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American Journal of Epidemiology logoLink to American Journal of Epidemiology
. 2024 Jul 3;194(1):103–113. doi: 10.1093/aje/kwae178

Trends in endometrial cancer incidence in the United States by race/ethnicity and age of onset from 2000 to 2019

Victoria E Rodriguez 1,✉, Sora Park Tanjasiri 2,3, Annie Ro 4, Michael A Hoyt 5,6, Robert E Bristow 7, Alana M W LeBrón 8,9,10
PMCID: PMC12034838  PMID: 38960701

Abstract

Endometrial cancer is one of few cancers that has continued to rise in incidence over the past decade, with disproportionate increases in adults younger than 50 years old. We used data from the Surveillance, Epidemiology, and End Results Registry (2000-2019) to examine endometrial cancer incidence trends by race/ethnicity and age of onset among women in the United States. Case counts and proportions, age-adjusted incidence rates (per 100 000), and average annual percent changes were calculated by race/ethnicity, overall and stratified by age of onset (early vs late). We found a disproportionate increase in endometrial cancer incidence among women of color, for both early and late onset endometrial cancer. The highest increases in early onset endometrial cancer (<50 years old) were observed among American Indian/Alaska Native women (4.8), followed by Black (3.3), Hispanic/Latina (3.1), and Asian and Pacific Islander women (2.4), whereas White women (0.9) had the lowest increase. Late onset (≥50 years old) endometrial cancer incidence followed a similar pattern, with the greatest increases for women of color. The increasing burden of endometrial cancer among women of color, particularly those younger than 50 years old, is a major public health problem necessitating further research and clinical efforts focused on health equity.

This article is part of a Special Collection on Gynecological Cancer.

Keywords: endometrial cancer, early onset, racial/ethnic disparities

Introduction

Endometrial cancer, cancer that begins in the lining of the uterus, is the most common gynecologic cancer and the fourth most common cancer among women in the United States (US).1 Over the last decade, cancer incidence rates have been declining, but endometrial cancer is one of the few cancers that has continued to rise in incidence.1,2 Increases in endometrial cancer incidence are hypothesized to be linked with increased exposures to estrogens (ie, early age at menarche, late age at menopause, nulliparity, and obesity) and overall increased lifespan of individuals.1-10 Further, medical comorbidities such as diabetes, hypertension, and metabolic syndrome have been associated with endometrial cancer risk.6,7,9-12

Along with rises in overall endometrial cancer incidence, endometrial cancer has been disproportionately rising in adults younger than 50 years old.5 While age at diagnosis is an important prognostic factor and younger age at diagnosis is usually associated with improved outcomes and cancer survival,13-15 early onset cancers are particularly concerning as there are considerable consequences for survivors’ subsequent health and quality of life. For instance, past studies have found that individuals diagnosed with endometrial cancer are at an increased risk for developing secondary cancers.16-21 One population-based study conducted in Taiwan found that the overall risk of developing a secondary cancer was higher for women who were diagnosed with endometrial cancer before 50 years of age.17 Another population-based study on endometrial cancer conducted in Germany and Sweden found elevated risk for secondary tumors among women diagnosed with endometrial cancer before 55 years of age.19 Additionally, endometrial cancer survivors are at risk for various long-term physical effects and psychological symptoms due to their cancer and cancer treatment.22-28

Over the last few decades in the US, endometrial cancer incidence has been highest among non-Hispanic White women and postmenopausal women over the age of 60.6,29,30 However, recent studies have noted a disproportionate rise in endometrial cancer incidence for women of color and younger premenopausal and perimenopausal women.2,4,5,31,32 Several population-based studies have examined endometrial cancer incidence trends over the last few decades and have consistently found increases for women of color.2,31,32 For instance, one study found that both early onset and late onset endometrial cancer incidence rates increased between 1995 and 2018 among non-Hispanic Asian and Pacific Islander, non-Hispanic Black, Hispanic/Latina, and non-Hispanic White women.31 Another study found that overall endometrial cancer incidence rates rose between 2000 and 2011 among Asian, non-Hispanic Black, Hispanic/Latina, and non-Hispanic White women.2 Additionally, another study found that despite having lower overall incidence rates between 1974 and 2003, American Indian/Alaska Native women had significantly larger increases in uterine cancer incidence compared to White women.32 Few population-based studies have also accounted for hysterectomy prevalence in their examination of uterine and endometrial cancer incidence.8,33,34 One study found that hysterectomy-corrected incidence rates for uterine cancer was higher than the uncorrected rate, with the fastest increases observed among Hispanic/Latina, Asian, and Black women.33 A recent study also found that incidence of uterine cancer significantly increased for Black women after correcting for hysterectomy. Lastly, one study that focused on women younger than 50 found that endometrial cancer incidence was higher for Black and Hispanic/Latina women after hysterectomy-corrected rates, with rates remaining stable for White women.8

