Reproductive risk factors and endometrial cancer: the European Prospective Investigation into Cancer and Nutrition

Endometrial Cancer in Reproductive-Aged Females: Etiology and Pathogenesis

Endometrial cancer is the most common gynecologic malignancy in developed countries, and the incidence is rising in premenopausal females. Type I EC is more common than Type II EC (80% vs. 20%) and is associated with a hyperestrogenic state. Estrogen unopposed by progesterone is considered to be the main driving factor in the pathogenesis of EC. Studies show that BMI > 30 kg/m2, prolonged duration of menses, nulliparity, presence of polycystic ovarian syndrome, and Lynch syndrome are the most common causes of EC in premenopausal women. Currently, there are no guidelines established to indicate premenopausal patients who should be screened. This review aims to synthesize current data on the etiology, risk factors, presentation, evaluation, and prognosis of endometrial cancer in this population.

Vitamin D and its role in gynecology: emerging importance of checking vitamin D status in certain gynecological entities

Among non-bone effects of vitamin D, the three main chronological stages in gynecology ‒ menarche, reproductive stage and menopause/postmenopause - are possibly impacted by vitamin D deficiency. A large amount of emerging data show that vitamin D is a confounding factor in these parameters. Gynecology stays at the crossroads with endocrinology and, in the light of the rising knowledge about the involvement of vitamin D in many gynecological disorders, it is worth to investigate the exact role of vitamin D in this area. Especially since vitamin D is easy to substitute in case of deficiency. Authors present some emerging data on the role of vitamin D in gynecology, suggesting when it is necessary to check vitamin D status to intervene with vitamin D supplementation and raising gynecologists' awareness of the need for further clinical studies.

The impact of reproductive factors on the metabolic profile of females from menarche to menopause

We explore the relation between age at menarche, parity and age at natural menopause with 249 metabolic traits in over 65,000 UK Biobank women using multivariable regression, Mendelian randomization and negative control (parity only). Older age of menarche is related to a less atherogenic metabolic profile in multivariable regression and Mendelian randomization, which is largely attenuated when accounting for adult body mass index. In multivariable regression, higher parity relates to more particles and lipids in VLDL, which are not observed in male negative controls. In multivariable regression and Mendelian randomization, older age at natural menopause is related to lower concentrations of inflammation markers, but we observe inconsistent results for LDL-related traits due to chronological age-specific effects. For example, older age at menopause is related to lower LDL-cholesterol in younger women but slightly higher in older women. Our findings support a role of reproductive traits on later life metabolic profile and provide insights into identifying novel markers for the prevention of adverse cardiometabolic outcomes in women.

Circulating Adipocytokines and Insulin Like-Growth Factors and Their Modulation in Obesity-Associated Endometrial Cancer

The rising global incidence of uterine cancer is linked to the escalating prevalence of obesity. Obesity results in alterations in adipocytokines and IGFs, driving cancer progression via inflammation, increased cell proliferation, and apoptosis inhibition, although the precise mechanisms are still unclear. This study examined a set of six markers, namely, adiponectin, leptin, IL6, TNFα, IGF1, and IGF2 and compared them between fifty age-matched endometrial cancer patients (study group) and non-cancer patients with benign gynaecological conditions (control group). We also assessed the relationship of these markers with obesity and explored the correlation between these markers and various tumour characteristics. In the cancer population, these markers were also assessed 24 h and 6 months post-surgery. Remarkably, low adiponectin levels were associated with a 35.8% increase in endometrial cancer risk. Interestingly, compared to control subjects where IGF levels decreased after menopause, post-menopausal women in the study group showed elevated IGF1 and IGF2 levels, suggesting a potential influence of endometrial cancer on the IGF system, particularly after menopause. Lastly, it is noteworthy that a discernible inverse relationship trend was observed in the levels of adipocytokines and IGFs 6 months post-surgery. This indicates that treatment for endometrial cancer may have a differential impact on adipocytokines and IGFs, potentially holding clinical significance that merits further investigation.

An updated meta-analysis of the relationship between vitamin D levels and precocious puberty

Background

Some studies have investigated the association between vitamin D levels and precocious puberty (PP) but with limited sample sizes and inconsistent conclusions across studies.

Methods

Until July 2022, a comprehensive electronic search of works of literature was conducted in MEDLINE, Web of Science, and CNKI (Chinese National Knowledge Infrastructure). A systematic review and meta-analysis of 15 case-control studies with 2145 cases and 2063 controls was conducted to explore the relationship between vitamin D and PP. Stratified analyses by year of publication, country, diagnosis category of PP, child's sex, and methods of 25(OH)D test were conducted.

Results

There was a negative correlation between 25(OH)D concentrations and PP in all study populations (SMD = -1.046, 95%CI = -1.366, -0.726). The pooled SMD remained significant in Chinese studies (SMD = -1.113, 95%CI = -0.486, -0.741), studies published before or after 2018 (SMD = -0.9832 and -1.185, 95%CI = -2.044, -1.133 and -1.755, -0.726), studies with female children (SMD = -1.114, 95%CI = -1.446, -0.781), and studies using electrochemiluminescence to detect 25(OH)D (SMD = -0.999, 95%CI = -1.467, -0.531). Vitamin D deficiency also increased the risk of PP (OR = 1.531, 95%CI = 1.098, 2.134). Unfortunately, heterogeneity was high in all analyses, and there was some publication bias.

Conclusion

This systematic review and meta-analysis demonstrated an association between vitamin D and precocious puberty. We recommend more high-quality studies, especially prospective cohort studies with big sample sizes or some randomized controlled intervention trials, to validate the reliability of the results.

Review of mendelian randomization studies on age at natural menopause

Menopause marks the end of the reproductive phase of life. Based on epidemiological studies, abnormal age at natural menopause (ANM) is thought to contribute to a number of adverse outcomes, such as osteoporosis, cardiovascular disease, and cancer. However, the causality of these associations remains unclear. A powerful epidemiological method known as Mendelian randomization (MR) can be used to clarify the causality between ANM and other diseases or traits. The present review describes MR studies that included ANM as an exposure, outcome and mediator. The findings of MR analyses on ANM have revealed that higher body mass index, poor educational level, early age at menarche, early age at first live birth, early age at first sexual intercourse, and autoimmune thyroid disease appear to be involved in early ANM etiology. The etiology of late ANM appears to be influenced by higher free thyroxine 4 and methylene tetrahydrofolate reductase gene mutations. Furthermore, early ANM has been found to be causally associated with an increased risk of osteoporosis, fracture, type 2 diabetes mellitus, glycosylated hemoglobin, and the homeostasis model of insulin resistance level. In addition, late ANM has been found to be causally associated with an increased systolic blood pressure, higher risk of breast cancer, endometrial cancer, endometrioid ovarian carcinoma, lung cancer, longevity, airflow obstruction, and lower risk of Parkinson's disease. ANM is also a mediator for breast cancer caused by birth weight and childhood body size. However, due to the different instrumental variables used, some results of studies are inconsistent. Future studies with more valid genetic variants are needed for traits with discrepancies between MRs or between MR and other types of epidemiological studies.

Reproductive Factors and Endometrial Cancer Risk Among Women

Importance

Despite evidence of an association between reproductive factors and endometrial cancer risk, prospective studies have been conducted mainly in non-Asian countries.

Objective

To assess the association between reproductive factors, such as number of deliveries, age at menarche, or menopause, and endometrial cancer risk.

Design, Setting, and Participants

This cohort study used pooled individual data from 13 prospective cohort studies conducted between 1963 and 2014 in the Asia Cohort Consortium. Participants were Asian women. Data analysis was conducted from September 2019 to April 2023.

Exposures

Reproductive factors were assessed using a questionnaire in each cohort.

Main Outcomes and Measures

The main outcome was time to incidence of endometrial cancer. A Cox proportional hazards model was used to calculate hazard ratios (HRs) and 95% CIs.

Results

A total of 1005 endometrial cancer cases were detected among 332 625 women (mean [SD] age, 54.3 [10.4] years) during a mean (SD) of 16.5 (6.4) years of follow-up. Increasing number of deliveries was associated with a decreased endometrial cancer risk in a dose-response manner (≥5 deliveries vs nulliparous [reference]: HR, 0.37; 95% CI, 0.26-0.53; P for trend < .001). Compared with menarche at younger than 13 years, menarche at 17 years or older had an HR of 0.64 (95% CI, 0.48-0.86; P for trend < .001). Late menopause (age ≥55 years) showed an HR of 2.84 (95% CI, 1.78-4.55; P for trend < .001) compared with the youngest age category for menopause (<45 years). Age at first delivery, hormone therapy, and breastfeeding were not associated with endometrial cancer risk.

Conclusions and Relevance

This large pooled study of individual participant data found that late menarche, early menopause, and a higher number of deliveries were significantly associated with a lower risk of endometrial cancer. These convincing results from Asian prospective studies add to the growing body of evidence for the association between reproductive factors and endometrial cancer.

Quality of Life after Risk-Reducing Hysterectomy for Endometrial Cancer Prevention: A Systematic Review

BACKGROUND

Risk-reducing hysterectomy (RRH) is the gold-standard prevention for endometrial cancer (EC). Knowledge of the impact on quality-of-life (QoL) is crucial for decision-making. This systematic review aims to summarise the evidence.

METHODS

We searched major databases until July 2022 (CRD42022347631). Given the paucity of data on RRH, we also included hysterectomy as treatment for benign disease. We used validated quality-assessment tools, and performed qualitative synthesis of QoL outcomes.

RESULTS

Four studies (64 patients) reported on RRH, 25 studies (1268 patients) on hysterectomy as treatment for uterine bleeding. There was moderate risk-of-bias in many studies. Following RRH, three qualitative studies found substantially lowered cancer-worry, with no decision-regret. Oophorectomy (for ovarian cancer prevention) severely impaired menopause-specific QoL and sexual-function, particularly without hormone-replacement. Quantitative studies supported these results, finding low distress and generally high satisfaction. Hysterectomy as treatment of bleeding improved QoL, resulted in high satisfaction, and no change or improvements in sexual and urinary function, although small numbers reported worsening.

