Why Do Black Women Have Worse Uterine Cancer Outcomes?

Uterine cancer is relatively common, but it doesn’t affect everyone equally. Black women have worse uterine cancer outcomes, including higher mortality and recurrence rates.

Exploring the underlying factors causing this disparity is essential for moving forward and implementing solutions.

What is uterine cancer?

Endometrial carcinoma is a type of cancer that begins in the uterus, a female reproductive organ in the pelvis. It’s the fourth most common cancer in women in the US as well as the most common gynecologic malignancy.¹

Unlike most other cancers, uterine cancer mortality rates are increasing. This highlights the significance of uterine cancer as a major health issue today.²

Data from the Surveillance, Epidemiology, and End Results (SEER) Program outlines current uterine cancer statistics in the US. As of 2020, around 845,825 American women were living with uterine cancer. It’s estimated that 66,200 women will be diagnosed with uterine cancer in 2023. 13,030 of these people will sadly die.³

The five-year survival rate for uterine cancer is 81% overall. However, the survival rate depends on the cancer’s stage and type. For example, the five-year survival rate is 94.9% for localized uterine cancer, 69.8% for regional uterine cancer, and 18.4% for distant uterine cancer.⁴

Not all races are affected by uterine cancer equally. Black women face the worst outcomes of any racial group and are currently experiencing the largest increase in uterine cancer cases and deaths.⁵

Terminology

Understanding the terminology below can be useful when learning about uterine cancer.

Most uterine cancer research refers to “women” or “females” as the gender the disease affects. However, it’s important to note that some people who have a uterus may identify with different terms.⁶

In everyday language, the uterus is often referred to as the womb. Researchers and healthcare workers tend to use the scientific term, uterus, or its lining, the endometrium.⁷

Health disparities are defined by the Centers for Disease Control and Prevention (CDC) as “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.”⁸

For example, Black women experience health disparities in uterine cancer. However, the etiology of the difference is unknown. Factors that vary by race in the US cannot fully explain the disparities.⁹

Risk factors for uterine cancer

Here are some of the factors that can increase your risk of developing uterine cancer:¹⁰

Overweight/obesity

This is the single most important risk factor. Almost 80% of people with endometrial carcinoma are overweight, and 50% have obesity.¹¹

Obesity causes insulin resistance, androgen excess, anovulation (when an egg does not release from the ovaries), and chronic progesterone deficiency. These are all factors in the disease’s pathophysiology.¹²

Endometrial cancer is 1.34–1.43 times more likely to occur in women who are overweight and 2.54–3.33 times more likely to occur in women with obesity.¹³

Unopposed estrogen therapy

Taking estrogen without progesterone increases endometrial cancer risk for both premenopausal and postmenopausal women.

Tamoxifen use (postmenopausal)

Tamoxifen is mainly used as a breast cancer treatment. It has tissue-specific pro-estrogenic effects.

The risk of endometrial carcinoma increases by seven times in women with breast cancer who are exposed to tamoxifen. However, tamoxifen use in premenopausal women is not associated with an increased risk of endometrial carcinoma.¹⁴ ¹⁵

Age > 50 years

The risk of uterine cancer increases with age.

63% of uterine cancer diagnoses occur between the ages of 55–75. The median age of diagnosis is 63. Older women are less at risk.¹⁶

Diet

Research has found that a Western dietary pattern increases the risk of uterine cancer.¹⁷

For example, a diet high in total and saturated fats can indirectly increase the risk of uterine cancer by promoting obesity and potentially modulating chronic inflammation. In the same context, researchers have observed that endometrial carcinoma risk declines with increased fiber consumption.¹⁸ ¹⁹

Physical activity

Not doing enough physical activity and living a sedentary lifestyle may increase your risk of uterine cancer.²⁰

Family history of some other diseases

Your risk of developing uterine cancer is 21–71% if you have the genetic condition hereditary nonpolyposis colon cancer (HNPCC) — also known as Lynch syndrome.²¹

Women with a first-degree family history of endometrial cancer or colorectal cancer appear to have a higher risk of developing endometrial carcinoma than those without a family history.²²

Some studies have found that having a family history of breast or ovarian cancer increases your risk for uterine cancer. However, other studies did not establish a link between these conditions, so more research is needed.²³ ²⁴

Unopposed endogenous estrogen

Having more menstrual cycles due to early menarche, anovulation, infertility, never becoming pregnant (nulliparity), or late menopause increases your risk of uterine cancer.²⁴

Medical history

Women who have polycystic ovarian syndrome (PCOS) or atypical endometrial hyperplasia (increased growth of the endometrium) are more likely to develop uterine cancer.

