Endometrial Cancer

Importance: Endometrial cancer accounts for 95% of uterine cancers. Uterine cancers are the fourth most common cancer in women in the US, with an estimated 68 270 new cases and 14 450 cancer deaths projected to occur in 2026. The US mortality rate from uterine cancer rose by 1.6% annually from 2014 to 2023, increasing from 4.8 deaths per 100 000 persons to 5.6 deaths per 100 000 persons. Observations: Endometrial cancer develops most commonly due to the effect of estrogen on the uterine lining. Circulating estrogen is produced by adipose cells; rising obesity rates are correlated with an increase in US endometrial cancer incidence from 2013 to 2022 (26.4 per 100 000 in 2013 and 28.8 per 100 000 in 2022). Although 80% of endometrial cancers arise in postmenopausal women, the incidence increased from 2000 to 2019 by 3.0% annually in women aged 20 to 29 years and 3.3% annually in women aged 30 to 39 years. The age-adjusted incidence of endometrial cancer is similar among Black and White women, but mortality was 18.4 per 100 000 among Black women and 8.1 per 100 000 among White women from 2019 to 2023. Many patients (75%-90%) with endometrial cancer present with vaginal bleeding, which should be evaluated with office endometrial biopsy or surgical dilation and curettage for pathologic diagnosis. Initial endometrial cancer management is surgery, including hysterectomy, bilateral salpingo-oophorectomy, and lymph node assessment. Ovarian retention can be considered in select younger patients. Surgical pathology defines histology and molecular subtype, which guide staging and adjuvant therapy. Early-stage, low-risk disease is managed with observation after surgery. Patients with early-stage, high-intermediate risk disease typically undergo adjuvant radiation therapy and patients with aggressive histologic subtypes or advanced-stage disease are treated with adjuvant chemotherapy. First-line chemotherapy for advanced-stage endometrial cancer is carboplatin and paclitaxel plus consideration of anti-programmed cell death protein 1 immunotherapy. Radiation therapy is used for localized recurrences in the pelvis; distant or multifocal recurrences are treated with systemic therapy, including chemotherapy, without or with immunotherapy, or hormonal therapy such as progestins or antiestrogens. Five-year survival is greater than 86% for stage I endometrial cancer, greater than 75% for stage II, greater than 41% for stage III, and greater than 18% for stage IV disease. Conclusions and Relevance: Endometrial cancer accounts for 95% of uterine cancers, which are the fourth most common cancer in women in the US. Surgery is first-line treatment. Adjuvant radiation is recommended for early-stage, high-intermediate risk endometrial cancer. Adjuvant chemotherapy with carboplatin and paclitaxel is recommended for early-stage disease with aggressive histologic subtypes and advanced-stage disease, which is also treated with immunotherapy in some cases.