Risk for breast and colorectal cancers subsequent to cancer of the endometrium in a population-based case series

Population incidence and characteristics of secondary breast cancer after uterine cancer: a competing risk analysis

PURPOSE

To examine incidence and characteristics of women who developed secondary breast cancer after uterine cancer.

METHODS

This is a population-based retrospective cohort study utilizing the National Cancer Institute's Surveillance, Epidemiology, and End Result Program from 1973 to 2013. Women with uterine cancer who did not have synchronous or a history of breast cancer were followed after their uterine cancer diagnosis (N = 236,561). A time-dependent competing risk analysis was performed to examine cumulative incidences and clinico-pathological characteristics of those who subsequently developed breast cancer.

RESULTS

There were 7110 (3.0%) women who developed secondary breast cancers after uterine cancer with 5-, 10-, and 20-year cumulative incidence rates of 1.5, 2.8, and 4.7%, respectively. The increase in the rate of secondary breast cancer was particularly high in the first 3 years after a uterine cancer diagnosis (annual percent change [APC] 4.9), followed by 3-7 years (APC 1.6) after diagnosis (P < 0.001). The median time to develop secondary breast cancer was 6.4 years. Older women had significantly shorter time intervals between uterine and breast cancer diagnoses (3.7 years for aged > 71, 5.9 for aged 64-71, 7.6 for aged 56-63, and 9.4 for aged < 56, P < 0.001). In a multivariable analysis, older age, White race, married status, endometrioid, serous, and mixed histology types, and early-stage tumors remained as independent factors of developing secondary breast cancer (all, P < 0.05).

CONCLUSION

Tumor factors with endometrioid and serous histology types and early-stage disease were the factors associated with secondary breast cancer after uterine cancer diagnosis. Older women had shorter time to develop secondary breast cancer.

Survival for endometrial cancer as a second primary malignancy

BACKGROUND

Endometrial cancer (EC) often occurs subsequently to a primary cancer arising from a different site. However, little is known regarding the survival experience of EC as a second primary (ECSP) malignancy, specifically in relation to the original primary site and prior treatment.

METHODS

Using Florida's cancer registry, all EC cases (first, second, or higher-order) diagnosed from 2005-2016 were analyzed. Kaplan-Meier methods and Cox Regression were used in a cause-specific survival analysis.

RESULTS

A total of 2879 clinically independent ECSPs and 42,714 first primary ECs were analyzed. The most common first primary sites for ECSPs were breast cancer (BC) (n = 1422) and colorectal cancer (CRC) (n = 359). Five-year cause-specific survival was 84.0% (95% CI: 83.6-84.3) for first primary ECs and 81.8% (95% CI: 80.0-83.4) for ECSPs. After adjusting for age, race/ethnicity, histology, and stage at diagnosis, ECSPs had a lower risk of EC mortality than first primary ECs (hazard ratios [HR] 0.88, 95% CI: 0.79-0.97). ECSPs with a first primary CRC had a higher risk of EC-specific death (HR 1.47, 95% CI: 1.04-2.06) compared to ECSPs that followed BC in multivariable analysis. Finally, women who had chemotherapy for ECSP and preceding BC did not have a higher risk of death (HR 0.80, 95% CI: 0.49-1.31) compared to those who only received chemotherapy for first primary EC.

CONCLUSIONS

ECSPs present a complex clinical profile. ECSP survival is superior to that of first primary EC. However, ECSPs following CRC may constitute a population of interest for their worse prognosis. Chemotherapy for a previous BC does not seem to impact the effectiveness of chemotherapy for ECs.

The association between histological subtype of a first primary endometrial cancer and second cancer risk

OBJECTIVE

To evaluate the risk of a second primary cancer after endometrial cancer according to histological subtype.

METHODS

Using data from the 13 National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registries we identified women diagnosed with a primary endometrial cancer between 1992 and 2014. We calculated standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) for second primary cancer risk (all anatomical sites combined and for individual anatomical sites) among patients with endometrial cancer compared with the general population, in the overall study population and according to histological subtype.

