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Racial differences in patients with adenocarcinoma of the endometrium
Int J Gynecol Obstet, 1992, 39: 213-218
213
International Federation of Gynecology and Obstetrics
Racial differences in patients with adenocarcinoma endometrium H.S. CronjC, S. Fourie,
M.J. Doman,
of the
J.B. Helms, J.T. Nel and L. Goedhals
Gynecologic Oncology Group, University of the Orange Free State, Bloemfontein (South Africa) (Received November Sth, 1991) (Revised and accepted March 30th, 1992)
Abstract
Introduction
OBJECTIVE: To determine the differences between white and black women with regard to the presentation and behavior of adenocarcinema of the endometrium. METHOD: Records of 273 (48%) white patients and 117 (32%) black patients with endometrial adenocarcinoma were reviewed in Bloemfontein, South Africa. Survival data was calculated according to the direct method where losses in follow-up were regarded as tumor deaths. RESULTS: Most patients (82%) were treated by pre-operative radium followed by total abdominal hysterectomy and bilateral salpingooophorectomy, with post-operative external irradiation where indicated. Pre-operatively, fewer black women had reached FIG0 stage I, while a larger number had advanced to stages II-IV (P = 0.0024). In addition, the tumor differentiation was more often poor in the black group (P < 0.0001). Ten-year follow-up was achieved in 84% of the white patients and 51% of the black patients and the IO-year survival figures were 67%for white patients and 28%for blacks (P < 0.0001). CONCLUSION: Endometrial adenocarcinoma is a more aggressive disease in black women than it is in whites.
Adenocarcinoma of the endometrium is less extensively studied in black females than white women. The prevalence is also lower in blacks: 5.40 per 1000 women in black females, compared with 7.38 per 1000 in white women [l]. Several studies documented a higher grade and stage of disease with a lower survival rate in black patients [2-41. Beckner et al. found that 45.5% of adenocarcinomas in black women were poorly differentiated in contrast to only 21.8% in white women [2]. Papillary serous adenocarcinoma in particular has been found to be more prevalent in elderly blacks [5]. Bain et al. reported a prevalence of 21% grade I tumors and 37% grade III tumors in black patients. In white patients the prevalence was 46% for grade I and 21% for grade III [3]. No difference was found concerning the depth of myometrial infiltration. The 3-year survival in this study was 61.6% for black patients and 89.2% for whites. Steinhorn et al. documented significant differences stage by stage between black and white patients [4]. In stage I 69.6% of black patients survived 5 years, compared to 88.4% of white patients. The corresponding figures in stage IV were 6.5% and 29.8%. No racial differences was found in sarcomas in this study. Although convincing data concerning racial differences was documented in these
Keywords: Endometrial adenocarcinoma; Survival; Racial differences; Ethnic groups. 0020-7292/92/$05.00 0 1992 International Federation of Gynecology and Obstetrics Printed and Published in Ireland
Article
214
Cronji et al.