CONCLUSIONS

There is very limited evidence on QoL after RRH. Whilst there are benefits, most adverse consequences arise from oophorectomy. Benign hysterectomy allows for some limited comparison; however, more research is needed for outcomes in the population of women at increased EC-risk.

The mortalities of female-specific cancers in China and other countries with distinct socioeconomic statuses: A longitudinal study

INTRODUCTION

Female-specific cancers seriously affect physical and psychological health of women worldwide.

OBJECTIVES

We aimed to elucidate trends in the age-standardized mortality rates (ASMRs) of breast cancer, cervical cancer, uterine cancer, and ovarian cancer in female populations with different socioeconomic statuses in China and in countries with different Human Development Index (HDI).

METHODS

A longitudinal study was performed using the data of cancer death in China and other 39 countries. The mortality rates were standardized with the Segi's world population. Trends in the mortalities were exhibited by estimated annual percentage change (EAPC). Pearson correlation was used to assess the association between EAPC and HDI.

RESULTS

In mainland China, female breast cancer, cervical cancer, uterine cancer, and ovarian cancer accounted for 6.60 %, 4.21 %, 2.50 %, and 2.02 % of cancer death (n = 1,314,040) in women with 1,220,251,032 person-years, respectively. The ASMRs of cervical cancer (EAPC = 3.87 %, P < 0.001) and ovarian cancer (EAPC = 1.81 %, P < 0.001) increased, that of female breast cancer unchanged, whereas that of uterine cancer was extremely higher and rapidly decreased (EAPC =  - 7.65 %, P < 0.001), during 2004-2019. The ASMRs of female breast and ovarian cancers were higher in urban and developed regions than in rural and undeveloped regions, in contrast to cervical and uterine cancers. The ASMRs of female breast and ovarian cancers were lower in China than in other countries, in contrast to uterine cancer. The ASMR of cervical cancer decreased, that of uterine cancer increased, in other countries during 2004-2017. EAPCs for the ASMRs of breast and ovarian cancers were inversely correlated to HDI.

CONCLUSION

The ASMRs of cervical and ovarian cancers increased, in contrast to uterine cancer, in China during socioeconomic transition. Trends in the ASMRs of breast and ovarian cancers were inversely associated with HDI. These data help control female-specific cancers.

Endometrial Cancer in Pre-Menopausal Women and Younger: Risk Factors and Outcome

Endometrial cancer is the sixth most common malignancy in women, and it is known to be a disease among postmenopausal women, but there is rising in the number of endometrial cancers among premenopausal women. This study aims to determine the clinical characteristic, risk factors, outcomes, and survival in pre and postmenopausal women with endometrial cancer in Malaysia. A retrospective study was conducted in Hospital Melaka that involved all women who were diagnosed with endometrial cancer in Hospital Melaka from January 2002 until July 2020. All subjects’ histopathological examination result was confirmed, and their clinical data were extracted and transferred into a standardized data checklist and analysed. A total number of 392 cases was obtained from the Annual Cancer Registry Hospital Melaka. However, only 281 cases were studied, including 44.8% premenopausal and 55.2% postmenopausal women. In the premenopausal group, there were higher incidence of obesity (30.8 + 8.6 vs. 28.9 + 7.1), younger age at menarche (12.7 + 1.5 vs. 13.3 + 1.6), lesser parity (1.47 vs. 3.26), and a higher number of nulliparous women (46.8% vs. 19.4%) as compared to postmenopausal group. The premenopausal group tends to be presented with a well-differentiated grading of tumour (52.4%) and a higher incidence of having concomitant endometrial hyperplasia (41.3%). The mean survival among the premenopausal group (200.3 + 7.9 months) is higher compared to postmenopausal group (153.9 + 6.5 months). These findings correlate with good survival and prognosis among the premenopausal group compared to the postmenopausal group.

Pathological brain lesions in girls with central precocious puberty at initial diagnosis in Southern Vietnam

PURPOSE

Cranial magnetic resonance imaging (MRI) is recommended to identify intracranial lesions in girls with central precocious puberty (CPP). Yet, the use of routine MRI scans in girls with CPP is still debatable, as pathological findings in girls 6 years of age or older with CPP are limited. Therefore, we aimed to identify the prevalence of brain lessons in CPP patients stratified by age group (0-2, 2-6, and 6-8 years).

METHODS

This retrospective cross-sectional study recruited 257 girls diagnosed with CPP for 6 years (2010-2016). MRI was used to detect brain abnormalities. Levels of luteinizing hormone, follicle-stimulating hormone, and sex hormones in blood samples were measured.

RESULTS

Most girls had no brain lesions (82.9%, n=213), and of the minor proportion of girls with CPP that exhibited brain lesions (17.1%, n=44), 32 girls had organic CPP. Pathological findings were detected in 33.3% (2 of 6) of girls aged 0-2 years, 15.6% (5 of 32) of girls aged 2-6 years, and 3.6% (8 of 219) of girls aged 6-8 years. Hypothalamic hamartoma and tumors in the pituitary stalk were the most common pathological findings. The likelihood of brain lesions decreased with age. Girls with organic CPP were more likely to be younger (6.1±2.4 vs. 7.3±1.3 years, p<0.01) than girls with idiopathic CPP.

CONCLUSION

Older girls appeared to have a lower prevalence of organic CPP. Clinicians should cautiously use cranial MRI for girls aged 6-8 years with CPP.

Associations between infant growth and pubertal onset timing in a multiethnic prospective cohort of girls

BACKGROUND

Early puberty increases risk of adverse health conditions throughout the life course. US girls are experiencing earlier puberty without clear reasons. Studies suggest early life factors, such as infant growth, may influence pubertal timing. We assessed the associations between infant growth and onset of breast development (thelarche), pubic hair development (pubarche), and menarche in girls.

METHODS

A prospective cohort of girls born at a Kaiser Permanente Northern California medical facility in 2005-11 was used. Weight-for-age z-scores were calculated at birth and 24 months. Difference in z-scores greater than 0.67 represent rapid "catch-up" growth, less than -0.67 represent delayed "catch-down" growth, and between -0.67 and 0.67 represent "normal" growth. Pubertal onset was measured using clinician-assessed sexual maturity ratings (SMRs) and defined as the age at transition from SMR 1 to SMR 2 + for both thelarche and pubarche. SMR data was collected through June 2020. Menarche was analyzed as a secondary outcome. Weibull and modified Poisson regression models were used. Models were adjusted for potential confounders.

RESULTS

There were 15,196 girls included in the study. Approximately 30.2% experienced catch-up growth, 25.8% experienced catch-down growth, and 44% had normal growth. Girls with catch-up growth had increased risk of earlier thelarche (hazard ratio = 1.26, 95% confidence interval (CI): 1.18, 1.35), pubarche (1.38, 95% CI: 1.28, 1.48), and menarche (< 12y, relative risk = 1.52, 95% CI: 1.36, 1.69) compared to those with normal growth, after adjusting for covariates. These associations were partially mediated by childhood body mass index. Catch-down growth was associated with later pubertal onset.

CONCLUSIONS

Girls who experience infant catch-up growth have higher risk of earlier pubertal development compared to girls with normal growth and the associations are partially explained by childhood obesity. This information may help clinicians to monitor girls who are at high risk of developing earlier.

Is age of menarche directly related to vitamin D levels?

INTRODUCTION

Very few studies have examined the direct link between age of menarche and vitamin D level and controversial results have been reported. This study aimed to investigate the association between vitamin D and age of menarche in a group of adolescent girls in an area with plenty of sunshine.

METHODS

At baseline, data were collected on 722 middle schoolgirls that were randomly selected by probability proportional to size sampling method. Of this group, 598 were followed including 173 who had their menarche during the follow-up. Serum 25-hydroxyvitamin D (25OHD) was measured at baseline using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Data on potential confounders were collected at baseline from the parents using self-administered questionnaire and from schoolgirls through face-to-face interview. Multiple linear regression and time-to-event analysis were used to investigate the association between 25OHD concentration and age of menarche.

RESULTS

The mean (SD) age of the study group was 12.51 (0.91) years while the main (SD) age of menarche was 11.82 (1.04) years. The prevalence of vitamin D deficiency (<50 nmol/L) among schoolgirls was 91.69%. We found no evidence for the association between 25OHD levels and age of menarche before (β, .00, 95% confidence interval (CI) [-0.01, 0.01]; p = .808) or after (β, .00, 95% CI [-0.01, 0.01]; p = .765) adjusting for potential confounders. We also found no evidence for association between 25OHD status and age of menarche before (p = .424) or after (p = .356) adjusting for potential confounders. Time-to-event analysis showed no association between 25OHD level or status and age of menarche (p = .850).

CONCLUSION

In Middle Eastern setting, where vitamin D deficiency is common despite plenty of sunshine, vitamin D is not a major determinant of the age at menarche. Regardless of the link between vitamin D and age of menarche, there are several other health benefits of having adequate vitamin D level during childhood and adolescence.

Spatiotemporal trends in burden of uterine cancer and its attribution to body mass index in 204 countries and territories from 1990 to 2019

BACKGROUND

Uterine cancer is one of the most common female cancers worldwide, with huge heterogeneity in morbidity and mortality. Although a high body-mass index (BMI) has been linked to uterine cancer, systematic reports about the influence of high BMI and its temporal trends are scarce.

METHODS

The annual morbidity, mortality, and disability-adjusted life years (DALYs) of uterine cancer in 204 countries or territories were retrieved from the GBD 2019 study. To reflect trends in disease burden, we also calculated the estimated annual percentage change (EAPC) based on the age-standardized rates of uterine cancer from 1990 to 2019.

