Endometrial cancer is the second most common and fourth leading cause of death due to gynecological malignancy worldwide as recorded in 2020. Global incidence reported in 2020 was 417,367 which constitutes about 2.2% of newly diagnosed cancer cases in that year making it sixth most commonly diagnosed cancer in the world. In 2020, around 97,370 deaths were attributed to endometrial cancer which is 1% of all deaths due to cancer. Age-standardized incidence is 8.7, and mortality is 1.8/1 lakh population. The incidence of endometrial cancer is seen to be higher in developed countries.
In India, the incidence of endometrial cancer is very low as compared to developed countries with a reported incidence of 16,413 cases in 2020. GLOBOCAN 2020 also reported the mortality of 6385 cases and the cumulative risk of diagnosis as 0.75.
The exact etiology of endometrial cancer is unknown, but prolonged exposure to estrogen is considered the main causative factor. Hence, women having early menarche and delayed menopause are at high risk for developing endometrial cancer. The other risk factors include nulliparity, obesity, comorbidities such as hypertension, diabetes, estrogen only hormone replacement therapy (HRT) and genetic factors such as lynch syndrome and cowden syndrome. It arises mainly in postmenopausal women. The peak incidence is in the 55–65 years’ age group.
Histopathologically, endometrioid type constitutes 80% of all the endometrial carcinoma cases. The less common subtypes are mucinous carcinoma, serous carcinoma, clear cell carcinoma, and squamous carcinoma. Rarely, mixed histology and undifferentiated types are also seen.
The treatment of carcinoma endometrium depends on the stage at presentation. Surgery stays the mainstay of treatment in most of the localized tumors. Total hysterectomy with bilateral salpingo-oophorectomy with or without lymph node dissection is the most commonly performed surgery. Postoperative external beam radiotherapy or vaginal brachytherapy depends on the stage, grade, and lymphovascular invasion of the tumor.
There are limited studies available on risk factors in endometrial cancer from the National capital Territory (NCT) of India. Along with this, the data furnishing the correlation to types of endometrial cancer with management and outcome are limited. Hence, the present study was conducted to identify the epidemiological characteristics of the patients of endometrial cancer in NCT of India.
MATERIALS AND METHODS
The present study retrospectively analyzed the data of women (patients) attending a tertiary care hospital in NCT, i.e., Lok Nayak Hospital, for treatment of endometrial cancer between January 2016 and December 2019. A total of 86 patients of histopathologically confirmed carcinoma endometrium were found, out of all cases of gynecological malignancies registered during this period in the Department of Radiotherapy at this hospital. Patient’s case history was reviewed, and sociodemographic data were collected about the age of presentation, occupation, religion, residence, and substance addiction. Information about clinical presentation and diagnostic and therapeutic procedures was also analyzed. The data on known risk factors such as age at menarche and menopause, parity, obesity, use of oral contraceptive pills, HRT, and comorbidities such as hypertension and diabetes were assessed. Body mass index (BMI) was calculated by weight (in kg) and height (in cm) using standard techniques. WHO definition of overweight (BMI 25–29 kg/m2) and obesity (BMI >30 kg/m2) was followed. Women were considered premenopausal at baseline when they reported having regular menses over the past 12 months. Data were analyzed, and results were presented as mean + standard deviation and frequency.
The mean age of the patients at diagnosis of endometrial cancer was 54 years. Majority of the patients (86%, n = 73) were in the age group of 40–70 years. The frequency of presence of other factors is shown in Table 1. The sociodemographic data revealed that 81% (n = 70) of the patients were resident of urban areas. Majority of the patients (67%, n = 54) belonged to Hindu religion. All the patients were housewives with nonsedentary lifestyle.
The most common clinical presentation was bleeding per vaginum seen in 88% (n = 76) of the patients. The clinical evaluation revealed that 59% (n = 51) had stage I disease, followed by 15% (n = 13) with stage II, 14% (n = 12) with stage III, and 12% (n = 10) with stage IV disease. Diagnosis was confirmed with histopathological examination in all the patients. Endometrioid carcinoma was the most common variant seen in 82% (n = 72) of the patients. However, other less common variants such as mixed Mullerian malignant tumor, squamous, adenosquamous, serous, and endometrioid stromal were also seen [Table 2]. Grade I tumor was seen in 44% (n = 38) of the tumor specimen, followed by 39% (n = 34) with grade II and 16% (n = 14) with grade III. At the time of presentation, 53.5% of the cases (n = 46) had >50% myometrial invasion while 46.5% of the cases (n = 40) had <50% myometrial invasion.
The information regarding the known risk factors for endometrial carcinoma revealed that 82% (n = 71) of the patients were postmenopausal whereas only 17% (n = 15) were premenopausal. The mean age at menarche was 13 years and 66% (n = 57) of the patients had menarche at or before 13 years of age. The mean age of menopause was 47 years and 14% (n = 10) of the patients attained menopause at 51 years of age or later. Only a small subset of patients that is about 15% (n = 13) of the patients were nulliparous and 43% (n = 37) had <3 children. The data also revealed that 46% (n = 40) patients were overweight and 16% (n = 14) were obese. Most of the patients (82%) had no history of addiction. About 25% (n = 22) of the patients had hypertension, and 27% (n = 23) has diabetes as comorbidity.