While some literature has examined racial/ethnic disparities in endometrial cancer incidence,2,31 less is known about the increasing burden of endometrial cancer among a wider segment of racially minoritized groups over time. As the United States has a steadily growing racially minoritized population,35 it is important to understand the increasing burden of endometrial cancer for women of color as past research has documented racial/ethnic disparities in the diagnosis, treatment, and survival of endometrial cancer. For instance, Black and Hispanic/Latina women are diagnosed at more advanced stages and with more aggressive histological subtypes of endometrial cancer compared to White women.13,14,36-42 Moreover, American Indian/Alaska Native, Black, and Hispanic/Latina women are more likely to experience treatment delays, less likely to receive minimally invasive techniques such as laparoscopic hysterectomies, less likely to undergo adequate lymph node sampling, and less likely to receive guideline-concordant care compared to White women.36,41-47 Additionally, racially minoritized groups such as American Indian, Asian American, Black, Hispanic/Latina, Native Hawaiian, and Pacific Islander women are less likely to be included in federally funded clinical trials compared to White women.41 Further, Black women consistently exhibit lower endometrial cancer survival rates across all ages and cancer stages relative to White woman.9,13,29,40-42,48-50 Thus, as women of color in the United States often experience systemic inequities in cancer diagnoses, treatment, and research, understanding racial inequities in endometrial cancer by age of onset may help to focus cancer equity efforts.

Examining endometrial cancer trends by both race/ethnicity and age of onset enables identification of racial/ethnic groups who have increasing endometrial cancer risk while simultaneously observing which groups are experiencing faster increases in early onset endometrial cancers. Thus, examining these trends will allow us to assess the burden of disease across and within racial/ethnic groups in order to inform targeted public health intervention strategies and preventive clinical practices and screening measures. This study examines endometrial cancer incidence and incidence trends by race/ethnicity and age of onset among women in the US.

Methods

Data and study variables

We used data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) national cancer registry to analyze trends in endometrial cancer incidence from 2000 to 2019. While 2020 data were available in the registry, we ended our study period in 2019, as 2020 incidence rates are likely inaccurate due to delayed diagnoses and decreased access to routine or preventive care during the COVID-19 pandemic.51,52 Endometrial cancer incidence was obtained from the SEER 22 database, which covers approximately 47.9% of the US population.53 The SEER database compiles population-based cancer registry data throughout the US and includes information on demographics, cancer characteristics, initial cancer treatment, and mortality.54 Endometrial cancer cases were identified using the SEER primary site code for endometrial cancers (C54.1).55 Race/ethnicity, as classified in the SEER registry, includes 6 mutually exclusive categories including non-Hispanic American Indian/Alaska Native (AI/AN), non-Hispanic Asian and Pacific Islander (API), non-Hispanic Black (Black), Hispanic/Latina (Hispanic/Latina), non-Hispanic White (White), and non-Hispanic unknown (unknown). Cases with unknown race/ethnicity (n = 2352) included individuals who did not have descriptions of race in their medical records and were excluded from analyses.56 Age of onset was dichotomized into early onset (<50 years old) and late onset (≥50 years old),5 captured by age at diagnosis as reported in the SEER registry.

Data analysis

Using SEER*Stat 8.4.1.2 software,57 we abstracted a total of 394 472 endometrial cancer cases diagnosed in the US between 2000 and 2019. Overall case counts and proportions of endometrial cancer cases within 5-year increment age groups were calculated. Next, we calculated crude numbers of incident endometrial cancers and annual overall age-adjusted incidence rates (AAIRs) per 100 000 population. Age-adjusted incidence rates were adjusted to the 2000 US standard population.58 We examined AAIRs and 95% confidence intervals by racial/ethnic group, overall and stratified by age of onset.

