uterine cancer

Uterine Cancer Incidence and Deaths on the Rise in US

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The incidence of uterine cancer and deaths from the disease are on the increase, with black women disproportionately affected, warn researchers at the Centers for Disease Control and Prevention (CDC). They call for greater awareness of the symptoms to allow early detection and treatment.

Uterine cancer “is one of the few cancers with increasing incidence and mortality in the United States,” the CDC notes. This reflects, in part, increases in the prevalence of overweight and obesity since the 1980s.

It is the fourth most common cancer diagnosed in US women and is the seventh most common cause of death.

The findings were published online December 7 in the Morbidity and Mortality Weekly Report.

S. Jane Henley, MSPH, from the National Center for Chronic Disease Prevention and Health Promotion, CDC, and colleagues studied the official incidence and mortality rates for uterine cancer from 1999 to 2015/6.

They found that rates of the disease have been increasing by approximately 0.7% per year, with uterine cancer deaths rising by an average of slightly more than 1.0% per year.

Worryingly, in comparision with other groups, black women were more likely to be diagnosed with harder-to-treat forms of the disease and with later-stage disease, in particular in comparision with white women.

“Multifactorial efforts at individual, community, clinical, and systems levels to help women achieve and maintain a healthy weight and obtain sufficient physical activity might reduce the risk for developing uterine cancer,” the authors write.

“Promoting awareness among women and health care providers of the need for timely evaluation of abnormal vaginal bleeding can increase the chance that uterine cancer is detected early and treated appropriately,” they add.

Study Details

The team gathered incidence data from the CDC’s National Program of Cancer Registries and the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program.

In addition, they obtained mortality data from the National Vital Statistics System, which covered 98% of the overall US population for the period 1999 to 2015/2016.

Uterine cancers were classified by histologic site and stage at diagnosis. Individuals were classified as white, black, non-Hispanic American, Indian/Alaska Native (AI/AN), non-Hispanic Asian/Pacific Islander (API), or Hispanic.

The researchers found that in 2015, there were 53,911 new, confirmed cases of uterine cancer, which occurred at a rate of 27 cases per 100,000 women. The rates were highest among white and black women (27 per 100,000 each).

The most commonly reported form the disease was endometrioid carcinoma, which occurred in 68% of women. The proportion was much lower in black women, at 47%. Black women who were more likely to have other carcinomas, carcinosarcomas, and sarcomas.

In non-black women, uterine cancers were diagnosed at the localized stage in 66% to 69% of cases. In black women, that rate was 55%.

Black women are also more likely to be diagnosed with disease of distant stage than other groups, at 16% vs 8% to 10%. This was particularly the case for sarcoma.

Sarcomas were more likely to be diagnosed at the distant stage (36%) than carcinosarcomas (22%), other carcinomas (18%), and endometrioid carcinomas (3%).

The incidence rate of uterine cancers increased between 1999 and 2015 by 12%, or an average of 0.7% per year.

The increase was far higher among AI/AN (53%), black (46%), API (38%), and Hispanic (32%) women than among white women (9%).

In 2016, there were 10,733 deaths due to uterine cancer, at five deaths per 100,000 women. The rate was highest among black women, at nine per 100,000 women.

The rate of uterine cancer deaths increased between 1999 and 2016 by 21%, or 1.1% per year on average.

The increases were higher in API (52%), Hispanic (33%) and black (29%) women than white women (18%). Rates of uterine cancer deaths remained stable in AI/AN women.

Obesity a Contributing Factor

The researchers say that one contributing factor in the increase in incidence could be “excess body weight,” inasmuch as overweight or obese women are two to four times more likely to develop endometrial cancer than women of healthy weight.

“During 2013-2016, approximately 40% of women in the United States had obesity, including 56% of black women and 49% of Hispanic women,” they add.

The team points out that, “as with other cancers, the odds of surviving uterine cancer are much higher when it is detected at an early stage, when treatment is more effective.” The rate of survival is 90% for patients with localized cancers, vs <30% for patients with distant cancers.

“This report found that black women were more likely to receive a diagnosis at distant stage and with more aggressive histologic types than were other women, which might in part account for the higher death rate among black women,” the investigators write.

Uterine Pathology in Women Undergoing Minimally Invasive Hysterectomy Using Morcellation.

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Even though minimally invasive surgery has improved outcomes for hysterectomy, the procedure requires removal of the uterus through small incisions. Morcellation, or fragmentation of the uterus into smaller pieces, is one method to remove the uterus. Recently, concern has been raised that morcellation may result in the spread of undetected malignancies.1

Despite the commercial availability of electric power morcellators for 2 decades, accurate estimates of the prevalence of malignancy at the time of electric power morcellation (herein referred to as morcellation) are lacking,1,2 with single-center studies reporting prevalences from 9 to 100 in 10 000.3,4 We used a large insurance database to investigate the prevalence of underlying cancer in women who underwent uterine morcellation.