studies, the number of studies is limited and contrasting data have been published in addition. Larson et al. were not able to document race as a significant prognostic factor [6]. This study was undertaken in view of a need for more data concerning racial differences in patients with adenocarcinoma of the endometrium. Patients and methods The Gynecologic Oncology Group of the University of the Orange Free State, Bloemfontein, South Africa, deals with a population consisting of 80% black patients. All patients are treated at one regional centre (Bloemfontein), but follow-up occurs in several hospitals and clinics distributed over the central third of the country. A departmental record system provided the basis for this study. The records of patients with a histopathologic diagnosis of adenocarcinoma of the endometrium in the Department of Oncotherapy, University of the Orange Free State and National Hospital, Bloemfontein, South Africa, were reviewed. The review covered all patients between 1970 and 1985 with 2 patients before 1970 giving a total of 400 patients. Demographic, clinical and pathological data were obtained, as well as follow-up data. Statistical comparisons were done with the chi-squared test for individual numbers, the ttest for means and the z-test for proportions. Alpha was set at 0.05. Survival data was calculated according to the direct method where losses in follow-up were regarded as tumor deaths. [4] Results The 400 patients consisted of 273 whites (68.25%), 116 blacks (29.0%) and 11 ‘coloreds’ (of mixed origin) (2.75%). For the purpose of analysis, the blacks and coloreds were combined as black patients, a total of 127 patients (31.75%). The mean gravidity and parity of the white In1 J Gynecol Obstet 39
patients was 2.77 with a standard deviation (SD) of 2.39 and 2.40 (SD 2.02). For black patients, the gravidity and parity were 4.48 (SD 3.20) and 4.06 (SD 3.08). The difference between the two groups was not statistically significant (P = 0.6873). Of all 400 patients, the youngest white patient was 36 and the oldest 94 years at diagnosis, with a mean of 64.27 years (SD 10.38). The black patients did not differ significantly (P = 0.8952): the youngest was 34 years, the oldest 89 years, with the mean 62.96 years (SD 11.00). Two hundred and thirtynine white patients (87.5%) were postmenopausal, 3 1 (11.4%) premenopausal and 3 (1. lo/) undetermined. The corresponding numbers for the black patients were 115 postmenopausal (90.5%), 10 premenopausal (7.9%) and 2 undetermined (1.6%). Again, the difference between the two groups was insignificant (P = 0.4692). Body weight was qualitatively expressed in the clinical records as normal, overweight and underweight (based on the clinician’s clinical impression). Of the white patients, 63 were of normal weight, 8 underweight, 138 overweight and unknown in 64. In black patients, the figures were 18 normal, 9 underweight, 68 overweight and unknown in 32. The difference between these two groups was significant (P = 0.0291). Fifty-eight percent (233 patients) of all 400 patients presented with associated disease. Of these, 169 were white and 64 black. Hypertension was most prevalent (59.3’), followed by diabetes mellitus (18.3%), hypertension and diabetes combined (12.4%), heart disease (7.7%) and other diseases (2.3%). Of the 169 white patients with associated disease, 84.6% presented with hypertension, compared to 90.6% of the 64 black patients with associated disease (P > 0.05). The proportions for the other diseases in these two groups were 30.2% and 17.2% for diabetes mellitus (P = 0.0152), 20.7% and 10.9% for hypertension and diabetes combined (P > 0.05), 11.8% and 9.4% for heart disease (P > 0.05) and 3.6% and 3.1% for other diseases (P > 0.05).
Analysis of endometrial adenocarcinoma
Postoperatively
?
I
II
III
IV
10 31
271 135
55 15
39 12
25 7
215
STAGE Fig. I.
FIG0 Staging (n = 400 and 200).
?? , preoperatively; H, postoperatively.
Only 22 patients reported estrogen therapy within the 5 years prior to diagnosis, 265 patients denied such therapy and the data were non-specific in 113. Of the 287 patients with established data, only 7.6% reported prior estrogen therapy. These were all white patients. Cervical cytological reports were available on 171 patients (42.75%). In these patients the cytology was positive for malignancy in 38.6% of cases. Patients were staged preoperatively according to the FIG0 classification (prior to 1989) (Fig. 1). The postoperative (surgical) staging was done on the basis of the operative findings and histological reports (Fig. 1). Only 169 could be staged surgically. Pre-operative
radium therapy accounted for 200 patients who could not be staged. In 27 patients the data were incomplete and in 4 absent. Figure 2 shows the differences in preoperative staging between the white and black groups. There were significantly less patients in stage I and more in stages II-IV in the black patients (P = 0.0024). The treatment consisted of surgery alone (24 patients, 6.0%), radiotherapy alone (44 patients; 1l.O%), chemotherapy alone (5 patients; 1.3%), or combination treatmentmainly preoperative radium therapy followed 6 weeks later by total abdominal hysterectomy and bilateral salpingo-oophorectomy, with or without postoperative external irradiation (327 patients; 81.7’). There were
STAGE Fig. 2.