In order to characterize the trends in endometrial cancer incidence rates over time, we used the JoinPoint regression program version 5.0.259 to calculate the average annual percent change (AAPC) of AAIRs. The AAPC calculates a summary measure of annual percent changes over a specified time period,60,61 which provides an overall picture of average growth or decline in incidence rates over the time period. For our study, the AAPC was calculated within each racial/ethnic group and stratified by age of onset between 2000 and 2019, with year of diagnosis as the primary predictor variable. All statistical tests were 2-sided, and statistical significance was set at P < .05.

Results

Cases of endometrial cancer diagnoses by race/ethnicity and age of onset

Between 2000 and 2019, there were 394 472 cases of all endometrial cancers, 51 546 cases of early onset endometrial cancers, and 342 926 cases of late onset endometrial cancers diagnosed among women in the US, as captured by the SEER database, which represents nearly half of the US population. Table 1 presents overall case counts and proportions of cancer diagnoses by age of onset and age groups among all racial/ethnic groups combined and by each respective racial/ethnic group. Among all racial/ethnic groups, 13.1% of endometrial cancers diagnosed during the study period were early onset, while 86.9% were late onset. Early onset cancers among all racial/ethnic groups were highest among the 45-49 age group (5.9%), followed by the 40-44 age group (3.5%). Looking across racial/ethnic groups, early onset cancers were highest among Hispanic/Latina (26%), AI/AN (24.4%), and API (23.2%) women; these groups had nearly double the proportion of early onset cancers compared to Black (10.7%) and White (10.2%) women. Among all racial/ethnic groups, late onset cancers were highest among the 60-64 age group (17%), followed by the 55-59 age group (15.8%), and the 65-69 age group (15.1%). Late onset cancers were highest among White women (89.9%), followed by Black women (89.3%). Additionally, AI/AN, API, and Hispanic/Latina women had a higher proportion of late onset cancers within younger age groups (eg, 50-54; 55-59 years) compared to Black and White women.

Table 1.

Endometrial cancer case counts and proportions by race/ethnicity and age of onset, surveillance, epidemiology, and end results (SEER) 22 database, United States, 2000-2019 (n = 394 472).

    All racial/ethnic groups (N = 394 472) American Indian/Alaska native, NH (AI/AN) (N = 1735) Asian and Pacific Islander, NH (API) (N = 23 494) Black, NH (N = 38 647) Hispanic/Latina (N = 49 659) White, NH (N = 280 937)
  Age groups n % n % n % n % n % n %
Early onset endometrial cancers (< 50 years) 10-14 years 4 0.00 0 0.00 0 0.00 1 0.00 1 0.00 2 0.00
15-19 years 42 0.01 0 0.00 3 0.01 4 0.01 19 0.04 16 0.01
20-24 years 384 0.10 2 0.12 37 0.16 49 0.13 174 0.35 122 0.04
25-29 years 1668 0.42 18 1.04 155 0.66 158 0.41 721 1.45 616 0.22
30-34 years 4353 1.10 49 2.82 467 1.99 431 1.12 1598 3.22 1808 0.64
35-39 years 8119 2.06 90 5.19 873 3.72 709 1.83 2500 5.03 3947 1.40
40-44 years 13 710 3.48 111 6.40 1464 6.23 1086 2.81 3436 6.92 7613 2.71
45-49 years 23 266 5.90 153 8.82 2444 10.40 1705 4.41 4476 9.01 14 488 5.16
Total 51 546 13.1 423 24.4 5443 23.2 4143 10.7 12 925 26.0 28 612 10.2
Late onset endometrial cancers (≥ 50 years) 50-54 years 42 270 10.72 237 13.66 3629 15.45 3022 7.82 6358 12.80 29 024 10.33
55-59 years 62 431 15.83 304 18.52 4176 17.77 5580 14.44 8009 16.13 44 362 15.79
60-64 years 66 909 16.96 254 14.64 3549 15.11 7691 19.90 7445 14.99 47 970 17.08
65-69 years 59 411 15.06 221 12.74 2732 11.63 7118 18.42 6083 12.25 43 257 15.40
70-74 years 44 343 11.24 135 7.78 1804 7.68 4977 12.88 4073 8.20 33 354 11.87
75-79 years 31 281 7.93 77 4.44 1150 4.89 3118 8.07 2477 4.99 24 459 8.71
80-84 years 20 636 5.23 62 3.57 589 2.51 1821 4.71 1423 2.87 16 741 5.96
85+ years 15 645 3.97 22 1.27 422 1.80 1177 3.05 866 1.74 13 158 4.68
Total 342 926 86.9 1312 75.6 18 051 76.8 34 504 89.3 36 734 74.0 252 325 89.9
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Abbreviation: NH, non-Hispanic.

