Non-Hispanic Black Women Have Highest Rates
BETHESDA, MD — The risk of an aggressive endometrial cancer diagnosis varies by race, ethnicity and country of origin, and non-Hispanic Black patients had the highest risk, according to a recent study.
The study published in Gynecologic Oncology investigated the risk of an aggressive endometrial cancer diagnosis by race, ethnicity and country of origin to further explain histologic disparities in different subgroups.1
Study authors are affiliated with Walter Reed National Military Medical Center in Bethesda, MD; Brooke Army Medical Center in San Antonio, TX; Uniformed Services University of the Health Sciences in Bethesda, MD; and The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc. in Bethesda, MD.
In 2023, “an estimated 66,200 people in the United States were diagnosed with uterine corpus cancer.” There has been a considerable “rise in the diagnosis of endometrial cancer in the past two decades, most rapidly among non-white populations and non-endometrioid histology.” However, “precise estimates of the proportion or risk of an aggressive endometrial cancer diagnosis within racial and ethnic groups and subgroups by country of origin are limited,” study authors pointed out.
While “low-grade, early-stage endometrioid endometrial carcinoma is highly curable, aggressive and higher stage endometrial cancers are associated with higher risk of poor outcomes, especially in non-white racial and ethnic groups. Endometrial cancer has a particularly devastating racial disparity in disease presentation at diagnosis and survival,” according to the authors.
Based on previous studies that show the importance of histology in endometrial cancer survival outcomes, the authors wanted to investigate the “distribution and risk of aggressive endometrial cancer histologic subtypes in racially and ethnically diverse patients relative to non-white patients.” They also wanted to study “these risks based on country of origin to determine the similarities and differences within these subgroups,” the authors explained.
This study involved patients diagnosed between 2004 and 2020 with low grade-endometrioid endometrial cancer or an aggressive endometrial cancer including grade 3 endometrioid endometrial cancer, serous carcinoma, clear cell carcinoma, mixed epithelial carcinoma, or carcinosarcoma in the National Cancer Database, a hospital-based registry program representing 70% of incident cancers in the U.S.” The odds ratio and 95% confidence interval for diagnosis of an aggressive endometrial cancer histology were estimated, the authors reported.
Their goal was to “compute accurate estimates of having an aggressive endometrial cancer diagnosis in order to motivate additional attention and research and generate more inclusive clinical trials, guidelines and policies in the U.S. and globally,” according to the study.
The report noted that “risk of an aggressive endometrial cancer diagnosis varied by race, ethnicity and country of origin. Non-Hispanic Black patients had the highest risk, followed by Dominican, South/Central American, Cuban, Korean, Thai, Vietnamese, and Filipino descendants.”
“In our large database study of more than 400,000 patients from the United States with endometrial cancer, we reported that women who self-reported as a racial or ethnic minority were at increased risk of aggressive, high-risk endometrial cancer as compared to non-Hispanic white patients,” Lt. Col. Stuart S. Winkler, M.D., a staff gynecologic oncologist at Brooke Army Medical Center and assistant professor of gynecologic surgery and obstetrics at Uniformed Services University of the Health Sciences, told U.S. Medicine. “Most dramatically, non-Hispanic Black patients were more than three times more likely than non-Hispanic White patients to have an aggressive type of endometrial cancer.”
“For the Hispanic and Asian/Pacific Islander subgroups, our study provided novel granularity on how the risk of these aggressive cancers varied by 14 self-reported countries or regions of origin. For instance, Dominican descendants had almost double the risk of aggressive endometrial cancer compared to non-Hispanic White patients. Hawaiian patients, on the other hand, did not have an increased risk compared to non-Hispanic White patients,” Winkler added.
Lowest Percentage for Non-Hispanic Whites
“Non-Hispanic white patients had the lowest percent, with an aggressive endometrial cancer histology of 30%. Meanwhile, 57% of non-Hispanic Black patients had an aggressive endometrial cancer histology that was a three-fold higher risk over non-Hispanic White patients. In Hispanics, risk varied by race (32% Hispanic-white to 48% Hispanic-Black) and country of origin (34% Mexican to 45% Dominican),” the authors pointed out.
The article advised that Black women are disproportionately affected by endometrial cancer, explaining, “Since 2002, EC has been more common among Black women than white women, with a higher death rate (8.7/100,000 vs 4.4/100,000). Black women also have a higher risk for high-grade EC compared to white and Hispanic women on the order of 2–3-fold. The hysterectomy (surgical removal of the uterus)-adjusted incidence rate for high-grade EC has increased steadily over the last 15 years for Black women, with poorer survival than whites, even when matched by stage.”
The researchers suggested the disproportional affect on Black women could increase over time, adding that the most common symptom of EC is post-menopausal bleeding (PMB). “Black women with post-menopausal bleeding (PMB) are less likely to undergo guideline-concordant diagnostic work-up, which further associates with higher stage and metastasis when a diagnosis is finally established,” they wrote. “Young Black women (<50 years) have higher EC mortality than White women of the same age. “
“Risk also varied in Asian descendants (33% Indian Pakistani to 39% Korean) or those from Pacific Islands (30% Hawaiian to 37% Samoan). Lastly, 32% of American Indian/Alsakan Native patients had an aggressive endometrial cancer histology and an age-adjusted risk of 1.30 compared to non-Hispanic white patients,” they added.