RESULTS

The global incident cases of uterine cancer increased 2.3 times from 187,190 in 1990 to 435,040 in 2019. Although the age-standardized incidence rate (ASIR) of uterine cancer increased worldwide from 8.67/100,000 in 1990 to 9.99/100,000 in 2019, the age-standardized death rate (ASDR) and DALY rate decreased during the same period. High socio-demographic index (SDI) countries tended to have a higher ASIR than developing regions, and their increasing trend in ASIR was also more pronounced. The disease was rare before 40 years old, but its risk rose sharply among women aged 50-70. A high BMI was linked to more than one-third of deaths from uterine cancer in 2019.

CONCLUSIONS

The incidence in developed areas was significantly higher than in developing areas and also increased much more rapidly. Elderly females, especially those with a high BMI, have a higher risk of uterine cancer. Therefore, more health resources may be needed to curb the rising burden in specific populations.

Improved long-term survival of corpus cancer in Japan: A 40-year population-based analysis

The incidence of uterine corpus cancer has been increasing globally due to increase in obesity. However, a detailed analysis of long‐term epidemiological trends of corpus cancer in Japan, where obesity is relatively minimal, has not been conducted. In this retrospective, population‐based study using the Osaka Cancer Registry, we analyzed 15 255 cases of corpus neoplasia registered between 1977 and 2016. We determined the age‐standardized incidence, mortality, relative survival and conditional survival rates, and the treatment trends for corpus cancer over the last 40 years in Japan. The age‐standardized incidence rate of corpus neoplasia increased sharply in 2000‐2011 (APC = 9.9, 95% CI: 8.4‐11.3), whereas the mortality rate trended to a much more modest increase (APC = 3.3, 95% CI: 2.7‐3.8). Compared to 1977‐2000, 10‐year survival rates for post‐2000 cases of localized and regional corpus cancers significantly improved (from 87.7% [95% CI: 85.8‐89.4] to 94.2% [95% CI: 92.7‐95.7] and from 47.5% [95% CI: 43.3‐51.6] to 64.4% [95% CI: 61.0‐67.6], respectively). This was largely associated with the significant increase in the percentage of localized and regional patients who received chemotherapy instead of radiation as an adjuvant therapy combined to surgery (P < .001 for both). We found that each histological type (endometrioid carcinoma, serous carcinoma, clear cell carcinoma and carcinosarcoma) has different characteristics of trend of age‐standardized incidence rate, relative survival and distribution of extent of disease. In endometrioid carcinoma, the age‐standardized incidence rate increased consistently after 1990, but the rate of increase was decreasing after 1997.

What's new?

For the past 40 years, age‐standardized incidence of corpus cancer in Japan, similar to other countries worldwide, has been increasing. However, whereas global increases in corpus cancer are linked to increasing obesity, obesity rates in Japan remain uniquely low. This population‐based study, drawing on data from the Osaka Cancer Registry, reveals a sharp increase in age‐standardized incidence of corpus neoplasia from 2000‐2011 in Japan. Each histological cancer type differed in incidence trend, relative survival, and distribution of extent of disease. Additional analyses indicate that recent changes in adjuvant therapy, particularly increased use of chemotherapy over radiation, have improved prognosis.

Canonical TGFβ Signaling and Its Contribution to Endometrial Cancer Development and Progression-Underestimated Target of Anticancer Strategies

Endometrial cancer is one of the leading gynecological cancers diagnosed among women in their menopausal and postmenopausal age. Despite the progress in molecular biology and medicine, no efficient and powerful diagnostic and prognostic marker is dedicated to endometrial carcinogenesis. The canonical TGFβ pathway is a pleiotropic signaling cascade orchestrating a variety of cellular and molecular processes, whose alterations are responsible for carcinogenesis that originates from different tissue types. This review covers the current knowledge concerning the canonical TGFβ pathway (Smad-dependent) induced by prototypical TGFβ isoforms and the involvement of pathway alterations in the development and progression of endometrial neoplastic lesions. Since Smad-dependent signalization governs opposed cellular processes, such as growth arrest, apoptosis, tumor cells growth and differentiation, as well as angiogenesis and metastasis, TGFβ cascade may act both as a tumor suppressor or tumor promoter. However, the final effect of TGFβ signaling on endometrial cancer cells depends on the cancer disease stage. The multifunctional role of the TGFβ pathway indicates the possible utilization of alterations in the TGFβ cascade as a potential target of novel anticancer strategies.

Statistical Meta-Analysis of Risk Factors for Endometrial Cancer and Development of a Risk Prediction Model Using an Artificial Neural Network Algorithm

Simple Summary

A robust and comprehensive meta-analysis, for the first time, identified definitely that BMI is by far the most influential risk factor in endometrial cancer. Risk factors were previously only studied individually and or in smaller meta-analysis studies which grouped some factors together. BMI was shown to be an important risk factor with other factors less so, but no rank order was established. This work also offers, for the first time, a neural network computer model to predict the overall increase or decreased risk of cancer for individual patients, which is 98.6% accurate. This prediction can be used as a tool to determine if a patient should be considered for testing and to predict diagnosis, as well as to suggest prevention measures to patients.

Abstract

Objectives: In this study we wished to determine the rank order of risk factors for endometrial cancer and calculate a pooled risk and percentage risk for each factor using a statistical meta-analysis approach. The next step was to design a neural network computer model to predict the overall increase or decreased risk of cancer for individual patients. This would help to determine whether this prediction could be used as a tool to decide if a patient should be considered for testing and to predict diagnosis, as well as to suggest prevention measures to patients. Design: A meta-analysis of existing data was carried out to calculate relative risk, followed by design and implementation of a risk prediction computational model based on a neural network algorithm. Setting: Meta-analysis data were collated from various settings from around the world. Primary data to test the model were collected from a hospital clinic setting. Participants: Data from 40 patients notes currently suspected of having endometrial cancer and undergoing investigations and treatment were collected to test the software with their cancer diagnosis not revealed to the software developers. Main outcome measures: The forest plots allowed an overall relative risk and percentage risk to be calculated from all the risk data gathered from the studies. A neural network computational model to determine percentage risk for individual patients was developed, implemented, and evaluated. Results: The results show that the greatest percentage increased risk was due to BMI being above 25, with the risk increasing as BMI increases. A BMI of 25 or over gave an increased risk of 2.01%, a BMI of 30 or over gave an increase of 5.24%, and a BMI of 40 or over led to an increase of 6.9%. PCOS was the second highest increased risk at 4.2%. Diabetes, which is incidentally also linked to an increased BMI, gave a significant increased risk along with null parity and noncontinuous HRT of 1.54%, 1.2%, and 0.56% respectively. Decreased risk due to contraception was greatest with IUD (intrauterine device) and IUPD (intrauterine progesterone device) at −1.34% compared to −0.9% with oral. Continuous HRT at −0.75% and parity at −0.9% also decreased the risk. Using open-source patient data to test our computational model to determine risk, our results showed that the model is 98.6% accurate with an algorithm sensitivity 75% on average. Conclusions: In this study, we successfully determined the rank order of risk factors for endometrial cancer and calculated a pooled risk and risk percentage for each factor using a statistical meta-analysis approach. Then, using a computer neural network model system, we were able to model the overall increase or decreased risk of cancer and predict the cancer diagnosis for particular patients to an accuracy of over 98%. The neural network model developed in this study was shown to be a potentially useful tool in determining the percentage risk and predicting the possibility of a given patient developing endometrial cancer. As such, it could be a useful tool for clinicians to use in conjunction with other biomarkers in determining which patients warrant further preventative interventions to avert progressing to endometrial cancer. This result would allow for a reduction in the number of unnecessary invasive tests on patients. The model may also be used to suggest interventions to decrease the risk for a particular patient. The sensitivity of the model limits it at this stage due to the small percentage of positive cases in the datasets; however, since this model utilizes a neural network machine learning algorithm, it can be further improved by providing the system with more and larger datasets to allow further refinement of the neural network.

Case-case analysis addressing ascertainment bias for multigene panel testing implicates BRCA1 and PALB2 in endometrial cancer

Hereditary endometrial cancer (EC) is most commonly attributed to pathogenic variants in mismatch repair genes. Evidence supports the existence of additional genetic risk factors in the context of multiple cancer diagnoses and/or family history of EC. EC patients (n = 5292) referred for diagnostic multigene cancer panel testing were annotated for presence of a pathogenic gene variant; personal history of prior, concurrent, or subsequent cancer of another type; reported family history of Lynch syndrome or EC. The Pearson χ² test was used to assess differences in gene variant prevalence between case sub-groups defined by personal and/or family history of cancer/s, using cases with no family history of Lynch/EC as reference. Another cancer diagnosis was reported for 55% of EC cases. EC cases with a prior and reported family history of Lynch cancer were enriched for variants in MLH1 (p = 3.5 × 10^-7 ), MSH2 (p = 3.1 × 10^-7 ), and PMS2 (p = .02). Consistent with expectations for a breast cancer gene also predisposing to EC, the variant frequency was increased in EC patients with prior BC and family history of EC for BRCA1 (p = 1.7 × 10^-5 ) and PALB2 (p = .0002). Strategic case-case analyses to address cohort ascertainment bias have provided a rationale to direct future studies of candidate hereditary EC genes.

Preliminary evaluation on the beneficial effects of pioglitazone in the treatment of endometrial cancer

Endometrial cancer (EMC) is one of the complicated gynecological cancers, affecting more than three million women worldwide. Anticancer strategies such as chemotherapy, radiation, and surgery are found to be ineffective and are associated with patient incompliances. The aim of the present study is to repurpose non-oncological drug, i.e., Pioglitazone, a peroxisome proliferator-activated receptor gamma (PPAR-γ) agonist, in the treatment of endometrial cancer. The study groups consist of 50 female Swiss albino mice, out of which 40 had endometrial cancer induced with N-ethyl-N-nitrosourea (ENU) and estradiol hexadrobenzoate (EHB). The other groups received saline, EHB, paclitaxel, and different test doses of pioglitazones. Different preliminary parameters such as weekly body weight, mean survival time, percentage increase in life span, and uterine tissue weight were analyzed along with histopathological analysis. We observed a significant change in weekly body weight, improvement in percentage life span, and partial restoration of uterine tissue weight to normal compared to a standard drug, paclitaxel. In the present preliminary evaluation, we have identified that pioglitazone exhibited a significant dose-dependent anticancer activity against ENU- and EHB-induced endometrial cancer, compared to the standard paclitaxel.