Examining patterns within each racial/ethnic group, the highest proportion of early onset cancers among AI/AN women was in the 45-49 age group (8.8%), followed by age 40-44 (6.4%), and age 35-39 (5.2%). The highest proportion of late onset cancers among AI/AN women was among the 55-59 age group (18.5%), followed by age 60-64 (14.6%), and age 50-54 (13.7%). Among API women with early onset cancers, the largest proportion of diagnoses were among the 45-49 age group (10.4%), followed by age 40-44 (6.2%). Late onset cancers among API women were highest among the 55-59 age group (17.8%), followed by age 50-54 (15.5%), and age 60-64 (15.1%). Among Black women, early onset cancers were highest in the 45-49 age group (4.4%). However, a larger proportion of endometrial cancer cases among Black women were represented within late onset cancers; the majority were within the 60-64 age group (19.9%), followed by age 65-69 (18.4%), and age 55-59 (14.4%). For Hispanic/Latinas, early onset cancers were diagnosed at earlier ages, with 9% representing the 45-49 age group, followed by age 40-44 (6.9%), and age 35-39 (5%). Late onset cancers among Hispanic/Latina women were highest in the 55-59 age group (16.1%), followed by age 60-64 (15%), and age 50-54 (12.8%). Lastly, White women with early onset cancers were most represented in the 45-49 age group (5%). White women with late onset cancers were largely represented in the 60-64 age group (17.1%), followed by age 55-59 (15.8%), and age 65-69 (15.4%).

Annual age-adjusted incidence of endometrial cancer

Annual age-adjusted incidence rates (AAIRs) between 2000 and 2019 by race/ethnicity and age of onset are displayed in Figure 1. Table 2 presents the age-adjusted incidence rates by race/ethnicity, age of onset, and year of diagnosis between 2000-2019. Table S1 presents the corresponding case counts for our study period. Among all racial/ethnic groups between 2000 and 2019, endometrial cancer incidence increased from 11.4 to 13.8 per 100 000 population. When examining endometrial cancer incidence by race/ethnicity, all racially minoritized groups had a higher increase in overall endometrial cancer incidence than White women: 9.9 to 15.5 for Black women; 6.7 to 12.4 for AI/AN women; 7.3 to 12.1 for API women; 8.9 to 13.3 for Hispanic/Latina women; and 12.3 to 13.7 for White women.

Figure 1.

Figure 1

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Age-adjusted endometrial cancer incidence rate per 100 000 by race/ethnicity, age of onset, and year of diagnosis in the surveillance, epidemiology, and end results (SEER) 22 database, United States, 2000-2019. A) all racial/ethnic groups; B) non-Hispanic American Indian/Alaska Native (AI/AN); C) non-Hispanic Asian and Pacific islander (API); D) non-Hispanic Black; E) Hispanic/Latina; F) non-Hispanic White.

Table 2.

Endometrial cancer annual age-adjusted incidence rates per 100 000 by race/ethnicity, age of onset, and year of diagnosis, surveillance, epidemiology, and end results (SEER) 22 database, United States, 2000-2019 (n = 394 472).