Preoperative staging. Racial differences (n = 400).
?? , whites; ?, ? blacks; P = 0.0024. Article
216
Cronji et al.
Well
Moderate
Poor
Undiff.
47 9.1
38.4 46.6
14.1 44.3
0.5 0
DIFFERENTIATION Fig. 3.
Tumor differentiation (n = 198 and 88).
?? , whites; 4 blacks:
200 post radium uterine specimens, of which 108 (54%) did not reveal any residual tumor, 66 (33%) contained viable residual tumor, 9 (4.5%) had metastasis, 5 (2.5%) both metastasis and residual tumor and in 12 (6%) cases the information was absent. Treatment complications occurred in 21% of all patients. Radiotherapy related complications occurred in 80.18% of the patients with complications (16.5% of all patients) and surgical complications in 14.46% (3% of all patients). The racial differences in tumor differentiation are shown in Fig. 3. A significant difference was found between white and black patients, there being more poorly differentiated tumors in the black group (P < 0.000 1).
Table 1. Survival (direct method).
5-year survival IO-year survival
Whites W)
Blacks W)
75.11 67.10
25.23 27~j9~
P < 0.0001 (5- and lO-year)
aThe 5- and IO-year groups differed in size and composition (direct method) and therefore the higher proportion of survivals in the IO-year group. Int J Gynecol Obstet 39
P < 0.0001.
Follow-up was calculated for 5 and 10 years. Of the white patients, 86.8% were followed for 5 years and 84.3% for 10 years. In the black group the 5-year follow-up was 55.7% and the IO-year figure was 51.2%. At the time of analysis, 112 (28.0%) of the patients were alive, 116 (41.5%) had died and 122 (30.3%) were lost to follow-up. Five- and lo-year survival figures differed significantly between white and black patients (P < 0.0001) (Table l), with a worse outcome amongst black patients. Survival figures by stage is shown in Table 2. Discussion A striking difference in the nature of the disease between the two racial groups was noted. Black patients presented with more advanced stages of disease and with worse grades of differentiation. Late presentation to medical services is a possible explanation, but this should not have influenced the histologic grade of disease. Furthermore, medical services are readily available throughout the region served by the investigators’ institution. The lower survival figures for black patients are attributed to more aggressive disease, as the treatment policy and methods did not differ between the groups. Several factors were investigated to explain the apparent difference in the nature of the
Analysis of endomerrial adenocarcinoma
Table 2.
217
Ten-year survival by stage (direct method).
Stage
White patients
Black patients
P-value
No.
% lost to follow-up
% survival
No.
% lost to follow-up
% survival
I II III IV Stage unknown
113 19 13 3 4
16 11 0 0 -
69.9 57.9 76.9 0 -
30 13 11 10 1
30 54 36 20
46.7 7.7 18.2 12.5
Totala
152
0.0178 0.0001 0.0101
65
aNumber of patients qualifying for the direct method.
disease. Body weight differed significantly between the two groups. However, this factor was qualitatively determined and may influence the significance of this finding. Diabetes mellitus also differed significantly. A detection bias might have been present in the diagnosis of diabetes mellitus, for it is generally accepted to be more prevalent amongst whites. Previous exposure to estrogen was negligible in both groups. Hypertension did not differ between the two groups. None of the above factors, therefore, account adequately for the differences in the stage and grade of the disease. It was not possible to review histologic specimens retrospectively due to a shortage in manpower. It is, however, unlikely that a significant deviation in the diagnostic profile will emerge after such a review. The staff in our pathological laboratory, as well as in the private laboratory in Bloemfontein (the two major laboratories concerned) remained stable during the period of investigation and observer variation is thereby limited. Mixed Mtillerian mesodermal tumors are often encountered in the population served by this institution. The pathologists involved in this study are especially familiar with this diagnosis and it is unlikely that any such tumour has been unwillingly included in this series.