Cigarette Smoking and Estrogen-Related Cancer

Cigarette smoking is a known cause of many cancers, yet epidemiologic studies have found protective associations with the risk of four "estrogen-related" malignancies: endometrial cancer, endometrioid and clear cell ovarian cancers, and thyroid cancer. This review considers epidemiologic and biological aspects of these associations, focusing particularly on estrogen signaling, and contrasts them with those for breast cancer, another estrogen-related malignancy. The observational findings regarding the inverse associations are consistent and remain after adjustment for possible confounding factors. In general, women who smoke do not have lower circulating estrogen levels than nonsmokers, eliminating one possible explanation for reduced risks of these malignancies. For endometrial and endometrioid ovarian cancer, the negative associations could plausibly be explained by interference with signaling through the estrogen receptor α. However, this is unlikely to explain the lower risks of thyroid and clear cell ovarian cancers. For thyroid cancer, an anti-inflammatory effect of nicotine and reduced TSH levels from smoking have been proposed explanations for the inverse association, but both lack convincing evidence. While the overall impact of cigarette smoking is overwhelmingly negative, protective associations such as those discussed here can provide potential clues to disease etiology, treatment, and prevention.

Pregnancy outcomes and risk of endometrial cancer: A pooled analysis of individual participant data in the Epidemiology of Endometrial Cancer Consortium

A full-term pregnancy is associated with reduced endometrial cancer risk; however, whether the effect of additional pregnancies is independent of age at last pregnancy is unknown. The associations between other pregnancy-related factors and endometrial cancer risk are less clear. We pooled individual participant data from 11 cohort and 19 case-control studies participating in the Epidemiology of Endometrial Cancer Consortium (E2C2) including 16 986 women with endometrial cancer and 39 538 control women. We used one- and two-stage meta-analytic approaches to estimate pooled odds ratios (ORs) for the association between exposures and endometrial cancer risk. Ever having a full-term pregnancy was associated with a 41% reduction in risk of endometrial cancer compared to never having a full-term pregnancy (OR = 0.59, 95% confidence interval [CI] 0.56-0.63). The risk reduction appeared the greatest for the first full-term pregnancy (OR = 0.78, 95% CI 0.72-0.84), with a further ~15% reduction per pregnancy up to eight pregnancies (OR = 0.20, 95% CI 0.14-0.28) that was independent of age at last full-term pregnancy. Incomplete pregnancy was also associated with decreased endometrial cancer risk (7%-9% reduction per pregnancy). Twin births appeared to have the same effect as singleton pregnancies. Our pooled analysis shows that, while the magnitude of the risk reduction is greater for a full-term pregnancy than an incomplete pregnancy, each additional pregnancy is associated with further reduction in endometrial cancer risk, independent of age at last full-term pregnancy. These results suggest that the very high progesterone level in the last trimester of pregnancy is not the sole explanation for the protective effect of pregnancy.

Racial/ethnic differences in anthropometric and hormone-related factors and endometrial cancer risk: the Multiethnic Cohort Study

BACKGROUND

Anthropometric and hormone-related factors are established endometrial cancer risk factors; however, little is known about the impact of these factors on endometrial cancer risk in non-White women.

METHODS

Among 110,712 women participating in the Multiethnic Cohort (MEC) Study, 1150 incident invasive endometrial cancers were diagnosed. Hazard ratios (HRs) and 95% confidence intervals (CIs) for associations with endometrial cancer risk for race/ethnicity and for risk factors across racial/ethnic groups were calculated.

RESULTS

Having a higher body mass index (BMI) at baseline or age 21 years was strongly associated with increased risk (p_int race/ethnicity ≥ 0.36). Parity (vs nulliparity) was inversely associated with risk in all the groups except African Americans (p_int 0.006). Current use of postmenopausal hormones at baseline (PMH-E; vs never use) was associated with increased risk in Whites and Japanese Americans (p_int 0.002). Relative to Whites, endometrial cancer risk was lower in Japanese Americans and Latinas and non-significantly higher in Native Hawaiians. Risk in African Americans did not differ from that in Whites.

CONCLUSIONS

Racial/ethnic differences in endometrial cancer risk were not fully explained by anthropometric or hormone-related risk factors. Further studies are needed to identify reasons for the observed racial/ethnic differences in endometrial cancer risk.

Complications of Pregnancy and the Risk of Developing Endometrial or Ovarian Cancer: A Case-Control Study

BACKGROUND

The association of complications of pregnancy and the risk of developing gynecological cancer is controversial with the limited study. In this study, we investigated the association of preeclampsia, or gestational diabetes mellitus (GDM), or large for gestational age (LGA), or intrauterine growth restriction (IUGR) and the risk of endometrial or ovarian cancer.

METHODS

In this case-control study, 189 women with endometrial cancer and 119 women with ovarian cancer were included. 342 women without gynecological cancers were randomly selected as a control group. Data on the history of pregnancy and age at diagnosis of gynecological cancer as well as the use of intrauterine devices (IUDs) were collected.

RESULTS

Women with a history of preeclampsia or IUGR did not have an increased risk of developing endometrial or ovarian cancer. While women with a history of GDM or with the delivery of LGA infant increased the risk of developing endometrial cancer but not ovarian cancer. The odds of women with a history of GDM or with the delivery of LGA infant developing endometrial cancer was 2.691 (95% CI: 1.548, 4.3635, p=0.0003), or 6.383 (95% CI: 2.812, 13.68, p<0.0001) respectively, compared to the controls. The odds ratio of women who did not use IUDs developing ovarian cancer was 1.606 (95% CI: 1.057, 2.434), compared to the controls. There was no association of age at first birth and developing endometrial or ovarian cancer.

CONCLUSION

Our observational data suggested that GDM and delivery of an LGA infant are associated with an increased risk of endometrial cancer.

Oral contraceptive use by formulation and endometrial cancer risk among women born in 1947-1964: The Nurses' Health Study II, a prospective cohort study

Oral contraceptives (OCs) have been associated with long-term lower endometrial cancer risk; relatively little is known about associations with more recent OC formulations and associations with longer-term risk. A total of 107,069 women from the Nurses’ Health Study II recalled OC use from age 13 to baseline (1989); biennial questionnaires updated data on OC use until 2009. OCs were classified by estrogen and progestin type, dose, and potency based on reported brand. 864 incident endometrial cancer cases were identified through 2017. Multivariable Cox proportional hazards models estimated hazard ratios (HR) and 95% confidence intervals [95% CI] for the association of OC use with endometrial cancer risk. OC use was associated with lower endometrial cancer risk (ever use, HR 0.77 [95% CI 0.65–0.91]; >10 years of use, 0.43 [0.32–0.58] vs. never OC use). Inverse associations for duration were evident regardless of time since last use. Longer durations (> 5 years) of ethinyl estradiol (0.52 [0.41–0.67]) and second-generation progestins (0.43 [0.30–0.61]), both versus never use, were more strongly associated with lower risk than mestranol (0.66 [0.50–0.88], p-het = 0.01) and first-generation progestins (0.62 [0.49–0.78], p-het = 0.03). Inverse associations were generally observed for cross-classified cumulative average estrogen and progestin dose and potency (< vs. ≥ median; ever use vs. never OC use), with the exception of high estrogen and low progestin dose. OCs were associated with lower endometrial cancer risk, independent of time since last use. Use of ethinyl estradiol and second-generation progestins were more strongly inversely associated with risk compared with older formulations.

Effect of Radiotherapy in Addition to Surgery in Early Stage Endometrial Cancer: A Population-Based Study

BACKGROUND

The role of radiotherapy in the management of early (FIGO I) endometrial cancer is controversial with limited availability of prospective data from randomized trials.

METHODS

German Epidemiologic Cancer Registries provided by the Robert Koch Institute. We considered FIGO I cases with recorded operative treatment (n = 12,718, 2000-2017). We computed hazard ratios (HR) from relative survival models in relation to the mortality of the general population with 95% confidence intervals (CI). Multivariate models were adjusted for age, stage (IA vs. IB), grading, and chemotherapy. Radiotherapy included external radiotherapy and brachytherapy.

RESULTS

Cases with a favorable risk profile (FIGO IA, G1/G2) had a slightly lower survival rate, relative to the general population (FIGO IA: 0.9, G1: 0.91). The proportion of FIGO IA cases was lower in the radiotherapy group (52.6%) vs. cases without radiotherapy (78.6%). Additional treatment with radiotherapy was beneficial in FIGO IB (HR = 0.74) and all histopathological grades, but not FIGO IA cases (HR = 0.93) cases. Compared to IA tumors, IB cases had a HR of 1.51 (95% CI: 1.34-1.7).

CONCLUSIONS

Radiotherapy in addition to surgery is beneficial for patients in a FIGO IB stage. Further studies need to address the impact of new techniques and risk assessment.

Population-Based Screening for Endometrial Cancer: Human vs. Machine Intelligence

Incidence and mortality rates of endometrial cancer are increasing, leading to increased interest in endometrial cancer risk prediction and stratification to help in screening and prevention. Previous risk models have had moderate success with the area under the curve (AUC) ranging from 0.68 to 0.77. Here we demonstrate a population-based machine learning model for endometrial cancer screening that achieves a testing AUC of 0.96. We train seven machine learning algorithms based solely on personal health data, without any genomic, imaging, biomarkers, or invasive procedures. The data come from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO). We further compare our machine learning model with 15 gynecologic oncologists and primary care physicians in the stratification of endometrial cancer risk for 100 women. We find a random forest model that achieves a testing AUC of 0.96 and a neural network model that achieves a testing AUC of 0.91. We test both models in risk stratification against 15 practicing physicians. Our random forest model is 2.5 times better at identifying above-average risk women with a 2-fold reduction in the false positive rate. Our neural network model is 2 times better at identifying above-average risk women with a 3-fold reduction in the false positive rate. Our machine learning models provide a non-invasive and cost-effective way to identify high-risk sub-populations who may benefit from early screening of endometrial cancer, prior to disease onset. Through statistical biopsy of personal health data, we have identified a new and effective approach for early cancer detection and prevention for individual patients.