  Overall Early onset (< 50 years old) Late onset (≥ 50 years old)
Year of DX All R/E AI/AN, NH API, NH B, NH H/L W, NH ALL R/E AI/AN, NH API, NH B, NH H/L W, NH ALL R/E AI/AN, NH API, NH B, NH H/L W, NH
2000 11.4 6.7 7.3 9.9 8.9 12.3 2.2 1.5 2.7 1.2 2.2 2.3 35.8 20.6 19.6 32.6 26.6 38.5
2001 11.9 7.4 7.5 10.4 8.8 12.9 2.3 3.5 2.7 1.6 2.3 2.4 37.3 17.9 20.3 33.4 26.0 40.6
2002 11.7 8.6 7.7 10.2 9.2 12.6 2.3 2.7 2.8 1.5 2.3 2.4 36.5 24.3 20.6 33.0 27.3 39.5
2003 11.4 7.5 8.0 10.4 90 12.2 2.3 2.1 2.7 1.3 2.3 2.4 35.5 21.7 21.8 34.3 26.6 38.1
2004 11.6 6.6 8.6 10.6 9.3 12.3 2.4 1.9 3.1 1.5 2.4 2.5 35.6 19.1 23.2 34.7 27.7 38.0
2005 11.7 7.5 8.4 10.6 9.4 12.4 2.4 1.9 3.1 1.4 2.5 2.5 36.0 22.5 22.3 34.9 27.8 38.6
2006 11.8 7.5 8.7 11.0 9.4 12.7 2.5 2.3 2.6 1.6 2.6 2.6 36.5 21.5 24.6 35.5 27.4 39.2
2007 11.9 10.1 9.2 11.4 9.3 12.7 2.4 3.5 2.9 1.6 2.4 2.5 36.9 27.5 26.0 37.4 27.5 39.4
2008 12.2 8.3 9.2 12.0 9.6 13.0 2.6 4.2 3.0 1.7 2.6 2.7 37.5 19.3 25.6 38.8 28.1 40.2
2009 12.4 10.6 9.7 12.2 10.2 13.1 2.6 3.1 3.2 1.7 2.8 2.6 38.3 30.3 27.0 39.8 29.7 40.8
2010 12.4 11.7 10.0 12.1 10.1 13.1 2.7 4.5 3.1 1.8 2.8 2.7 38.1 30.7 28.1 39.0 29.4 40.6
2011 12.6 10.8 9.7 13.0 10.7 13.1 2.6 3.9 3.2 1.7 2.9 2.6 38.7 28.9 27.0 42.4 31.3 40.9
2012 12.9 10.5 9.9 13.5 11.1 13.4 2.8 4.7 3.3 2.2 3.1 2.6 39.4 25.9 27.3 43.1 32.4 41.7
2013 12.9 15.0 10.7 13.1 11.4 13.4 2.8 5.8 3.5 2.0 3.1 2.7 39.5 39.4 29.8 42.3 33.3 41.5
2014 13.1 9.5 10.3 13.9 11.5 13.6 2.9 3.8 3.4 2.2 3.3 2.8 40.0 24.6 28.8 44.9 33.2 42.0
2015 13.2 10.9 10.8 13.7 11.9 13.6 3.0 2.7 3.3 2.2 3.4 2.9 39.9 32.6 30.5 44.1 34.3 41.7
2016 13.7 12.6 10.7 14.4 12.4 14.1 3.1 5.3 3.3 2.0 3.7 2.9 41.6 32.0 30.4 47.0 35.4 43.5
2017 13.5 10.8 11.8 14.9 12.1 13.8 3.0 3.0 3.7 2.4 3.5 2.8 41.2 31.1 33.2 47.7 34.8 42.7
2018 13.7 13.9 12.0 15.0 12.7 13.7 3.2 5.5 4.1 2.3 3.8 2.8 41.3 36.1 33.1 48.3 36.3 42.4
2019 13.8 12.4 12.1 15.5 13.3 13.7 3.3 6.2 4.1 2.4 4.1 2.8 41.6 29.0 33.2 49.9 37.5 42.3
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Abbreviations: DX, Diagnosis; R/E, Racial/Ethnic Groups; NH, non-Hispanic; AI/AN; American Indian/Alaska Native; API, Asian and Pacific Islander; B, Black; H/L, Hispanic/Latina; W, White.