The Perspective database was used to identify women who underwent a minimally invasive hysterectomy from 2006-2012. Perspective is an all-payer database including more than 500 hospitals capturing 15% of hospitalizations. Hospitals within this database are more frequently urban teaching centers and located in the southern United States. Data undergo a rigorous quality control process. Use of commercially available morcellators was captured by identification of charge codes.5 The analysis was deemed exempt by the Columbia University institutional review board.

The primary outcome was identification of uterine corpus cancer (all histologies) based onInternational Classification of Diseases, Ninth Revision, coding at surgery. We also examined the occurrence of uterine neoplasms of uncertain malignant potential; malignancies of other parts of the uterus, including cervical cancer, and surrounding adnexal structures (other gynecologic cancer); and endometrial hyperplasia.

Multivariable mixed-effects log-linear models, including clinical and demographic covariates and a random-intercept for the procedural hospital, were developed for uterine cancer and endometrial hyperplasia. The other outcomes were rare and the models did not converge.

All statistical analyses were 2-sided and performed with SAS version 9.4 (SAS Institute Inc). A Pvalue of <.05 was considered statistically significant.

Within the cohort of 232 882 women who underwent minimally invasive hysterectomy from 2006-2012, morcellation was performed in 36 470 (15.7%). Women who underwent morcellation differed in clinical and demographic characteristics from women who did not (eTable in the Supplement). Among those who underwent morcellation, 99 cases of uterine cancer were identified, a prevalence of 27/10 000 (95% CI, 22-32/10 000). Twenty-six cases of other gynecologic malignancies were found (a prevalence of 7/10 000 [95% CI, 4-10/10 000]), 39 uterine neoplasms of uncertain malignant potential (11/10 000 [95% CI, 7-14/10 000]), and 368 cases of endometrial hyperplasia (101/10 000 [95% CI, 91-111 per 10 000]).

Among women who underwent morcellation, advanced age was associated with underlying cancer and endometrial hyperplasia (Table). Compared with women younger than 40 years, the prevalence ratio for a uterine malignancy increased with increasing age from 4.97 (95% CI, 1.91-12.93) in women aged 50 to 54 years, to 19.37 (95% CI, 7.66-48.95) in those aged 55 to 59 years, to 21.36 (95% CI, 7.22-63.21) in those aged 60 to 64 years, and to 35.97 (95% CI, 14.14-91.53) for women aged 65 years or older.
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Table.  Multivariable Models Among Women Who Underwent Morcellation

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Our data demonstrate that uterine cancers occurred in 27 per 10 000 women undergoing morcellation. Other malignancies and precancerous abnormalities were also detected. Although morcellators have been in use since 1993, few studies have described the prevalence of unexpected pathology at the time of hysterectomy.2– 4 Prevalence information is the first step in determining the risk of spreading cancer with morcellation. Although data are limited, women with apparent uterine-confined neoplasms at the time of morcellation have been found to have intraperitoneal tumor dissemination at the time of reexploration.3,6

We recognize a number of limitations including the inability to verify pathological findings, possible misclassification of pathology, potential undercapture of morcellation, and the fact that our findings may not be generalizable to all hospitals. Last, we lack data on long-term follow-up, and the outcome of women with pathological abnormalities who underwent morcellation requires further study. Patients considering morcellation should be adequately counseled about the prevalence of cancerous and precancerous conditions prior to undergoing the procedure.

REFERENCES
1
 Patient safety must be a priority in all aspects of care. Lancet Oncol. 2014;15(2):123.
PubMed   |  Link to Article
2
Kho  KA, Nezhat  CH.  Evaluating the risks of electric uterine morcellation. JAMA. 2014;311(9):905-906.
PubMed   |  Link to Article
3
Seidman  MA, Oduyebo  T, Muto  MG, Crum  CP, Nucci  MR, Quade  BJ.  Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms. PLoS One. 2012;7(11):e50058.
PubMed   |  Link to Article
4
Hagemann  IS, Hagemann  AR, LiVolsi  VA, Montone  KT, Chu  CS.  Risk of occult malignancy in morcellated hysterectomy: a case series. Int J Gynecol Pathol. 2011;30(5):476-483.
PubMed   |  Link to Article
5
Wright  JD, Ananth  CV, Lewin  SN,  et al.  Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309(7):689-698.
PubMed   |  Link to Article
6
Oduyebo  T, Rauh-Hain  AJ, Meserve  EE,  et al.  The value of re-exploration in patients with inadvertently morcellated uterine sarcoma. Gynecol Oncol. 2014;132(2):360-365.
PubMed   |  Link to Article