The follow-up figure of 51.2% for 10 years for black patients is regarded as exceptionally good for Africa. This figure was achieved by a decentralized follow-up system at clinics throughout the region and the with aid of social workers in tracing lost patients. From this large series we conclude that endometrial adenocarcinoma in the black patient differs significantly from the white patient with respect to tumour differentiation and stage of disease. Consideration is now being given to revising the existing protocols for the management of endometrial adenocarcinema to accommodate these differences. Acknowledgments We wish to thank the following members of the Gynecologic Oncology Group for their valuable contributions: E.A. Lion-Cachet, A. Bester, B.F. Cooreman, C. Jordaan and C. Slater. References Koss LG, Schreiber K, Oberlander SG, Moussouris HF, Lesser M: Detection of endometrial carcinoma and hyperplasia in asymptomatic women. Obstet Gynecol64: 1, 1984. Beckner ME, Mori T, Silverberg SG: Endometrial carcinoma: nontumor factors in prognosis. Int J Gynecol Path01 4: 131, 1985. Article
218 3
4
5 6
Cronjt! et al. Bain RP, Greenberg RS, Chung KC: Racial differences in survival of women with endometrial cancer. Am J Obstet Gynecol 157: 914, 1987. Steinhom SC, Myers MH, Hankey BF, Pelham VF: Factors associated with the survival differences between black women and white women with cancer of the uterine corpus. Am J Epidemiol 124: 85, 1986. Sorem KA: Cancer incidence in the Zuni Indians of New Mexico. Yale J Biol Med 588:489, 1985. Larson DM, Copeland LJ, Gallager HS, Wharton JT, Gershenson DM, Edwards CL, Malone Jr JM, Rutledge FN: Prognostic factors in stage II endometrial carcinoma. Cancer 60: 1358, 1987.
Int J Gynecol Obsler 39
7
TNM General Rules of the IUCC, p 21-40. Second edn. G de Buren, Geneve, 1974.
Address for reprints:
H.S. Cronjt5 Department of Obstetrics and Gynecology PO Box 339 9380 Bloemfontein, South Afkica
213
International Federation of Gynecology and Obstetrics
Racial differences in patients with adenocarcinoma endometrium H.S. CronjC, S. Fourie,
M.J. Doman,
of the
J.B. Helms, J.T. Nel and L. Goedhals
Gynecologic Oncology Group, University of the Orange Free State, Bloemfontein (South Africa) (Received November Sth, 1991) (Revised and accepted March 30th, 1992)
Abstract
Introduction
OBJECTIVE: To determine the differences between white and black women with regard to the presentation and behavior of adenocarcinema of the endometrium. METHOD: Records of 273 (48%) white patients and 117 (32%) black patients with endometrial adenocarcinoma were reviewed in Bloemfontein, South Africa. Survival data was calculated according to the direct method where losses in follow-up were regarded as tumor deaths. RESULTS: Most patients (82%) were treated by pre-operative radium followed by total abdominal hysterectomy and bilateral salpingooophorectomy, with post-operative external irradiation where indicated. Pre-operatively, fewer black women had reached FIG0 stage I, while a larger number had advanced to stages II-IV (P = 0.0024). In addition, the tumor differentiation was more often poor in the black group (P < 0.0001). Ten-year follow-up was achieved in 84% of the white patients and 51% of the black patients and the IO-year survival figures were 67%for white patients and 28%for blacks (P < 0.0001). CONCLUSION: Endometrial adenocarcinoma is a more aggressive disease in black women than it is in whites.