Early life household intactness and timing of pubertal onset in girls: a prospective cohort study

Background

Girls who experience early-life familial stress may have heightened risk of early puberty, which has adverse implications for adolescent and adult health. We assessed the association between household intactness and pubertal onset using a racially/ethnically diverse cohort of girls from Northern California.

Methods

A prospective cohort study of 26,044 girls born in 2003-10. Girls living with both parents from birth up to 6 years were considered to come from “intact” households while others constituted “non-intact” households. Pubertal development was measured using pediatrician-assessed Tanner staging for breast and pubic hair. Pubertal onset was defined as the transition from Tanner Stage 1 to 2+ for breast (thelarche) and pubic hair (pubarche). Menarche data was collected from routine well-child questionnaires. Weibull regression models accommodating left, right, and interval censoring were used to determine risk of earlier thelarche and pubarche, and logistic regressions were used to assess the risk of early menarche (age < 12).

Results

Girls exposed to non-intact households before age 2 years were at increased risk for earlier thelarche and pubarche with significant effect modification by race/ethnicity, compared with girls from intact households. The associations were strongest among Black girls (adjusted hazard ratio [HR]: 1.60, 95% confidence interval [CI]: 1.29,1.98; HR: 1.42, 95%CI: 1.15,1.77 for thelarche and pubarche, respectively). There were no significant associations among Asian/Pacific Islanders. Girls who lived in non-intact households before age 2 years were also at increased risk for earlier menarche, but without race/ethnic interaction. Adjustment for prepubertal obesity did not change these associations. Associations between living in non-intact households after age 2 years and early puberty were weaker but still significant.

Conclusions

Exposure to a non-intact household early in life may increase the risk of early puberty in girls. Future psychosocial interventions focused on improving family cohesiveness and efforts to reduce childhood stress among families that are non-intact may mitigate these negative associations, thereby preventing future adverse health effects of early puberty and health disparities.

Betaglycan Gene (TGFBR3) Polymorphism Is Associated with Increased Risk of Endometrial Cancer

We investigated single nucleotide polymorphism (SNP) of the betaglycan gene (TGFBR3) encoding the TGFβ co-receptor in endometrial cancer (EC) and its association with betaglycan expression. The study group included 153 women diagnosed with EC and 248 cancer-free controls. SNP genotyping and gene expression were analyzed using TaqMan probes. Three out of the eight SNPs tested, i.e., rs12566180 (CT; OR = 2.22; 95% CI = 1.15-4.30; p = 0.0177), rs6680463 (GC; OR = 2.34; 95% CI = 1.20-4.53; p = 0.0120) and rs2296621 (TT; OR = 6.40; 95% CI = 1.18-34.84; p = 0.0317) were found to be significantly associated with increased risk of EC (adjusted to age, body mass index, menarche and parity). Among the analyzed SNPs, only rs2296621 demonstrated the impact on the increased cancer aggressiveness evaluated by the WHO grading system (G3 vs. G1/2, GT-OR = 4.04; 95% CI = 1.56-10.51; p = 0.0026; T-OR = 2.38; 95% CI = 1.16-4.85; p = 0.0151). Linkage disequilibrium (LD) analysis revealed high LD (r2 ≥ 0.8) in two haploblocks, constructed by rs2770186/rs12141128 and rs12566180/rs6680463, respectively. In the case of C/C haplotype (OR = 4.82; 95% CI = 1.54-15.07; p = 0.0116-Bonferroni corrected) and T/G haplotype (OR = 3.25; 95% CI = 1.29-8.15; p = 0.0328-Bonferroni corrected) in haploblock rs12566180/rs6680463, significantly higher frequency was observed in patients with EC as compared to the control group. The genotype-phenotype studies showed that SNPs of the TGFBR3 gene associated with an increased risk of EC, i.e., rs12566180 and rs2296621 may affect betaglycan expression at the transcriptomic level (rs12566180-CC vs. TT, p < 0.01; rs2296621-GG vs. TT, p < 0.001, GT vs. TT, p < 0.05). Functional consequences of evaluated TGFBR3 gene SNPs were supported by RegulomeDB search. In conclusion, polymorphism of the TGFBR3 gene may be associated with an increased EC occurrence, as well as may be the molecular mechanism responsible for observed betaglycan down-regulation in EC patients.

Nutrient Intake through Childhood and Early Menarche Onset in Girls: Systematic Review and Meta-Analysis

Among the genetic and environmental risk factors, nutrition plays a crucial role in determining the timing of puberty. Early menarche onset (EMO) is defined as when girls reach menarche onset at an age which is earlier than the mean/median age of menarche, between 12 and 13 years of age, according to individual ethnicity. The present study examined the association between nutrient intake in childhood and EMO risk in healthy girls by performing a systematic review and meta-analysis of prospective studies. We screened EMBASE, Cochrane Library, PubMed/MEDLINE, and Web of Science databases for 16 eligible studies with all medium-to-high quality scores ranging from 3 to 5 of 6 possible points with 10,884 subjects. Higher intakes of energy (risk ratio (RR) = 3.32, 95% confidence interval (CI) = 1.74–6.34, I² = 97%), and protein (RR = 3.15, 95% CI = 2.87–3.44, I² = 0%) were associated with EMO risk. For each additional 1 g/day animal protein intake in childhood, the age at menarche was approximately two months earlier (β = −0.13, I² = 55%), and high iron intake was associated with EMO (RR = 1.20, 95% CI = 1.03–1.40, I² = 0%). Polyunsaturated fatty acid (PUFAs) intake was associated with EMO risk with a dose-response effect (RR = 1.25, 95% CI = 1.05–1.49, I² = 44%). Girls with a high intake of fiber and monosaturated fatty acids (MUFAs) in childhood experienced later menarche onset (RR = 0.83, 95% CI = 0.69–1.00, I² = 31%; RR = 0.66, 95% CI = 0.50–0.86, I² = 0%, respectively). Thus, adherence to a high intake of animal proteins-, iron- and PUFA-rich food diet makes girls more likely to have EMO, while a high intake of fiber- and MUFA-rich foods may protect girls from EMO. Further studies are expected to investigate the role of specific types of PUFAs and MUFAs on EMO to promote healthy sexual maturity in girls.

Altered Organelle Calcium Transport in Ovarian Physiology and Cancer

Calcium levels have a huge impact on the physiology of the female reproductive system, in particular, of the ovaries. Cytosolic calcium levels are influenced by regulatory proteins (i.e., ion channels and pumps) localized in the plasmalemma and/or in the endomembranes of membrane-bound organelles. Imbalances between plasma membrane and organelle-based mechanisms for calcium regulation in different ovarian cell subtypes are contributing to ovarian pathologies, including ovarian cancer. In this review, we focused our attention on altered calcium transport and its role as a contributor to tumor progression in ovarian cancer. The most important proteins described as contributing to ovarian cancer progression are inositol trisphosphate receptors, ryanodine receptors, transient receptor potential channels, calcium ATPases, hormone receptors, G-protein-coupled receptors, and/or mitochondrial calcium uniporters. The involvement of mitochondrial and/or endoplasmic reticulum calcium imbalance in the development of resistance to chemotherapeutic drugs in ovarian cancer is also discussed, since Ca²⁺ channels and/or pumps are nowadays regarded as potential therapeutic targets and are even correlated with prognosis.

Toenail metal concentrations and age at menopause: A prospective study

BACKGROUND

Menopause timing is related to cancer, cardiovascular disease, and mortality. Lead has been associated with an earlier age at menopause, but no study has considered exposure to other metals or multiple metals simultaneously.

METHODS

At baseline, we measured toenail concentrations of 16 metals for 903 premenopausal women in the Sister Study (2003-2009). Age at menopause was ascertained through follow-up questionnaires. Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations between individual metals and age at menopause. We used quantile-g-computation to examine the association between age at menopause and the joint effect of a simultaneous increase in (1) all metals and for subgroups of metals categorized as (2) essential or (3) non-essential.

RESULTS

For individual metals, we observed negligible associations except for an interquartile range increase in lead which was modestly associated with an earlier age at menopause (HR = 1.03, 95% CI = 1.01, 1.05). In the mixture analyses, a quartile increase in all metals was associated with a later age at menopause (HR = 0.81, 95% CI = 0.64, 1.02). The metals with the largest negative contributions (i.e., associated with a later age at menopause) were chromium and nickel. The joint effect for the essential metals remained inverse (HR = 0.83, 95% CI = 0.64, 1.07), but was attenuated for nonessential metals (HR = 0.98, 95% CI = 0.76, 1.24).

CONCLUSIONS

Although no individual metal was strongly associated with age at menopause, our joint effect analysis suggests that having low levels of essential metals could be associated with an earlier age at menopause.

Interpregnancy and interbirth intervals and all-cause, cardiovascular-related and cancer-related maternal mortality: findings from a large population-based cohort study

INTRODUCTION

Scarce research is available regarding the association between interbirth intervals (IBI) and long-term maternal health outcomes, particularly cardiovascular disease (CVD) mortality. We aimed to assess whether IBIs were associated with all-cause, CVD-related and cancer-related mortality.

METHODS

We conducted a cohort study in the setting of the Jerusalem Perinatal Study. Women with at least two consecutive singleton live births in 1964-1976 (N=18 294) were followed through 2016. IBIs were calculated as the interval between women's first and second cohort birth. We estimated associations between IBIs and mortality using Cox's proportional hazards models, adjusting for age, parity, maternal education, maternal origin and paternal socioeconomic status. Date of last menstrual period was available for a subset of women. We assessed the interpregnancy interval (IPI) for these women and compared the models using IPI and IBI.