Increases in early onset endometrial cancers were also observed among all racial/ethnic groups. The highest increases in early onset endometrial cancers were observed among AI/AN women, followed by Hispanic/Latina women: 1.5 to 6.2 for AI/AN women; 2.2 to 4.1 for Hispanic/Latina women; 2.7 to 4.1 for API women; 1.2 to 2.4 for Black women; and 2.3 to 2.8 for White women. Additionally, increases in endometrial cancer incidence among all racial/ethnic groups were seen among late onset endometrial cancers. Increases in late onset endometrial cancers were highest among Black women, followed by API women: 32.6 to 49.9 for Black women; 19.6 to 33.2 for API women; 26.6 to 37.5 for Hispanic/Latina women; 20.6 to 29.0 for AI/AN women; and 38.5 to 42.3 for White women. Notably, White women had the smallest increases in overall, early onset, and late onset endometrial cancer incidence.

Average annual percent change of endometrial cancer incidence

Lastly, between 2000 and 2019 we found significant average annual percent changes (AAPCs) among all racial/ethnic groups (see Figure 2). Among all endometrial cancers regardless of age of onset, the highest increases in AAPCs were observed among AI/AN women (3.4), followed by API (2.6), Black (2.5), Hispanic/Latina (2.1), and White (0.7) women; all of which were statistically significant. Early onset endometrial cancers had significant AAPCs for all racial/ethnic groups with the highest increases among AI/AN women (4.8), followed by Black (3.3), Hispanic/Latina (3.1), API (2.4), and White (0.9) women. Lastly, there were significant increases in AAPCs for late onset cancers for all racial/ethnic groups. The highest AAPCs for late onset cancers were observed among API women (2.9), followed by AI/AN (2.8), Black (2.4), Hispanic/Latina (1.9), and White (0.5) women. Overall, our findings show a pattern of a disproportionate increasing growth of endometrial cancer incidence for women of color. This pattern holds when looking at overall endometrial cancers and those stratified by early and late onset.

Figure 2.

Figure 2

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Average annual percent change (AAPC) of age-adjusted endometrial cancer incidence rates per 100 000 among by race/ethnicity and age of onset, 2000-2019 in the surveillance, epidemiology, and end results (SEER) 22 database. *Indicates statistical significance; early onset endometrial cancers encompass cancers diagnosed before 50 years of age; late onset endometrial cancers encompass cancers diagnosed at or after 50 years of age. Abbreviations: AAPC, average annual percent change; NH, non-Hispanic.

Discussion

In this study, we examined trends in endometrial cancer incidence over the last 2 decades by race/ethnicity and age of onset. Utilizing a large population-based data set, this study responds to the critical need to examine trends and disparities in endometrial cancer incidence among racially minoritized women in the US, particularly those experiencing increases in early onset endometrial cancers. Further, this study focuses on comparisons in endometrial cancer incidence between and within racial/ethnic groups in order to illustrate points of intervention for future research and clinical practice that consider both race/ethnicity and age of onset. Our findings highlight the need to shift our conceptualization and understanding of endometrial cancer as one that is increasingly burdening younger women, particularly women of color. There are 3 key findings in our study which we unpack below.

Overall increases in endometrial cancer incidence among women of color

First, our findings indicated a general increasing trend in overall endometrial cancer incidence among all racial/ethnic groups during the study period, which is aligned with literature.2,31,33,34 However, we found that there were disproportionate increases in endometrial cancer incidence for women of color compared to White women. Our findings are comparable to past literature that found increases in endometrial cancer incidence for all racial/ethnic groups, with the highest and most rapid increases among women of color.2,33,34 Notably, our study extends this literature by including AI/AN women into our study population. Past research has indicated that the increasing trends in endometrial cancer incidence for women of color may be driven by increases in specific histological subtypes.33,34 For instance, 2 studies that examined uterine cancer incidence between 2000 and 2016 found that there were increasing trends in incidence for aggressive nonendometrioid subtypes, particularly among Black women.33,34 Future research is needed to understand the factors driving increases in endometrial cancer incidence for Black, AI/AN, Hispanic/Latina, and API women.