Disparities in uterine cancer mortality and outcome

Per 100,000 women per year, the incidence rates of uterine cancer are:²⁶

• 29.4 in Black women

• 28.8 in American Indian/Alaskan Native women

• 27.6 in White women

• 26.1 in Hispanic women

• 22.7 in Asian/Pacific Islander women 

Although the incidence of uterine cancer is only slightly higher in Black women than in White women, there’s an even greater disparity in mortality.

Black women with uterine cancer have the worst outcomes of any other ethnic minority group. Per 100,000 women, yearly mortality rates are:²⁷

• 9.1 in Black women

• 4.6 in White women

• 4.5 in American Indian/Alaskan Native women

• 4.3 in Hispanic women

• 3.5 in Asian/Pacific Islander women

Here are some other disparities:

• Five-year survival rate: 84% of White women live for five years after a diagnosis compared to just 63% of Black women. 

• Recurrence: Black women are more likely to experience a recurrence of their uterine cancer.²⁸

• Cancer stage at diagnosis: Black women are more likely to present with more advanced uterine cancer than White women. This negatively impacts their treatment and outcome. Even when the data is adjusted for cancer stage, Black women are more likely to die from the disease.²⁹ ³⁰

• Aggressiveness of cancer: Black women are more likely to be diagnosed with more aggressive forms of endometrial cancers.³¹

Which factors are linked to racial health disparities in uterine cancer?

Several factors may cause disparities in the development, diagnosis, aggressiveness, treatment, and outcome of uterine cancer. Factors such as comorbidities, healthcare facility characteristics, patient–doctor communication, bias, and structural racism may all play a part in creating disparities.³² ³³

It’s important to explore all possible factors, seeing as racial differences in diagnosis and survival persist even after controlling for access to healthcare and treatment.³⁴

Biological and genetic factors

Molecular, histopathological, and genetic differences between White and Black women with uterine cancer are important to consider. The interactions and pathways of molecules in endometrial carcinoma may differ between Black and White women and impact the aggressiveness of the cancer and overall survival.³⁵

The histologic subtype is the largest factor associated with racial disparities in uterine cancer mortality. Research suggests that molecular factors associated with cancer’s histologic subtype could account for 53–56% of the differences in mortality risk between Black and White people. These differences may be partly explained by age due to unbalanced estrogen levels or obesity in younger patients.³⁶ ³⁷

Genetic differences also exist. A study observed that Black women are less likely to have mutations in a tumor suppressor gene associated with favorable outcomes. On the other hand, they are more likely to have mutations in the p53 tumor suppressor gene that is associated with more aggressive tumors. Black women are also more likely to have comorbidities, which likely account for some of the disparities.³⁸ ³⁹ ⁴⁰

It’s important to note that biological differences cannot explain all the disparities. Even after controlling for age, tumor grade, and histology, Black women are more likely to present with advanced disease — so there must be other contributing factors.⁴¹

Socioeconomic factors

The social determinants of health are non-medical factors that positively or negatively impact health outcomes and quality of life. These factors can partly explain why Black women have worse uterine cancer outcomes.⁴²

Economic stability

In 2019, Black people made up 13.2% of the total US population but 23.8% of the population living in poverty. This means being Black in the US is a risk factor for economic instability, which increases your risk of poor health outcomes.

A 2018 study confirmed this, linking higher zip code income with a lower uterine cancer mortality rate.⁴³

Low income and economic instability make it difficult to get high-quality medical insurance. Insurance status was found to be the largest modifiable risk factor for women younger than 65 years with uterine cancer. The high cost of medical screening and treatment is a barrier to accessing healthcare, as is the need to take time off work for treatment.⁴⁴

Meanwhile, people living in poverty are more likely to adopt unhealthy lifestyle behaviors that increase their risk for uterine cancer (such as following an unhealthy diet and not doing enough exercise).

Education access and quality

Getting a good education can improve your health outcomes. For instance, those who have achieved a high level of education are more likely to get a well-paid job that provides economic stability and health insurance.

Education also improves health literacy, improving awareness about behavioral risk factors for cancer (such as poor diet).

Access to quality healthcare

This social determinant of health is closely intertwined with others. The level and quality of care you receive depends on your insurance status, affordability of care, availability of medical professionals and services, wait times, and ease of access to healthcare facilities.

