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The incidence of uterine cancer among White and Black women is expected to increase exponentially over the next two decades, possibly a result of rising rates of obesity, lower rates of hysterectomy, and an aging population. The rates in Black women are expected to rise even more sharply, challenging clinicians to detect disease earlier in the absence of well-defined screening protocols.

These trends point to a need to develop recommendations for screening of uterine cancer, and even developing screening tests, along with coming up with better prevention strategies, said Jason Wright, MD, a gynecologic oncologist at Columbia University College of Physicians and Surgeons in New York City and lead author of a recently published natural model study that projected uterine cancer incidence out to 2050.

“Over the last several years what we’ve seen is both the incidence and mortality of uterine cancer has risen,” Wright said in an interview. “That’s particularly true in Black women who are seeing a much higher increase in the incidence and mortality of uterine cancer.” The study included both endometrial and nonendometrial cancers of the uterus.

The study also showed that disparities in the incidence of uterine cancer are widening, Wright said, and that mortality continues to increase “despite the fact that for most cancers mortality is declining.”

Disease Projections

The study cited CDC data that showed the incidence and death rates from uterine cancer increased dramatically over the past 30 years, and a 2025 National Cancer Institute report that showed the average annual rate of uterine cancer increased by 0.8% from 2014 to 2019, but that mortality increased more than twice that: 1.9% annually from 2015 to 2019, the highest for any malignancy in women.

Wright’s natural model study has projected a number of disturbing trends in uterine cancer in the period from 2020 to 2050, using 2018 as the baseline year. Among them: 

• In White women, the incidence is projected to increase from 57.7 cases per 100,000 to 74.2 cases, a 28% increase.
• In Black women, the rate is projected to increase from 56.8 cases to 86.9 cases per 100,000, a 53% increase.
• In White women, the incidence-based mortality will increase from 6.1 to 11.2 deaths per 100,000, an 83% increase.
• In Black women, the mortality rate will increase from 14.1 to 27.9 per 100,000, a 98% increase.

The study noted that White women will have “only a slight increase” in nonendometrioid tumors, but the incidence of these tumors will “increase substantially” in Black women. The study projected the rate of nonendometrial cancer would increase from 21.4 to 36.3 cases per 100,000 in Black women from 2018 to 2050 and from 8.4 to 10.8 cases per 100,000 in White women — a rate almost four times higher in Black women.

What’s Driving the Increase

The study identified two population trends that may be driving the increase in uterine cancers but did not define a causal relationship: the aging population and the increasing rate of overweight and obesity. But the study stated, these trends “likely only explain a part of the changing trends in uterine cancer incidence and mortality.”

Aging seems to be a major driver, Wright said. “The median age of uterine cancer in most studies is typically in the early to mid-60s.” 

Another factor may be declining hysterectomy rates, he added.

“What we’ve seen in last several years is that the rate of hysterectomy is declining in the United States, and that’s probably due to alternative treatments for other gynecologic disorders so that, overall, fewer women have their uteruses removed for benign or noncancerous conditions earlier in life,” Wright said.

“Almost by definition if you have a larger number of women that still have a uterus as they age, it does increase the absolute number of uterine cancer cases.” 

A systematic database search published in 2020 reported that hysterectomy rates peaked at 10.6 per 1000 women in 1975 and predicted that rates would fall to 3.9 per 1000 by 2035. Wright’s natural model study acknowledged a “substantial racial variation” in hysterectomy rates as a contributing factor for higher uterine cancer rates in Black women, the study stated.

But even adjusting for declining hysterectomy rates, rising rates of obesity and aging, the numbers of uterine cancers are still rising, Kemi Doll, MD, director of the Gynecologic Research and Cancer Equity Canter at the University of Washington in Seattle, said, in an interview.

“We need to think outside of the box to potential environmental exposures that may have affected the currently aging generation, and uterine cancer is a clue to find out what that is,” Doll said.

The Disordered State of Screening

“One of the problems for uterine cancers is there are no real widespread recommendations for either screening or prevention for uterine cancer in a majority of the population,” Wright said.

Indeed, the American College of Obstetricians and Gynecologists (ACOG) and the Society of Gynecologic Oncology, among other clinical organizations, concurred in 2015 guidance that no effective routine screening exists for endometrial cancer in women with no symptoms. The guidance suggests that abnormal postmenopausal bleeding is a trigger for immediate evaluation with biopsy, ultrasound or hysteroscopy-guided screening.

Another risk factor is Lynch syndrome, previously known as hereditary nonpolyposis colorectal cancer. Women with the condition are at a 13%-26% increased risk for endometrial cancer, according to the National Comprehensive Cancer Network. For them, ACOG recommends annual endometrial sampling starting at age 30-35.

Women who previously took tamoxifen for breast cancer may also have greater risk for endometrial cancer. Its use has long been associated with a heightened risk for endometrial cancer, with the risk increasing the longer a patient is on the drug. But, again, no routine screening is recommended for users with no symptoms, although ACOG has stated that pretreatment screening may have a role before starting tamoxifen therapy.

The lack of effective screening tests for uterine cancers and detecting predictors of uterine cancer complicates the outlook, Wright said. “Neither exist currently,” he said.

Endometrial thickness > 4 mm, as measured on transvaginal ultrasound, is a biomarker for endometrial cancer. Despite this, Doll and her coauthors recently found that transvaginal ultrasound may not be reliable for evaluating endometrial thickness in Black women.

“ This study underlines the importance of new strategies that do not rely on a patient to have a symptom or a provider to believe them,” Doll said.

What Clinicians Can Do

Despite the absence of routine screening protocols or preventive strategies for uterine cancers, clinicians must become more astute about warning signs and symptoms, Doll said. These include abnormal menstrual bleeding, which Wright said is a symptom most women diagnosed with uterine cancer have.

“Women that have abnormal bleeding should be evaluated in a timely manner and the clinician, the gynecologist, must recognize the importance of bleeding and rule out uterine cancer,” Wright said.

Doll called for primary care providers to actively screen for abnormal and postmenopausal bleeding and provider education about “the limits of ultrasound triage and the need for tissue biopsy with any concern for endometrial cancer.”

“We need to educate the public, especially those most at risk, about endometrial cancer symptoms and early detection,” she continued.

Disproportionate Rise in Black Women

Why uterine cancer rates in Black women are rising disproportionately compared with other groups is unclear, according to experts interviewed for this piece.

“Black women have been left behind in the world of uterine cancer research and it shows. Now that we have an increasing epidemic of nonendometrioid cancers — the histology that was always more common among Black women — we are faced with our major knowledge gaps in the etiology of these cancers and the fact our treatments are much less successful for them,” Doll said.

Timothy Rebbeck, PhD, a researcher specializing in cancer prevention at Dana-Farber Cancer Institute in Boston, pointed to some potential explanations.

Tumors in Black patients with prostate and colon cancers have unique molecular signatures compared with other ethnic groups, Rebbeck said. “We think it’s probably happening in uterine cancers as well.” 

Tumors in Black women may be more aggressive, he added.

Reproductive history may also come into play. The lack of screening for uterine cancer may also mean that Black women are diagnosed later in the disease course than other groups. It’s an area prime for more research, Rebbeck said.

The natural model study was supported by the National Cancer Institute. Wright reported receiving grant funding from Merck. Doll and Rebbeck had no relevant disclosures.

Richard Mark Kirkner is a medical journalist based in Philadelphia.