Disproportionate impact of early onset endometrial cancer among women of color

Second, we found that women of color were disproportionately impacted by increases in early onset endometrial cancers. Compared to White women, all racially minoritized groups had nearly 3 to 5 times the change in early onset incidence. Our findings are in line with a recent study examining trends in early onset cancers which found comparable increases for racially minoritized groups; however, our study found modestly lower increases for White women.31 Our findings also align with another study that reported significant increases in uterine cancer for women under 44 years old, with the highest increases observed within ages 20-24 and 25-29.34 Thus, our study builds upon this previous literature and shows the importance for future work to utilize smaller segments of age groups when examining early onset endometrial cancer trends by race/ethnicity in order to understand and mitigate the factors that are driving these increasing trends.

Our finding that AI/AN women had the highest growth in early onset endometrial cancer incidence compared to other racial/ethnic groups contribute to a small body of literature that examines endometrial cancer incidence and trends for AI/AN women.32,47,62 Specifically, we found that almost a quarter of endometrial cancer cases among AI/AN women were early onset, with the highest proportions occurring within the 35-49 age group. Our findings are in congruence with studies indicating that AI/AN women are diagnosed with uterine cancer at younger ages,47,63 have a higher incidence of early onset uterine cancers,62 and have increasing trends in early onset uterine cancers compared to White women.32 Together, our findings indicate that AI/AN women are an important group to focus future research and clinical attention, particularly for early onset endometrial cancers.

Additionally, our findings that early onset cancers are on the rise for Black women align with recent literature.31 This is an important finding because as younger age at diagnosis is often considered a protective factor for improved prognosis and outcomes,13-15 worse survival has been observed among Black women across all ages compared to White women.13 Further, one study found that Black women under 50 years old were more likely to present with aggressive and advanced tumors compared to their White counterparts.14 Hence, it is important to focus future research upon and be aware of the rising trends in early onset cancers for Black women in order to provide equitable and timely diagnosis and treatment, as they present with more aggressive and advanced stage of disease.43,50

Aligned with past literature,31 our findings indicate that early onset endometrial cancer is also on the rise for Hispanic/Latina and API women. Over a quarter of endometrial cancers diagnosed among Hispanic/Latina women in our sample were early onset, the highest among all racial/ethnic groups. Notably, Hispanic/Latina women had the highest proportions of early onset cancers occurring within the 35-49 age group. Among API women, over 20% of endometrial cancers diagnosed were early onset, and the highest proportion of diagnoses occurred between 40-49 years old. Hence, our study supports past research that found Hispanic/Latina and Asian women are diagnosed at younger ages compared to White women.4,36,37,63,64 As endometrial cancer is largely diagnosed in postmenopausal women with the presence of abnormal bleeding,46 our findings suggest that it is important for clinicians to be aware of the increase in early onset cancers for Hispanic/Latina and API women in order to provide equitable and tailored preventive and screening practices for younger premenopausal and perimenopausal women. Overall, more research is needed to understand the factors contributing to these increases in early onset cancers for women of color.

Disproportionate impact of late onset endometrial cancer among women of color

Third, across racial/ethnic groups, there were increases in late onset endometrial cancer, with the sharpest increases among women of color; our findings are in line with recent research that examined trends in late onset endometrial cancers.31 Though the change in late onset cancers was not as high as we found for early onset cancers, the disproportionate growth among women of color compared to White women is concerning given persistent patterns of racial inequities in healthcare quality and accessibility.29,44,45,49 As the majority of endometrial cancers are diagnosed at late onset,6 the increases among women of color should be acknowledged for clinicians and future preventive efforts. Further, as stated previously, the factors contributing to these increases are particularly important for future research to examine for women of color. Additionally, within-group observations indicate that AI/AN, API, and Hispanic/Latina women have a larger proportion of late onset cancers diagnosed between 50-69 years whereas Black and White women have a larger proportion of late onset cancer diagnoses between 55-74 years. These age differences in diagnoses for late onset cancers among women of color is an important consideration to improve long-term outcomes and survival and future research should work towards understanding these racial/ethnic differences.

Strengths and limitations

This study has several strengths that should be noted. First, the SEER registry involves a large sample size, representing nearly half of the US population. Second, the registry allows for examination of incidence rates and incidence trends among multiple racial/ethnic groups. The inclusion and representation of these racially minoritized populations is important to understand the impact that endometrial cancer has among women of color in order to focus future research and preventive interventions on those most at risk. Third, research often excludes AI/AN populations from population-based research due to low sample sizes; however, our study adds to a small body of literature that indicates the importance of focusing endometrial cancer research among AI/AN populations due to the overall increases in endometrial cancer incidence and disproportionate burden of growth in early onset cancers.

