Original Article

Uterine Corpus Malignancies in Appalachia Kentucky: Incidence, Survival, and Related Health Disparities

Authors: Marian Symmes Johnson, MD, Thomas C. Tucker, PhD, Quan Chen, PhD, Bin Huang, PhD, Christopher P. DeSimone, MD, Rachel W. Miller, MD, Lauren A. Baldwin, MD, Tricia I. Fredericks, MD, Brian T. Burgess, MD, Frederick R. Ueland, MD


Objectives: Uterine cancer is the nation’s most common gynecologic malignancy, but it is understudied in the geographically and socioeconomically diverse state of Kentucky (KY). Our aim was to assess the frequency, distribution, and survival of uterine corpus malignancies in KY, and specifically the differences between Appalachia (AP) and non-Appalachia (NAP) KY.

Methods: This population-based cohort study used Surveillance, Epidemiology, and End Results data and the Kentucky Cancer Registry to study uterine corpus malignancy between January 1, 2000 and December 31, 2014. The analysis looked at the incidence between diagnoses in AP and NAP. The evaluation criteria included tumor histology (type I, type II, sarcoma, and mixed uterine malignancy), age, race, smoking status, stage at diagnosis, insurance status, and county of residence at diagnosis.

Results: The overall age-adjusted incidence rate and survival are similar for US and KY populations; however, histologic types and distribution differ. Compared with the United States, the incidence of corpus cancers in KY is higher for type I (P = 0.03), but lower for type II (P = 0.003), sarcoma (P = 0.006), and mixed (P < 0.001). AP KY has a higher incidence of type I (P < 0.0001) and mixed malignancy (P = 0.04), younger age at diagnosis (P < 0.0001), larger non-Hispanic white population (P < 0.0001), fewer smokers (P = 0.002), and more uninsured and Medicaid recipients (P < 0.0001) compared with NAP KY. The hazard ratio for death is similar in AP and NAP KY (0.896; 95% confidence interval 0.795–1.009).

Conclusions: Type I and mixed uterine corpus cancers have a higher age-adjusted incidence and a younger age at diagnosis in AP compared with NAP KY.
Posted in: Gynecologic Cancer6 Uterine Disorders2