Adenocarcinoma of the endometrium is less extensively studied in black females than white women. The prevalence is also lower in blacks: 5.40 per 1000 women in black females, compared with 7.38 per 1000 in white women [l]. Several studies documented a higher grade and stage of disease with a lower survival rate in black patients [2-41. Beckner et al. found that 45.5% of adenocarcinomas in black women were poorly differentiated in contrast to only 21.8% in white women [2]. Papillary serous adenocarcinoma in particular has been found to be more prevalent in elderly blacks [5]. Bain et al. reported a prevalence of 21% grade I tumors and 37% grade III tumors in black patients. In white patients the prevalence was 46% for grade I and 21% for grade III [3]. No difference was found concerning the depth of myometrial infiltration. The 3-year survival in this study was 61.6% for black patients and 89.2% for whites. Steinhorn et al. documented significant differences stage by stage between black and white patients [4]. In stage I 69.6% of black patients survived 5 years, compared to 88.4% of white patients. The corresponding figures in stage IV were 6.5% and 29.8%. No racial differences was found in sarcomas in this study. Although convincing data concerning racial differences was documented in these
Keywords: Endometrial adenocarcinoma; Survival; Racial differences; Ethnic groups. 0020-7292/92/$05.00 0 1992 International Federation of Gynecology and Obstetrics Printed and Published in Ireland
Article
214
Cronji et al.
studies, the number of studies is limited and contrasting data have been published in addition. Larson et al. were not able to document race as a significant prognostic factor [6]. This study was undertaken in view of a need for more data concerning racial differences in patients with adenocarcinoma of the endometrium. Patients and methods The Gynecologic Oncology Group of the University of the Orange Free State, Bloemfontein, South Africa, deals with a population consisting of 80% black patients. All patients are treated at one regional centre (Bloemfontein), but follow-up occurs in several hospitals and clinics distributed over the central third of the country. A departmental record system provided the basis for this study. The records of patients with a histopathologic diagnosis of adenocarcinoma of the endometrium in the Department of Oncotherapy, University of the Orange Free State and National Hospital, Bloemfontein, South Africa, were reviewed. The review covered all patients between 1970 and 1985 with 2 patients before 1970 giving a total of 400 patients. Demographic, clinical and pathological data were obtained, as well as follow-up data. Statistical comparisons were done with the chi-squared test for individual numbers, the ttest for means and the z-test for proportions. Alpha was set at 0.05. Survival data was calculated according to the direct method where losses in follow-up were regarded as tumor deaths. [4] Results The 400 patients consisted of 273 whites (68.25%), 116 blacks (29.0%) and 11 ‘coloreds’ (of mixed origin) (2.75%). For the purpose of analysis, the blacks and coloreds were combined as black patients, a total of 127 patients (31.75%). The mean gravidity and parity of the white In1 J Gynecol Obstet 39
patients was 2.77 with a standard deviation (SD) of 2.39 and 2.40 (SD 2.02). For black patients, the gravidity and parity were 4.48 (SD 3.20) and 4.06 (SD 3.08). The difference between the two groups was not statistically significant (P = 0.6873). Of all 400 patients, the youngest white patient was 36 and the oldest 94 years at diagnosis, with a mean of 64.27 years (SD 10.38). The black patients did not differ significantly (P = 0.8952): the youngest was 34 years, the oldest 89 years, with the mean 62.96 years (SD 11.00). Two hundred and thirtynine white patients (87.5%) were postmenopausal, 3 1 (11.4%) premenopausal and 3 (1. lo/) undetermined. The corresponding numbers for the black patients were 115 postmenopausal (90.5%), 10 premenopausal (7.9%) and 2 undetermined (1.6%). Again, the difference between the two groups was insignificant (P = 0.4692). Body weight was qualitatively expressed in the clinical records as normal, overweight and underweight (based on the clinician’s clinical impression). Of the white patients, 63 were of normal weight, 8 underweight, 138 overweight and unknown in 64. In black patients, the figures were 18 normal, 9 underweight, 68 overweight and unknown in 32. The difference between these two groups was significant (P = 0.0291). Fifty-eight percent (233 patients) of all 400 patients presented with associated disease. Of these, 169 were white and 64 black. Hypertension was most prevalent (59.3’), followed by diabetes mellitus (18.3%), hypertension and diabetes combined (12.4%), heart disease (7.7%) and other diseases (2.3%). Of the 169 white patients with associated disease, 84.6% presented with hypertension, compared to 90.6% of the 64 black patients with associated disease (P > 0.05). The proportions for the other diseases in these two groups were 30.2% and 17.2% for diabetes mellitus (P = 0.0152), 20.7% and 10.9% for hypertension and diabetes combined (P > 0.05), 11.8% and 9.4% for heart disease (P > 0.05) and 3.6% and 3.1% for other diseases (P > 0.05).