The incidence of endometrial cancer is on the rise in recent years and it is estimated to increase by 50% worldwide by 2040. The incidence and mortality vary among countries. It is seen that the incidence is higher in high-income or developed countries than low- and middle-income countries. In our study, the mean age of the patients at diagnosis of endometrial cancer was 54 years. Majority of the patients (86%, n = 73) were in the age group of 40–70 years. Only 10 out of 86 patients (11%) were <40 years of age. Similar results with a median age of 61 and an age range from 28 to 78 years were reported by Elissawy etal. The results of Tanvir etal. also showed a similar age presentation with maximum patients belonging to the age group of 51–60 years.
Age at menarche
In this study, the mean age at menarche was 13, and 66% (n = 57) of the patients had menarche at or before 13 years of age, while 33.72 (n = 29) had achieved menarche after 13 years of age. Early age of menarche and late age of menopause are two risk factors related to increased risk for uterine cancer.[5–9]
Majority (82.5%, n = 71) of the patients in our study were postmenopausal. While only 17.5% (n = 15) had disease before attaining menopause. Our findings coincide with Gottwald etal. and Van den Bosch and Mertens, respectively, who reported incidence figures of 87.3% and 70%, respectively.
Age at menopause
The mean age of menopause in our study was 47, and 61 patients (86%) out of total 86 patients have menopause at the age of 50 years or less. Only a few, i.e., 14% (n = 10) of the patients, attained menopause at 51 years of age or later.
About 15% (n = 13) of the patients were nulliparous and 43% (n = 37) had <3 children. Forty-two percent (n = 36) had four or more children similar to Asyikeen etal.
About 25% (n = 22) of the patients had hypertension and 27% (n = 23) has diabetes as comorbidity. Hypothyroidism was present in 10.5% (n = 9) patients. Coinciding with different literature[11,13,14] like Zachary Nicholas et al reported in his study that 47% patients had hypertension and 26% had diabetes mellitus. Both diabetes mellitus and hypertension affects survival in patients of endometrial carcinoma and thus relevant in its implication in endometrial cancer patients.
Most of the patients (82%) had no history of addiction. History of smoking was elicited from 2.5% (n = 2) cases. Only one case (1%) each was addicted to tobacco and alcohol.
Body mass index
The data also revealed that 46% (n = 40) patients were overweight and 16% (n = 14) were obese which clearly agrees with different researches.[16–19] On the contrary, Jimñnez-López etal. included 358 patients among whom only 31 patients (9%) were of BMI ≥30 kg/m2. 32.5% (n = 28) had normal BMI while 5% (n = 4) were underweight.
All the patients were housewives with nonsedentary lifestyle.
Majority of the patients (67%, n = 54) belonged to Hindu religion. 31.3% (n = 27) were Muslims, and only one (1%) was from Sikh community.
Place of residence
The sociodemographic data revealed that 81% (n = 70) of the patients were residents of urban areas. Only 18.5% (n = 16) were from rural areas.
The most common clinical presentation was bleeding per vagina seen in 88% (n = 76) of the patients which conforms with many literatures.[13,14,21–23] Other common clinical presentations were discharge per vagina (5.9%; n = 5) with pain in abdomen (4.6%; n = 4) and menometrorrhagia (1.1%; n = 1).
Tumor characteristic of patients
Endometrioid carcinoma was the most common variant seen in 82% (n = 72) of the patients. However, other less common variants such as mixed Mullerian malignant Tumor (7%, n = 6), serous (3.5%, n = 3), adenosquamous (2.5%; n = 2), endometrioid stromal (2.5%; n = 2), and squamous (1%; n = 1) were also seen. Christopherson etal. described adenocarcinoma, adenoacanthoma, adenosquamous carcinoma, clear-cell carcinoma, and papillary serous carcinoma in 60%, 22%, 7%, 6%, and 5% of the cases.
Grade I tumor was seen in 44% (n = 38) of the tumor specimen, followed by 39% (n = 34) with grade II and 16% (n = 14) with grade III.
The clinical evaluation revealed that 59% (n = 51) had stage I disease, followed by 15% (n = 13) with stage II, 14% (n = 12) with stage III, and 12% (n = 10) with stage IV disease. Majority of patients had early stage of presentation.
Percentage of myometrial invasion
In our study, 53.5% (n = 46) had >50% myometrial invasion at the time of presentation while 46.5% (n = 40) had <50% myometrial invasion.
Endometrium cancer is one of the most common malignancies affecting women worldwide and its incidence has shown a steady rise for two decades. Early age of menarche, late age of menopause, nulliparity, obesity, and diabetes mellitus are well-documented risk factors for uterine cancer. A better understanding of endometrial cancer etiology, risk factors, and its preventive measures can contribute toward better outcomes and control of disease. Thus, a robust screening program is warranted to detect the disease in early stage and for increased survival.
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Conflicts of interest
There are no conflicts of interest.
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