“While prior studies had shown that Black patients are more likely to have aggressive endometrial cancers compared to White women, our study showed that nearly all non-White minority subgroups are at increased risk of aggressive endometrial cancer,” Winkler said. “This descriptive study provided new information on these risks that have not previously been reported in detail. We don’t yet fully understand the roles that genetic ancestry, molecular alterations, and structural determinants of health play here, but race is a self-reported historic political, economic, and social construct. Race often simplifies highly complex ancestry and biology with migration patterns, exposures, lifestyles, structural determinants of health, neighborhood factors and sociocultural influences. The roles that racism, oppression, forced migration, systems and structures play in the observed disparities between racial and ethnic groups and country of origin subgroups deserve attention.”
There were 439,439 patients with endometrial cancer evaluated in the study, including 343,868 non-Hispanic white, 48,897 non-Hispanic Black, 30,013 Hispanic, 15,015 Asian/Pacific Islander and 1,646 American Indian/Alaskan Native patients.
The odds ratio (95% confidence interval) for an aggressive endometrial cancer diagnosis was 3.07 (3.01–3.13) for non-Hispanic Black, 1.08 (1.06–1.11) for Hispanic, 1.17 (1.13–1.21) for Asian/Pacific Islander and 1.07 (0.96–1.19) for American Indian/Alaskan Native, relative to non-Hispanic White patients, according to the study.
Analyses by country of origin found the diversity in the odds ratio for an aggressive endometrial cancer diagnosis to be as follows: Hispanic (1.18 for Mexican to 1.87 for Dominican), Asian (1.14 Asian Indian-Pakistani to 1.48 Korean) and Pacific Islander (1.00 for Hawaiian to 1.33 for Samoan) descendants, the authors explained.
The authors also found that “Hispanic, Asian/Pacific Islander and American Indian/Alaskan Native patients were diagnosed five years younger than non-Hispanic White patients, and the risk for an aggressive endometrial cancer histology were all significantly higher than non-Hispanic White patients after correcting for age. In addition, insurance status was an independent risk factor for aggressive histology.”
VA data shows that more than 40% of women who use VHA health services identify as a racial or ethnic minority, so this population of veterans is certainly at risk, Winkler pointed out.
“Given the racial and ethnic diversity of the military and veteran populations and the higher proportion of racial and ethnic minorities, healthcare professionals working in the VA, MHS and IHS care need to be aware that [patients who are a racial or ethnic minority] are at higher risk for these aggressive endometrial cancers,” Winkler said. “Unfortunately, these cancers may be less likely to present with postmenopausal bleeding compared to low-grade endometrial cancer and may be less often associated with a thickened endometrial stripe on ultrasound. While there is no screening test for endometrial cancer, a greater degree of vigilance by the healthcare team is warranted for these patients at higher risk for aggressive endometrial cancer.”
Winkler suggested for healthcare professionals to consult with the National Comprehensive Cancer Network and the Society of Gynecologic Oncology for guidelines on staging, molecular assessments and treatment recommendations.
A recent review article on endometrial cancer published in Cancer Control also reported that “endometrial cancer, the most common gynecologic cancer in the U.S. which has had significant increases in aggressive tumors and death from disease over the last several decades, has mostly affected Black women.”
That article noted that “symptom awareness, lack of treatment access and failure of providers to provide guideline-concordant care are some of the drivers” behind these increases. The review explored unique considerations in early detection, risk and awareness of endometrial cancer in Black women and focused on specific individual-level influences that impact disease diagnosis and care-seeking among Black women. This information is crucial for developing knowledge awareness and empowerment programs for diverse communities at risk, according to the study.2
“The classic teaching in medical school is that endometrial cancer is most commonly low-grade and curable with surgery,” Winkler explained. “While this is true for White women, our study showed that over half of the endometrial cancers diagnosed in Black women were high-risk. Many other groups have documented the rising trends in both endometrial cancer incidence and mortality trends in the U.S., most notably in non-White patients. In 2024, the mortality associated with endometrial cancer is estimated to eclipse that for ovarian cancer for the first time in the U.S. We and others have also shown that many Black patients with endometrial cancer present with aggressive molecular alterations and subtypes compared with White patients with endometrial cancer.”
- Winkler SS, Tian C, Casablanca Y, Bateman NW, et. Al. Racial, ethnic and country of origin disparities in aggressive endometrial cancer histologic subtypes. Gynecol Oncol. 2024 Jan 25;184:31-42. doi: 10.1016/j.ygyno.2024.01.009. Epub ahead of print. PMID: 38277919.
- Schlumbrecht M, Wright K, George S. Unique Considerations in Early Detection, Risk, and Awareness of Endometrial Cancer in Black Women. Cancer Control. 2023 Jan-Dec;30:10732748231202952. doi: 10.1177/10732748231202952. PMID: 37732413; PMCID: PMC10515581.