Analysis of endometrial adenocarcinoma
Postoperatively
?
I
II
III
IV
10 31
271 135
55 15
39 12
25 7
215
STAGE Fig. I.
FIG0 Staging (n = 400 and 200).
?? , preoperatively; H, postoperatively.
Only 22 patients reported estrogen therapy within the 5 years prior to diagnosis, 265 patients denied such therapy and the data were non-specific in 113. Of the 287 patients with established data, only 7.6% reported prior estrogen therapy. These were all white patients. Cervical cytological reports were available on 171 patients (42.75%). In these patients the cytology was positive for malignancy in 38.6% of cases. Patients were staged preoperatively according to the FIG0 classification (prior to 1989) (Fig. 1). The postoperative (surgical) staging was done on the basis of the operative findings and histological reports (Fig. 1). Only 169 could be staged surgically. Pre-operative
radium therapy accounted for 200 patients who could not be staged. In 27 patients the data were incomplete and in 4 absent. Figure 2 shows the differences in preoperative staging between the white and black groups. There were significantly less patients in stage I and more in stages II-IV in the black patients (P = 0.0024). The treatment consisted of surgery alone (24 patients, 6.0%), radiotherapy alone (44 patients; 1l.O%), chemotherapy alone (5 patients; 1.3%), or combination treatmentmainly preoperative radium therapy followed 6 weeks later by total abdominal hysterectomy and bilateral salpingo-oophorectomy, with or without postoperative external irradiation (327 patients; 81.7’). There were
STAGE Fig. 2.
Preoperative staging. Racial differences (n = 400).
?? , whites; ?, ? blacks; P = 0.0024. Article
216
Cronji et al.
Well
Moderate
Poor
Undiff.
47 9.1
38.4 46.6
14.1 44.3
0.5 0
DIFFERENTIATION Fig. 3.
Tumor differentiation (n = 198 and 88).
?? , whites; 4 blacks:
200 post radium uterine specimens, of which 108 (54%) did not reveal any residual tumor, 66 (33%) contained viable residual tumor, 9 (4.5%) had metastasis, 5 (2.5%) both metastasis and residual tumor and in 12 (6%) cases the information was absent. Treatment complications occurred in 21% of all patients. Radiotherapy related complications occurred in 80.18% of the patients with complications (16.5% of all patients) and surgical complications in 14.46% (3% of all patients). The racial differences in tumor differentiation are shown in Fig. 3. A significant difference was found between white and black patients, there being more poorly differentiated tumors in the black group (P < 0.000 1).
Table 1. Survival (direct method).
5-year survival IO-year survival
Whites W)
Blacks W)
75.11 67.10
25.23 27~j9~
P < 0.0001 (5- and lO-year)
aThe 5- and IO-year groups differed in size and composition (direct method) and therefore the higher proportion of survivals in the IO-year group. Int J Gynecol Obstet 39
P < 0.0001.
Follow-up was calculated for 5 and 10 years. Of the white patients, 86.8% were followed for 5 years and 84.3% for 10 years. In the black group the 5-year follow-up was 55.7% and the IO-year figure was 51.2%. At the time of analysis, 112 (28.0%) of the patients were alive, 116 (41.5%) had died and 122 (30.3%) were lost to follow-up. Five- and lo-year survival figures differed significantly between white and black patients (P < 0.0001) (Table l), with a worse outcome amongst black patients. Survival figures by stage is shown in Table 2. Discussion A striking difference in the nature of the disease between the two racial groups was noted. Black patients presented with more advanced stages of disease and with worse grades of differentiation. Late presentation to medical services is a possible explanation, but this should not have influenced the histologic grade of disease. Furthermore, medical services are readily available throughout the region served by the investigators’ institution. The lower survival figures for black patients are attributed to more aggressive disease, as the treatment policy and methods did not differ between the groups. Several factors were investigated to explain the apparent difference in the nature of the
Analysis of endomerrial adenocarcinoma
Table 2.
