterine cancer, often attributing them to other conditions.

• Patients’ lack of knowledge was compounded by gendered acceptance of discomfort, disconnection from gynecological care, and prior healthcare experiences.

• Patients often viewed racial disparities in early diagnosis through other social determinants of health, which may mask systemic racism in healthcare.

• Patients were sometimes uncomfortable discussing racial disparities but were motivated to improve early diagnosis and cancer care for other women.