RESULTS

During 868 079 years of follow up (median follow-up: 49.0 years), 3337 women died. Women with IBIs <15 months had higher all-cause mortality rates (HR 1.18; 95% CI 1.05 to 1.33) compared to women with 33-month to 68-month IBIs (reference category). IBI and CVD mortality appeared to have a J-shaped association; IBIs of <15, 15-20, 21-2626-2632, 33-68 and ≥69 months had HRs of 1.44, 1.40, 1.33, 1.14, 1.00 and 1.30, respectively. No substantial association was found with cancer mortality. Models using IPIs and those using IBI were similar.

CONCLUSION

Our results support the WHO recommendations for IPIs of ≥24 months and add additional evidence regarding long-term CVD mortality.

Association between the incidence and mortality rates for corpus uteri cancer and human development index (HDI): a global ecological study

Objective

The aim of this study was to determine the association between the incidence of and mortality due to corpus uteri cancer (CUC) and the human development index (HDI) across the world.

Methods

This was an ecological study. The incidence and mortality rates of CUC along with HDI data were extracted from the Global Cancer Data in 2018. Subsequently, correlation coefficient and linear regression model were used to determine the association between the incidence and mortality rates of CUC and the HDI. STATA-14 was used for data analysis.

Results

There was a positive and significant correlation between the incidence (r=0.693; P<0.001) and mortality (r=0.284; P<0.001) rates of uterine cancer and the HDI. A positive and significant correlation was also observed between the incidence rate and the gross national income per 1,000 capita (r=0.440; P<0.001), mean years of schooling (MYS) (r=0.740; P<0.001), life expectancy at birth (LEB) (r=0.590; P<0.001), and expected years of schooling (r=0.650; P<0.001). The results of the linear regression model showed a significant statistical association between MYS and the incidence of CUC (β=1.10; 95% confidence interval [CI], 0.60-1.70) and LEB and mortality due to uteri cancer (β=0.40; 95% CI, 0.10-0.90).

Conclusion

The results of this study suggest a significant statistical association between the incidence and mortality rates of CUC and the HDI.

Socioeconomic inequalities in cancer incidence in Europe: a comprehensive review of population-based epidemiological studies

Background

Since the end of the previous century, there has not been a comprehensive review of European studies on socioeconomic inequality in cancer incidence. In view of recent advances in data source linkage and analytical methods, we aimed to update the knowledge base on associations between location-specific cancer incidence and individual or area-level measures of socio-economic status (SES) among European adults.

Materials and methods

We systematically searched three databases (PubMed, Scopus and Web of Science) for articles on cancer incidence and SES. Qualitative synthesis was performed on the 91 included English language studies, published between 2000 and 2019 in Europe, which focused on adults, relied on cancer registry data and reported on relative risk (RR) estimates.

Results

Adults with low SES have increased risk of head and neck, oesophagogastric, liver and gallbladder, pancreatic, lung, kidney, bladder, penile and cervical cancers (highest RRs for lung, head and neck, stomach and cervix). Conversely, high SES is linked with increased risk of thyroid, breast, prostate and skin cancers. Central nervous system and haematological cancers are not associated with SES. The positive gap in testicular cancer has narrowed, while colorectal cancer shows a varying pattern in different countries. Negative associations are generally stronger for men compared to women.

Conclusions

In Europe, cancers in almost all common locations are associated with SES and the inequalities can be explained to a varying degree by known life-style related factors, most notably smoking. Independent effects of many individual and area SES measures which capture different aspects of SES can also be observed.

Global, Regional, and National Burden of Endometrial Cancer, 1990-2017: Results From the Global Burden of Disease Study, 2017

Endometrial cancer (EC) is the most common malignancy affecting women in developed countries. Recently, the EC disease burden has changed; therefore, the Global Burden of Disease (GBD) 2017 was used to comprehensively analyze the global, regional, and national burden of EC between 1990 and 2017. General GBD cancer estimation methods were used with the data input from vital registration systems and cancer registries. Annual percent changes were calculated to quantify the trends of EC burden estimates during the study period. Furthermore, the sociodemographic index (SDI) was used to assess the relationship between the EC burden estimates and development level. From 1990 to 2017, the age-standardized incidence and prevalence rate of EC increased globally by 0.58 and 0.89% per year, respectively. In contrast, the age-standardized death rate and disability-adjusted-life years (DALYs) decreased by 1.19 and 1.21% per year, respectively. Increasing trends in both the incidence and prevalence were observed in all SDI quintiles, except for the low SDI quintiles, whereas decreasing trends were observed in all SDI quintiles for mortality and DALYs. Additionally, a non-linear association existed for the level of mortality rate, DALYs, and SDI. Of note, there was a strong positive association between a high body mass index and DALYs across all SDI quintiles. In conclusion, EC incidence and prevalence rates are growing globally, whereas the death rate and DALYs decreased between 1990 and 2017. Greater efforts, particularly detailed prevention strategies for reducing obesity, should be performed to reverse this phenomenon.

Pregnancy duration and endometrial cancer risk: nationwide cohort study

OBJECTIVE

To explore the association between pregnancy duration and risk of endometrial cancer.

DESIGN

Nationwide register based cohort study.

SETTING

Denmark.

PARTICIPANTS

All Danish women born from 1935 to 2002.

MAIN OUTCOME MEASURES

Relative risk (incidence rate ratio) of endometrial cancer by pregnancy number, type, and duration, estimated using log-linear Poisson regression.

RESULTS

Among 2 311 332 Danish women with 3 947 650 pregnancies, 6743 women developed endometrial cancer during 57 347 622 person years of follow-up. After adjustment for age, period, and socioeconomic factors, a first pregnancy was associated with a noticeably reduced risk of endometrial cancer, whether it ended in induced abortion (adjusted relative risk 0.53 (95% confidence interval 0.45 to 0.64) or childbirth (0.66, 0.61 to 0.72). Each subsequent pregnancy was associated with an additional reduction in risk, whether it ended in induced abortion (0.81, 0.77 to 0.86) or childbirth (0.86, 0.84 to 0.89). Duration of pregnancy, age at pregnancy, spontaneous abortions, obesity, maternal birth cohort, fecundity, and socioeconomic factors did not modify the results.

CONCLUSIONS

The risk of endometrial cancer is reduced regardless of whether a pregnancy ends shortly after conception or at 40 weeks of gestation. This reduction in risk could be explained by a biological process occurring within the first weeks of pregnancy, as pregnancies ending in induced abortions were associated with similar reductions in risk as pregnancies ending in childbirth.

Breastfeeding and timing of pubertal onset in girls: a multiethnic population-based prospective cohort study

Background

Early puberty is associated with higher risk of adverse health and behavioral outcomes throughout adolescence and adulthood. US girls are experiencing earlier puberty with substantial racial/ethnic differences. We examined the association between breastfeeding and pubertal timing to identify modifiable risk factors of early puberty and potential sources of racial/ethnic differences in the timing of pubertal development.

Methods

A prospective cohort study of 3331 racially/ethnically diverse girls born at Kaiser Permanente Northern California (KPNC) between 2004 and 06. All data were obtained from KPNC electronic clinical and administrative datasets. Mother-reported duration of breastfeeding was obtained from questionnaires administered at each ‘well-baby’ check-up exam throughout the baby’s first year and categorized as ‘Not breastfed’, ‘Breastfed < 6 months’, and ‘Breastfed ≥ 6 months’. Pubertal development data used Tanner stages assessed by pediatricians during routine pediatric checkups starting at age 6. Pubertal onset was defined as transition from Tanner Stage 1 to Tanner Stage 2+ for breast (thelarche) and pubic hair (pubarche). Weibull regression models accommodating for left, right, and interval censoring were used in all analyses. Models were adjusted for maternal age, education, race/ethnicity, parity and prepubertal body mass index (BMI). We also examined race/ethnicity as a potential effect modifier of these associations.

Results

Not breastfeeding was associated with earlier onset of breast and pubic hair development compared to breastfeeding ≥6 months (adjusted hazard ratio [HR]: 1.25; 95% confidence interval [CI]: 1.07–1.46; HR: 1.24; 95% CI: 1.05–1.46, respectively). Breastfeeding for < 6 months was also associated with the risk of earlier pubic hair development (HR: 1.14; 95% CI: 1.00–1.30, compared to breastfeeding ≥6 months). Inclusion of girls’ prepubertal BMI slightly attenuated the association between breastfeeding and timing of breast onset but remained significant. The association between not breastfeeding and early breast development may be stronger among African American girls (HR: 1.92; 95% CI: 1.01–3.66, no breastfeeding vs. ≥6 months) than other racial/ethnic groups.

Conclusions

Breastfeeding is an independent predictor of pubertal onset in girls, and the strength of the association may vary by race/ethnicity. Providing breastfeeding support and lactation education for high risk mothers may help prevent earlier pubertal onset and promote positive health outcomes later in life.

Changing Incidence of Uterine Cancer in Rural Egypt: Possible Impact of Nutritional and Epidemiologic Transitions

PURPOSE

Uterine cancer is a top-ranking women's cancer worldwide, with wide incidence variations across countries and by rural and urban areas. Hormonal exposures and access to health care vary between rural and urban areas, globally. Egypt has an overall low incidence of uterine cancer but variable rural and urban lifestyles. Are there changes in the incidence of uterine cancer in rural and urban areas in middle-income countries such as Egypt? No previous studies have addressed this question from a well-characterized and validated population-based cancer registry resource in middle-income countries. The aim of this study was to explore the differences in clinical and demographic characteristics of uterine cancer over the period of 1999 to 2010 in rural and urban Gharbiah province, Egypt.

METHODS

Data were abstracted for all 660 patients with uterine cancer included in the Gharbiah Population-based Cancer Registry. Clinical variables included tumor location, histopathologic diagnosis, stage, grade, and treatment. Demographic variables included age, rural or urban residence, parity, and occupation. Crude and age-adjusted incidence rates (IRs) and rate ratios by rural or urban residence were calculated.