217
Ten-year survival by stage (direct method).
Stage
White patients
Black patients
P-value
No.
% lost to follow-up
% survival
No.
% lost to follow-up
% survival
I II III IV Stage unknown
113 19 13 3 4
16 11 0 0 -
69.9 57.9 76.9 0 -
30 13 11 10 1
30 54 36 20
46.7 7.7 18.2 12.5
Totala
152
0.0178 0.0001 0.0101
65
aNumber of patients qualifying for the direct method.
disease. Body weight differed significantly between the two groups. However, this factor was qualitatively determined and may influence the significance of this finding. Diabetes mellitus also differed significantly. A detection bias might have been present in the diagnosis of diabetes mellitus, for it is generally accepted to be more prevalent amongst whites. Previous exposure to estrogen was negligible in both groups. Hypertension did not differ between the two groups. None of the above factors, therefore, account adequately for the differences in the stage and grade of the disease. It was not possible to review histologic specimens retrospectively due to a shortage in manpower. It is, however, unlikely that a significant deviation in the diagnostic profile will emerge after such a review. The staff in our pathological laboratory, as well as in the private laboratory in Bloemfontein (the two major laboratories concerned) remained stable during the period of investigation and observer variation is thereby limited. Mixed Mtillerian mesodermal tumors are often encountered in the population served by this institution. The pathologists involved in this study are especially familiar with this diagnosis and it is unlikely that any such tumour has been unwillingly included in this series.
The follow-up figure of 51.2% for 10 years for black patients is regarded as exceptionally good for Africa. This figure was achieved by a decentralized follow-up system at clinics throughout the region and the with aid of social workers in tracing lost patients. From this large series we conclude that endometrial adenocarcinoma in the black patient differs significantly from the white patient with respect to tumour differentiation and stage of disease. Consideration is now being given to revising the existing protocols for the management of endometrial adenocarcinema to accommodate these differences. Acknowledgments We wish to thank the following members of the Gynecologic Oncology Group for their valuable contributions: E.A. Lion-Cachet, A. Bester, B.F. Cooreman, C. Jordaan and C. Slater. References Koss LG, Schreiber K, Oberlander SG, Moussouris HF, Lesser M: Detection of endometrial carcinoma and hyperplasia in asymptomatic women. Obstet Gynecol64: 1, 1984. Beckner ME, Mori T, Silverberg SG: Endometrial carcinoma: nontumor factors in prognosis. Int J Gynecol Path01 4: 131, 1985. Article
218 3
4
5 6
Cronjt! et al. Bain RP, Greenberg RS, Chung KC: Racial differences in survival of women with endometrial cancer. Am J Obstet Gynecol 157: 914, 1987. Steinhom SC, Myers MH, Hankey BF, Pelham VF: Factors associated with the survival differences between black women and white women with cancer of the uterine corpus. Am J Epidemiol 124: 85, 1986. Sorem KA: Cancer incidence in the Zuni Indians of New Mexico. Yale J Biol Med 588:489, 1985. Larson DM, Copeland LJ, Gallager HS, Wharton JT, Gershenson DM, Edwards CL, Malone Jr JM, Rutledge FN: Prognostic factors in stage II endometrial carcinoma. Cancer 60: 1358, 1987.
Int J Gynecol Obsler 39
7
TNM General Rules of the IUCC, p 21-40. Second edn. G de Buren, Geneve, 1974.
Address for reprints:
H.S. Cronjt5 Department of Obstetrics and Gynecology PO Box 339 9380 Bloemfontein, South Afkica