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2018. CA Cancer J Clin 2018;68:7-30.
2. Pollard K, Jacobsen L, , Population Reference Bureau. The Appalachian region: a data overview from the 2012-2016 American Community Survey. https://www.arc.gov/assets/research_reports/DataOverviewfrom2012to2016ACS.pdf. Published March 2018. Accessed May 15, 2018.
3. Centers for Disease Control and Prevention. BRFSS Prevalence & Trends Data. https://www.cdc.gov/brfss/brfssprevalence. Published September 13, 2017. Accessed April 3, 2018.
4. Appalachian Regional Commission. Appalachian Development Highway System. https://www.arc.gov/program_areas/AppalachianDevelopmentHighwaySystem.asp. Accessed March 15, 2018.
5. Wilson RJ, Ryerson AB, Singh SD, et al. Cancer incidence in Appalachia, 2004-2011. Cancer Epidemiol Biomarkers Prev 2016;25:250-258.
6. Cote ML, Alhaii T, Ruterbusch JJ, et al. Risk factors for endometrial cancer in black and white women: a pooled analysis from the Epidemiology of Endometrial Cancer Consortium (E2C2). Cancer Causes Control 2015;26:287-296.
7. Trabert B, Wentzensen N, Felix AS, et al. Metabolic syndrome and risk of endometrial cancer in the United States a study in the SEER-Medicare linked database. Cancer Epidemiol Biomarkers Prev 2015;24:261-267.
8. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin 2008;58:71-96.
9. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008;61:344-349.
10. Bokhman JV. Two pathogenetic types of endometrial carcinoma. Gynecol Oncol 1983;15:10-17.
11. Kurman RJ, Carcangiu ML, Herrington S, et al. , eds. WHO Classification of Tumours of Female Reproductive Organs. 4th ed. Geneva:WHO Press;2014.
12. Cantrell LA, Blank SV, Duska LR. Uterine carcinosarcoma: a review of the literature. Gynecol Oncol 2015;137:581-588.
13. Fuji H, Yoshida M, Gong ZX, et al. Frequent genetic heterogeneity in the clonal evolution of gynecological carcinosarcoma and its influence on phenotypic diversity. Cancer Res 2000;60:114-120.
14. Fay MP, Tiwari RC, Feuer EJ, et al. Estimating average annual percent change for disease rates without assuming constant change. Biometrics 2006;62:847-854.
15. Bregar AJ, Alejandro Rauh-Hain J, Spencer R, et al. Disparities in receipt of care for high-grade endometrial cancer: a National Cancer Data Base analysis. Gynecol Oncol 2017;145:114-121.
16. Zhou Y, Jorgensen EM, Gan Y, et al. Cigarette smoke increases progesterone receptor and homeobox A10 expression in human endometrium and endometrial cells: a potential role in the decreased prevalence of endometrial pathology in smokers. Biol Reprod 2011;84:1242-1247.
17. Zhou B, Yang L, Sun Q, et al. Cigarette smoking and the risk of endometrial cancer: a meta-analysis. Am J Med 2008;121:501-508.e3.
18. Nevadunsky N, Van Arsdale A, Strickler HD, et al. Obesity and age at diagnosis of endometrial cancer. Obstet Gynecol 2014;124( 2 Part 1 ):300-306.
19. Setiawan VW, Yang HP, Pike MC, et al. Type I and II endometrial cancers: have they different risk factors? J Clin Oncol 2013;31:2607-2618.
20. Yang HP, Wentzensen N, Trabert B, et al. Endometrial cancer risk factors by 2 main histologic subtypes: the NIH-AARP Diet and Health Study. Am J Epidemiol 2013;177:142-151.
21. Felix AS, Weissfeld JL, Stone RA, et al. Factors associated with type I and type II endometrial cancer. Cancer Causes Control 2010;21:1851-1856.
22. Wysowski DK, Honig SF, Beitz J. Uterine sarcoma associated with tamoxifen use. N Engl J Med 2002;346:1832-1833.
23. Wickerham DL, Fisher B, Wolmark N, et al. Association of tamoxifen and uterine sarcoma. J Clin Oncol 2002;20:2758-2760.
24. Cecil G. Sheps Center, Appalachian Regional Commission. Health disparities in Appalachia. https://www.arc.gov/assets/research_reports/Health_Disparities_in_Appalachia_August_2017.pdf. Published August 2017. Accessed April 30, 2018.
25. D'Angelo E, Prat J. Uterine sarcomas: a review. Gynecol Oncol 2010;116:131-139.
26. Modesitt SC, Huang B, Shelton BJ, et al. Endometrial cancer in Kentucky: the impact of age, smoking status, and rural residence. Gynecol Oncol 2006;103:300-306.
27. Toro JR, Travis LB, Wu HJ, et al. Incidence patterns of soft tissue sarcomas, regardless of primary site, in the surveillance, epidemiology and end results program, 1978-2001: an analysis of 26,758 cases. Int J Cancer 2006;119:2922-2930.
28. Silverberg SG, Major FJ, Blessing JA, et al. Carcinosarcoma (malignant mixed mesodermal tumor) of the uterus. A Gynecologic Oncology Group pathologic study of 203 cases. Int J Gynecol Pathol 1990;9:1-19.
29. Matsuo K, Takazawa Y, Ross MS, et al. Significance of histologic pattern of carcinoma and sarcoma components on survival outcomes of uterine carcinosarcoma. Ann Oncol 2016;27:1257-1266.
30. Matsuo K, Ross MS, Machida H, et al. Trends of uterine carcinosarcoma in the United States. Gynecol Oncol 2018;29:e22.
31. Abeler VM, Rø O, Thoresen S, et al. Uterine sarcomas in Norway. A histopathological and prognostic survey of a total population from 1970 to 2000 including 419 patients. Histopathology 2009;54:355-364.
32. Nordal RR, Thoresen SO. Uterine sarcomas in Norway 1956-1992: incidence, survival and mortality. Eur J Cancer 1997;33:907-911.
33. Walker GV, Grant SR, Guadagnolo BA, et al. Disparities in stage at diagnosis, treatment, and survival in nonelderly adult patients with cancer according to insurance status. J Clin Oncol 2014;32:3118-3125.