RESULTS

No significant differences were observed in most clinical and demographic characteristics between rural and urban patients. The age standardized IR (ASR) was 2.5 times higher in urban than in rural areas (6.9 and 2.8 per 100,000 in urban and rural areas, respectively). The rate ratio showed that the IR in urban areas was 2.46 times the rate in rural areas.

CONCLUSION

This study showed that the disease IR in rural areas has increased in the past decade but is still low compared with the incidence in urban areas in Egypt, which did not show a significant increase in incidence. Nutritional transitions, obesity, and epidemiologic and lifestyle changes toward Westernization may have led to IRs increasing more in rural than in urban areas in Egypt. This pattern of increasing incidence in Egypt, which used to have a low incidence of uterine cancer, may appear in other middle-income countries that experience emerging nutritional and epidemiologic transitions. The rate of uterine cancer in urban areas in Gharbiah is almost similar to the corresponding rates globally. However, the rate in rural areas in this population has increased over the past decade but is still lower than the corresponding global rates. Future studies should examine the etiologic factors related to increasing rates in rural areas and quantify the improvement in rural case finding.

Associations of Maternal Gestational Weight Gain and Obesity With the Timing of Pubertal Onset in Daughters

Early puberty is associated with adverse health outcomes, but little is known regarding early-life determinants influencing pubertal timing. We examined the associations between maternal gestational weight gain (GWG) and the timing of the onset of breast development (thelarche) and pubic hair development (pubarche) in a cohort of 2,070 girls born in a Kaiser Permanente Northern California facility between 2005 and 2006. Using Weibull regression models accommodating interval censoring and adjusting for important confounders, we found that excess GWG was associated with increased risk of early thelarche (hazard ratio (HR) = 1.50, 95% confidence interval (CI): 1.26, 1.78) and early pubarche (HR = 1.35, 95% CI: 1.10, 1.66). Inadequate GWG was associated with early thelarche (HR = 1.36, 95% CI: 1.08, 1.71). The associations between excess or inadequate GWG and risk of earlier thelarche were stronger if mothers were obese before or at the beginning of pregnancy (body mass index ≥30 kg body weight per m height squared) (HR = 2.01, 95% CI: 1.53, 2.63; HR = 2.08, 95% CI: 1.45, 2.98, respectively). Similar associations were found for pubarche outcome. Inclusion of girls' prepubertal body mass index slightly attenuated these associations, but they remained significant. Monitoring of maternal weight before and throughout pregnancy might help prevent early pubertal onset and subsequent negative health outcomes.

Associations of pregnancy-related factors and birth characteristics with risk of endometrial cancer: A Nordic population-based case-control study

Many pregnancy-related factors are associated with reduced endometrial cancer risk. However, it remains unclear whether pregnancy-related complications (e.g., hypertensive conditions) are associated with risk and whether these associations vary by endometrial cancer subtype. Thus, we evaluated the risk of endometrial cancer, overall and by subtype, in relation to pregnancy-related factors, pregnancy complications and birth characteristics. Utilizing population-based register data from four Nordic countries, we conducted a nested case-control analysis of endometrial cancer risk. We included 10,924 endometrial cancer cases and up to 10 matched controls per case. Odds ratios (ORs) with 95% confidence intervals (CIs) were derived from unconditional logistic regression models. We further evaluated associations by individual histology (i.e., endometrioid, serous, etc.) or, for rare exposures (e.g., pregnancy complications), by dualistic type (Type I [n = 10,343] and Type II [n = 581]). Preexisting and pregnancy-related hypertensive conditions were associated with increased endometrial cancer risk (OR [95% CI]: preexisting hypertension 1.88 [1.39-2.55]; gestational hypertension 1.47 [1.33-1.63]; preeclampsia 1.43 [1.30-1.58]), with consistent associations across dualistic type. Increasing number of pregnancies (≥4 vs. 1 birth: 0.64 [0.59-0.69]) and shorter time since last birth (<10 vs. ≥30 years: 0.34 [0.29-0.40]) were associated with reduced endometrial cancer risk, with consistent associations across most subtypes. Our findings support the role for both hormonal exposures and cell clearance as well as immunologic/inflammatory etiologies for endometrial cancer. This research supports studying endometrial hyperplasia, a precursor condition of endometrial cancer, in the context of pregnancy-related exposures, as this may provide insight into the mechanisms by which pregnancy affects subsequent cancer risk.

A Prospective Evaluation of Serum Vitamin D (1, 25(OH)2 D3) and Endogenous Sex Hormone Levels in Colorectal Cancer Patients

Background: Data on 25-OH VD concentrations and the associated factors in colorectal cancer (CRC) patients are scarce and need to be investigated.

Methods: A total of 200 CRC patients participated in this cross-sectional study conducted in Pakistan. Socio-demographic and other health data were collected in a pretested questionnaire. Serum measurements of Vitamin D (1, 25(OH)₂ D₃) levels and hormones were performed. Association of age, sex, primary site, effects of hormone therapy and stage of disease and selected reproductive health indicators on vitamin D status were primarily scrutinized by univariate analysis.

Results: Mean age of the population was 55.3 years (±15.6; Range: 20–90 years). Estradiol concentration was considerably elevated in young females compared to young male patients (p < 0.001). The concentrations of FSH, LH testosterone and estradiol were significantly lower in post-menopausal female CRC patients as compared to their male counterparts of old age (p, for all trends < 0.05). Both LH and FSH showed significant gender difference but only in older patients. Level of estrogen was markedly decreased in older post-menopausal CRC patients compared to premenopausal CRC patients, which might be associated with CRC progression. In the group of women, who “ever used hormone therapy” had differences of statistical significance (p, for all trends < 0.05) in their mean serum 25-OH VD concentrations, while in the group of women who “never used hormone therapy” had non-significant differences in their mean serum 25-OH VD concentrations (p, for all trends > 0.05). High 25-OH VD concentrations were observed in women who had their menarche at the age of 15 years or more. Nulliparous women had the highest mean 25-OH VD concentrations as compared to unparious or multiparious women. In addition, women having their menopause at 40–44 years of age had the highest 25-OH VD concentrations, although the difference was not significant (p = 0.08). Women who “never used any oral contraceptive” had higher 25-OH VD concentrations as compared to those “whoever used oral contraceptives.”

Conclusion: Our findings suggest that vitamin D has a positive effect on the development of CRC through the mediation of hormones. Other health and reproductive traits that affect hormone levels may have an indirect effect on the development of CRC. Further potential studies that directly evaluate levels of circulating hormones and hormone therapy in women in association to 25-OH VD concentrations, as well as their possible role in colorectal cancer risk, would be vastly edifying.

Age at Menopause and Risk of Developing Endometrial Cancer: A Meta-Analysis

Object

The association of age at menopause with endometrial cancer remains controversial. Therefore, we quantitatively summarized the evidence from observational studies with a meta-analysis.

Methods

We searched PubMed, Web of Science, Embase, Medline, Chinese National Knowledge Infrastructure (CNKI), and Wan Fang Med online up to March 2019, and all eligible case-control and cohort studies were included in the study. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated using the random-effects model. The dose-response relationship was assessed by restricted cubic spline model. The heterogeneity among studies was evaluated by I². Metaregression was used to explore the potential sources of between-study heterogeneity. Egger's test was used to estimate publication bias.

Results

Eighteen articles including 957242 subjects with 4781 cases were included in the meta-analysis. The pooled RR (95%CI) of endometrial cancer for the highest versus the lowest age at menopause was 1.89 (95%CI: 1.58-2.26). For dose-response analysis, a nonlinear relationship was found between age at menopause and endometrial cancer, and the positive association became statistically significant when age at menopause was greater than 46.5 years old.

Conclusions

This meta-analysis suggested that age at menopause was positively associated with endometrial cancer. For women whose menopausal age over 46.5 years old, the risk of endometrial cancer increased with the age at menopause.

Combined estrogen-progestin pill is a safe and effective option for endometrial hyperplasia without atypia: a three-year single center experience

Objective

To evaluate the effectiveness of oral contraceptive pill (OCP) as therapy for endometrial hyperplasia (EH) without atypia in reproductive-aged women compared with oral progestin.

Methods

A retrospective cohort study was carried out in our reproductive center. Consecutive patients diagnosed with infertility and non-atypical EH identified through electronic database who met inclusion criteria (n=309). Patients were assigned to two treatment groups: OCP (n=216) and oral progestin (n=93); clinical and reproductive outcomes were recorded.

Results

Reversal of EH to normal endometrium, clinical pregnancy, live birth and miscarriage rate. Women in OCP group were younger, had higher prevalence of Polycystic Ovary Syndrome and other uterine pathology and longer duration of infertility than women in progestin group. Reversal of EH was observed in 93.52% women on OCP and in 86.02% women on progestin (p=0.032; adjusted odds ratio [aOR]= 2.35; 95% confidence interval [CI]=1.06-5.21) after the initial course of treatment for 2 to 6 months. Cyclic OCP (n=184) resulted in better response to treatment compared to continuous OCP (n=32) (95.11% vs. 84.38%; p=0.039; aOR =3.60; 95% CI =1.12-11.55). Clinical pregnancy rate in OCP group was marginally higher than progestin group (87/208, 41.83% vs. 27/90, 30.00%; p=0.054). Miscarriage (25.29% vs. 29.63%; p=0.654) and live birth rate (31.25% vs. 21.11%; p=0.074) were comparable between the groups.

Conclusion

For the first time we demonstrate that OCP is an effective therapy for non-atypical EH and is associated with higher remission rate compared with oral progestin. Reproductive outcomes are reassuring and comparable between the two groups.

Reproductive cancer risk factors among relatives of cancer patients in a tertiary oncology center

Background

The aim of this study was to evaluate the prevalence of some gynecological cancer risk factors in a population of female relatives of cancer patients in Hacettepe University Oncology Hospital. Additionally, what are the levels of the women’s awareness /behavior toward available screening tools?