Neighborhood and built environment

Where you live affects your ability to access food stores that sell healthy, affordable food. For example, if you live in a food desert but there are a disproportionate amount of fast food outlets nearby, you are more likely to adopt unhealthy eating behaviors.

Not doing enough exercise, another risk factor for uterine cancer, is directly influenced by your neighborhood and built environment. You’re more likely to exercise if you can access large and open green spaces. Meanwhile, local crime levels may impact your ability to leave the house and exercise safely.

Social and community context

Relationships and interactions play a key role in how you access healthcare, but these can be affected by systemic discrimination, racism, and isolation.

Black people continue to face racism in healthcare settings. This can result in delays in receiving cancer screening and treatment. 

According to research, a lack of trust in the healthcare system leads to Black women presenting with uterine cancer at a later stage. This mistrust is perpetuated by the fact that Black women continue to receive lower-quality care compared to their White counterparts. Research shows that Black women are less likely to receive care in accordance with national guidelines.⁴⁵ ⁴⁶

They are also less likely to receive surgery (such as a hysterectomy), chemotherapy, and definitive surgical treatment. When Black women do receive surgery, it’s less likely to be the optimal choice. It will probably be less invasive than what White patients would receive.⁴⁷

Advocacy and solutions

Efforts to close the statistical gap in uterine cancer outcomes may include the following:

Addressing disparities in uterine cancer

Research needs to identify barriers to care and what causes them. It also needs to assess how treatment access and biological differences give rise to uterine cancer disparities.⁴⁸

A holistic approach that recognizes socioeconomic barriers, community views toward cancer treatment, and implicit bias in the healthcare space is needed.

Providing culturally sensitive education on risk factors and the importance of early screening

Education should be provided on risk factors for uterine cancer. Improving awareness about symptoms, diagnosis, screening, and treatment can improve health literacy and access to treatment.⁴⁹

Interventions should be developed that are culturally appropriate and can be delivered to women in safe, friendly, and welcoming settings.⁵⁰

Another possible solution is increasing the number of Black women in the healthcare profession, which could improve patient–doctor communication.

Enhancing access to healthcare and reducing healthcare bias

Providing education on the importance of screening and early treatment is important, but there are barriers that need to be overcome. Policies are needed that expand access to screening, treatment, and clinical trials for Black women.⁵¹

Surgical plans should be adapted to the patient’s medical condition. This is especially important for Black women because they more often experience worse treatment outcomes.⁵²

Looking ahead

Here are some research initiatives and other measures designed to reduce disparities:

The Carolina Endometrial Cancer Study

This study aims to reduce disparities in endometrial cancer treatment. Its goal is to have a representative study population in which half of the participants are Black.⁵³

Accountability for Cancer Care through Undoing Racism and Equity (ACCURE)

The successful ACCURE program aimed to improve treatment access and cancer outcomes in Black people. The program trained nurse navigators to understand the struggles faced by Black people when accessing healthcare services, such as medical mistrust, patient–doctor miscommunication, transportation barriers, financial struggles, and difficulty getting time off work.⁵⁴

These nurses also explored reasons why the patients may have missed an appointment and provided them with resources to help them access care. Another goal was to provide monthly updates to clinical teams on the treatment completion rate among Black and White women.

Implementing patient navigators and community health educators

Community health educators are needed to work with Black women to engage them in discussions around cancer prevention, screening, treatment, and other services. This will help them receive timely healthcare.⁵⁵

Linking Black women up with patient navigators can enable discussions around payment support, where to get healthcare, and how to travel there. To achieve this, it’s important that patient navigators receive funding and investments within the healthcare system.

The lowdown

Uterine cancer is a worldwide health concern, but the burden falls disproportionately on minority populations. Black women experience the highest incidence and mortality rates for uterine cancer.

Biological differences, socioeconomic status, racism, and bias in the healthcare system all contribute to these disparities. Looking forward, research needs to focus on identifying and addressing racial disparities so that equity in uterine cancer rates, care, and outcomes can be achieved.

Frequently asked questions

Why is uterine cancer on the rise?

Researchers hypothesize that higher obesity rates may be contributing to the increase in uterine cancer cases. Yet, correlation does not mean causation.⁵⁶

Research needs to investigate why non-endometrioid uterine cancer is on the rise, because these subtypes are less associated with obesity and hormonal risk factors. Even so, they are accounting for most of the rise in cases.⁵⁷

Who is most affected by uterine cancer?

Uterine cancer mostly affects postmenopausal women above the age of 45. In the US, Black women are affected by uterine cancer more than any other race.⁵⁸