Despite these strengths, our study has limitations that should be acknowledged. First, there may have been misclassification of race/ethnicity, as SEER uses registry reported race/ethnicity as opposed to a person’s self-reported racial/ethnic identity. Second, we were unable to disaggregate incidence rates and trends for subgroups of API and Hispanic/Latina populations. Future research should work towards disaggregating these groups in order to examine which subgroups are at most risk for endometrial cancer growth, as not all subgroups may be experiencing the same increasing incidence trends. Third, there are limitations of using population-based cancer registries in assessing the overall burden of cancer incidence for AI/AN populations, as we may be underestimating the true endometrial cancer incidence for this group due to problems with identification of AI/AN individuals in cancer registries and numerator-denominator bias.65 Future work should continue to expand cancer surveillance research on AI/AN populations while acknowledging limitations in cancer registry data and including methodological strategies to improve data for this group. Fourth, the SEER database does not collect information related to hysterectomy prevalence, and therefore the findings presented here likely underestimate the true incidence of endometrial cancer as we cannot allow for hysterectomy correction. Past studies have indicated that correction for hysterectomy allows for more accurate reporting of endometrial cancer incidence rates, particularly among Black, Hispanic/Latina, and American Indian/Alaska Native populations, as hysterectomy rates in these populations are higher compared to White women, which may be linked with injustices in health care experiences among women of color.8,33,34,66-68 Future research should incorporate correction for hysterectomy prevalence, and population-based data sets should work to routinely include this data so as to accurately present the impact that endometrial cancer has on racially minoritized groups.

Conclusions

Overall, we found that endometrial cancer incidence has risen over the past 2 decades with a disproportionate growth among racially minoritized women, suggesting that endometrial cancer is a growing public health issue for which racial/ethnic inequities are widening. Additionally, there was a disproportionate burden of early onset cancers for women of color. Further research is needed among women of color to understand the underlying factors contributing to these increases, both at structural and individual levels.69-72 Moreover, clinicians should be aware of the rising trends in endometrial cancer incidence among women of color, particularly the groups who have higher increases at younger ages in order to provide equitable and timely preventive measures and screening practices. Lastly, it is important to recognize that the growth in early onset cancers translates to a younger segment of the endometrial cancer survivorship population, particularly among women of color, to which future survivorship research and practice should focus attention.

Supplementary Material

Web_Material_kwae178
web_material_kwae178.docx (29.2KB, docx)

Contributor Information

Victoria E Rodriguez, Department of Health, Society, and Behavior, University of California Irvine, Irvine, California, United States.

Sora Park Tanjasiri, Department of Health, Society, and Behavior, University of California Irvine, Irvine, California, United States; Chao Family Comprehensive Cancer Center, University of California Irvine, Irvine, California, United States.

Annie Ro, Department of Health, Society, and Behavior, University of California Irvine, Irvine, California, United States.

Michael A Hoyt, Population Health and Disease Prevention, University of California Irvine, Irvine, California, United States; Chao Family Comprehensive Cancer Center, University of California Irvine, Irvine, California, United States.

Robert E Bristow, Department of Obstetrics & Gynecology School of Medicine, University of California, Irvine, Orange, California, United States.

Alana M W LeBrón, Department of Health, Society, and Behavior, University of California Irvine, Irvine, California, United States; Department of Chicano/Latino Studies, University of California Irvine, Irvine, California, United States; Chao Family Comprehensive Cancer Center, University of California Irvine, Irvine, California, United States.

Acknowledgments

Presented at the 2023 American Society of Preventive Oncology Annual Meeting, San Diego, CA, March 12-14, 2023.

Supplementary material

Supplementary material is available at the American Journal of Epidemiology online.

Funding

This work was supported by the National Institutes of Health, National Cancer Institute F31 Predoctoral Fellowship (1F31CA271700-01).

Conflict of interest

The authors declare no conflicts of interest.

Disclaimer

The views expressed in this article are those of the authors and do not reflect those of the National Institutes of Health.

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