Methods

An individual cancer risk assessment questionnaire has been developed in the Department of Preventive Oncology, which questions the medical history, health behaviors and cancer awareness, as well as their behavior toward available cancer screening tools.

Results

The mean age of the study population was 45.7 ± 12.2 years. Median age at menarche was 13 years (IQR, 12–14), 6.9% of the women reported their menarche was before age of 12. About 11.1% of the women had intercourse before age of 18. The median age at first delivery was 22 years. Median BMI was 24.9, with 18.3% of population having obesity. Of the women 65% were current/past smokers. Sixty-two percent of the women had never used condom. About 8% of the women were unaware about mammography and 17.7% about the Pap test.

Conclusions

This study has documented high tobacco use, low protective condom use and low rates of physical activity. Percentage of some risk factors like early menarche was lower than what was suggested for general Turkish population. Awareness and behavior of the women were better about mammography when compared to the Pap test. Considering our results, some measures should be put in place to increase people’s awareness, and to modify their behavior toward cancer prevention.

Increased Incidence of Endometrial Cancer Following the Women's Health Initiative: An Assessment of Risk Factors

BACKGROUND

The Surveillance, Epidemiology, and End Result (SEER) database shows a variable increase in endometrial cancer incidence over time. The objective of this review was to examine published endometrial cancer rates and potential etiologies.

METHODS

Endometrial cancer incidence was obtained from the SEER Program database from 1975 through 2014, and a test for trend in incidence was calculated. Changes in risk factors thought to be associated with endometrial cancer, including age, obesity, diabetes, diet and exercise, reproductive factors, and medications (hormone therapy [HT] including Food and Drug Administration [FDA]-approved and non-FDA-approved [compounded] estrogens and progestogens, tamoxifen, and hormonal contraceptives) were found through PubMed searches. Temporal trends of risk factors were compared with endometrial cancer trends from SEER.

RESULTS

Although endometrial cancer rates were constant from 1992 to 2002 (women 50-74 years of age), they increased 2.5% annually with a 10% increase from 2006 to 2012 (trend test 0.82). Use of approved prescription estrogen-progestogen combination products decreased after the publication of the Women's Health Initiative (WHI) data, whereas other risk factors either remained constant or decreased during the same time; however, compounded bioidentical HT (CBHT) use increased coincident with the endometrial cancer increase.

CONCLUSION

Endometrial cancer rate increases after the first publication of WHI data in 2002 may be associated with the decreased use of approved estrogen-progestogen therapy, the increase in CBHT use, and the prevalence of obesity and diabetes; potential relationships require further evaluation.

Association of Combined Estrogen-Progestogen and Progestogen-Only Contraceptives with the Development of Cancer

Combined estrogen-progestogen contraceptives (oral contraceptives or OCs) and progestogen-only contraceptives (POCs) are synthetic steroids that bind to steroid hormone receptors, which are widespread throughout the body. They have a profound effect on cellular physiology. Combined OCs have been classified by the International Agency for Research on Cancer (IARC) as Group 1 carcinogens, but their findings have not been updated recently. In order to update the information and better understand the impact that OCs and POCs have on the risk of development of cancers, a comprehensive literature search was undertaken, focusing on more recently published papers. In agreement with the IARC, the recent literature confirms an increased risk of breast cancer and cervical cancer with the use of OCs. The recent literature also confirms the IARC conclusion that OCs decrease the risk of ovarian and endometrial cancers. However, there is little support from recent studies for the IARC conclusion that OCs decrease the risk of colorectal cancer or increase the risk of liver cancer. For liver cancer, this may be due to the recent studies having been performed in areas where hepatitis is endemic. In one large observational study, POCs also appear to increase the overall risk of developing cancer. OCs and POCs appear to increase the overall risk of cancer when carefully performed studies with the least intrinsic bias are considered.

Summary

OCs have been classified as cancer-causing agents, especially leading to increases in breast cancer and cervical cancer. A review of the recent scientific literature was performed to see whether this still appears to be the case. The recent literature supports the cancer-causing role of OCs especially for breast cancer and cervical cancer. Studies also indicate that progesterone-only contraceptives (such as implants and vaginal rings) also can cause cancer. This is especially true for breast cancer and cervical cancer.

Age at Menarche and Menstrual Abnormalities in Adolescence: Does it Matter? The Evidence from a Large Survey among Italian Secondary Schoolgirls

OBJECTIVE

To explore the independent role of age at menarche on menstrual abnormalities among adolescents.

METHODS

The present study was a multicenter cross-sectional study on a large sample (n = 3782) of Italian girls aged 13-21 y attending secondary school who already had menarche. Girls were asked to fill in a questionnaire on menarcheal age and menstrual features during the latest three menses. The gynecological age was computed as the difference between age at the survey and the age at menarche. Main outcome measures were: prevalence of oligomenorrhea, polymenorrhea, menstrual cycle irregularity, abnormal bleeding length and dysmenorrhea. Irregularity in the recent past and since menarche was also studied. Multiple logistic models were used to identify any independent association between each abnormal feature and age at menarche or gynecological age. Adjusted ORs and 95%CI were performed.

RESULTS

After adjusting for covariates, menarcheal age was not independently associated with polymenorrhea (OR = 0.81; 95%CI 0.63-1.04), oligomenorrhea (OR = 1.16; 95%CI 0.94-1.43), menstrual cycle irregularity (OR = 0.99; 95%CI 0.86-1.14), abnormal bleeding length (OR = 0.96; 95%CI 0.87-1.06) and dysmenorrhea (OR = 1.03; 95%CI 0.85-1.24). The multivariate analysis suggests that the higher prevalence of oligomenorrhea and menstrual cycle irregularity among the girls who were older at menarche might be purely explained by their younger gynecological age.

CONCLUSIONS

No evidence of any independent influence of age at menarche on menstrual abnormalities among young girls was shown by the investigation. The findings suggest that, after menarche, adolescent girls' menstrual health should be checked to monitor the endocrine system maturation and to early intercept latent disorders becoming symptomatic.

Age at First Birth and the Risk of Endometrial Cancer Incidence: A Pooled Analysis of Two Prospective Cohort Studies among Japanese Women

Background: Age at first birth has been increasing among women in developed countries. Meanwhile, endometrial cancer has also been increasing worldwide, being one of the most common female hormone-related cancers. The purpose of this study was to examine the association between age at first birth and the risk of endometrial cancer among Japanese women, and to examine the hypothesis that the recent increase in endometrial cancer incidence can be partly explained by the trend for increasing age at first birth.

Methods: We conducted a pooled analysis of two prospective studies among residents in Miyagi Prefecture in rural northern in Japan. The Miyagi Cohort Study started in 1990 and included 21,455 parous women. The Ohsaki Cohort Study started in 1994 and included 17,287 parous women. The subjects responded to a self-administrated questionnaire including reproductive factors such as age at first birth. Incident cases of cancer were identified through linkage to the Miyagi Prefectural Cancer Registry, which covers the study area.

Results: In a consortium of two prospective studies with 598,933 person-years, we identified 105 incident case of endometrial cancer. Compared with women aged 22 years or less at first birth, multivariate hazard ratios (HRs) and 95% confidence intervals (CIs) for the risk of endometrial cancer were 0.79 (0.49-1.26) for women aged 23 to 25 years at first birth, and 0.53 (0.28-1.00) for those aged 26 years and older (p-trend<0.05).

Conclusion: This pooled analysis of two prospective studies does not support the hypothesis that the recent increase in the incidence of endometrial cancer can be partly explained by the increase in the age at first birth.

Interdisciplinary Diagnosis, Therapy and Follow-up of Patients with Endometrial Cancer. Guideline (S3-Level, AWMF Registry Nummer 032/034-OL, April 2018) - Part 1 with Recommendations on the Epidemiology, Screening, Diagnosis and Hereditary Factors of Endometrial Cancer

Summary The first German interdisciplinary S3-guideline on the diagnosis, therapy and follow-up of patients with endometrial cancer was published in April 2018. Funded by German Cancer Aid as part of an Oncology Guidelines Program, the lead coordinators of the guideline were the German Society of Gynecology and Obstetrics (DGGG) and the Gynecological Oncology Working Group (AGO) of the German Cancer Society (DKG).

Purpose The use of evidence-based, risk-adapted therapy to treat low-risk women with endometrial cancer avoids unnecessarily radical surgery and non-useful adjuvant radiotherapy and/or chemotherapy. This can significantly reduce therapy-induced morbidity and improve the patientʼs quality of life as well as avoiding unnecessary costs. For women with endometrial cancer and a high risk of recurrence, the guideline defines the optimal surgical radicality together with the appropriate chemotherapy and/or adjuvant radiotherapy where required. The evidence-based optimal use of different therapeutic modalities should improve survival rates and the quality of life of these patients. The S3-guideline on endometrial cancer is intended as a basis for certified gynecological cancer centers. The aim is that the quality indicators established in this guideline will be incorporated in the certification processes of these centers.

Methods The guideline was compiled in accordance with the requirements for S3-level guidelines. This includes, in the first instance, the adaptation of source guidelines selected using the DELBI instrument for appraising guidelines. Other consulted sources include reviews of evidence which were compiled from literature selected during systematic searches of literature databases using the PICO scheme. In addition, an external biostatistics institute was commissioned to carry out a systematic search and assessment of the literature for one area of the guideline. The identified materials were used by the interdisciplinary working groups to develop suggestions for Recommendations and Statements, which were then modified during structured consensus conferences and/or additionally amended online using the DELPHI method with consent being reached online. The guideline report is freely available online.

Recommendations Part 1 of this short version of the guideline presents recommendations on epidemiology, screening, diagnosis and hereditary factors, The epidemiology of endometrial cancer and the risk factors for developing endomentrial cancer are presented. The options for screening and the methods used to diagnose endometrial cancer including the pathology of the cancer are outlined. Recommendations are given for the prevention, diagnosis, and therapy of hereditary forms of endometrial cancer.