RESULTS

Among 96 256 women diagnosed with endometrial cancer, 8.4% (n=8083) developed a second primary cancer. The risk of second primary cancer was higher among patients with endometrial cancer than in the general population (SIR=1.05, 95% CI 1.03 to 1.07). We observed significantly higher second primary cancer risk among women with high grade endometrioid (SIR=1.12, 95% CI 1.05 to 1.19), serous (SIR=1.24, 95% CI 1.11 to 1.38), carcinosarcoma (SIR=1.18, 95% CI 1.02 to 1.35), mixed epithelial (SIR=1.22, 95% CI 1.06 to 1.40), and sarcoma (SIR=1.28, 95% CI 1.12 to 1.45) compared with the general population, but not for women with low grade endometrioid (SIR=1.01, 95% CI 0.98 to 1.03) or clear cell (SIR=1.09, 95% CI 0.88 to 1.33) endometrial cancer. Women with low grade endometrioid endometrial cancer had significantly lower second primary cancer risks in the gum and other mouth (SIR=0.57, 95% CI 0.30 to 0.97), lung and bronchus (SIR=0.72, 95% CI 0.66 to 0.77), and lymphocytic leukemia (SIR=0.71, 95% CI 0.54 to 0.93) while women with high risk endometrial cancer histological subtypes experienced significantly higher second primary cancer risk at several anatomical sites.

CONCLUSIONS

Risk of developing second primary cancersat all anatomic sites combined and at individual anatomical sites varied according to histological subtype. Clinicians should be aware that women with different histological subtypes carry different second primary cancer risks .

Increased risk of second primary malignancies following uterine cancer: a population-based study in Taiwan over a 30-year period

BACKGROUND

Previous studies assessing second primary malignancies (SPMs) after uterine cancer have been conducted in Western populations with conflicting results. This study aimed to define the incidence and risk of SPMs in Taiwanese patients with an initial diagnosis of uterine cancer.

METHODS

Using population-based data from the Taiwan Cancer Registry for the period 1979-2008, we quantified standardized incidence ratios (SIRs) among 11,571 women with an initial diagnosis of uterine cancer.

RESULTS

Among the 11,571 women, 555 (4.80%) developed at least one SPM during 69,987 person-years of follow-up. There was a 71% increased risk of SPM following uterine cancer (SIR=1.71, 95% CI, 1.57-1.86), with higher risks in the vagina/vulva (SIR=9.06), small intestine (SIR=8.45), ovary (SIR=4.15), urinary bladder (SIR=2.31), kidney (SIR=2.24), colorectum (SIR=2.24), lung (SIR=1.96), and breast (SIR=1.43). The risk of SPM was found to be the highest within the first 5 years after diagnosis of uterine cancer, with surveillance bias possibly contributing to the extremely high risk observed in the first follow-up year. The overall risk and pattern of SPM development observed in this study differed from those previously reported in Western populations, possibly because of the methodology and shorter follow-up period employed in this study. The cumulative incidence of SPMs was significantly higher in older patients (≥50 years) than in younger patients (P<0.001).

CONCLUSIONS

To our knowledge, this is the first study in an Asian population to report 71% increased risk in SPMs in women previously diagnosed with uterine cancer. A younger age at diagnosis of uterine cancer conferred an increased risk of second malignancies, and SPMs worsened survivorship in patients who survived uterine cancer.

Multiple synchronous primary neoplasms of the breast, colon and rectum after surgery for endometrial cancer: A case report

INTRODUCTION

Endometrial cancer survivors exhibit an increased incidence of subsequent neoplasms.

PRESENTATION OF CASE

We present a patient with a history of endometrial cancer who, 3 years after surgery and radiotherapy, developed synchronous neoplasms of the breast, colon and rectum. The patient underwent abdominoperineal resection, a limited right colectomy, and excision of the breast tumour and axillary lymph node dissection. 18 months after surgery, there has been no disease recurrence.

DISCUSSION

Multiple primary malignancies represent 16% of new cancer diagnoses. Research on subsequent malignancies after endometrial cancer has shown an increase in risk in colorectal, urinary bladder, lung and breast primaries.

CONCLUSION

This case report illustrates the need for physicians to be aware of and counsel patients on the risk of subsequent cancers on endometrial cancer survivors.

Risk factors for developing multiple malignancies in patients with endometrial cancer

OBJECTIVE

The purposes of this study were to investigate the clinical and pathologic characteristics of patients with endometrial cancer (EC) and associated breast, colorectal, or ovarian cancer, and to define the risk of developing an associated malignancy during follow-up after EC treatment.

METHODS/MATERIALS

During a 13-year period, 1028 women had a hysterectomy for EC at our institution and available clinical information. An associated malignancy was defined as diagnosis of another malignant disease before or at the time of operation for EC or during follow-up.

RESULTS

Of these 1028 patients, 208 (20%) had a history of another malignancy besides EC. Most frequent were carcinomas of the breast (10%), colon-rectum (3%), and ovary (4%). Patients with a family history of hereditary nonpolyposis colorectal cancer (HNPCC)-related cancers and presence of EC in the lower uterine segment (LUS) had a higher risk of developing colorectal cancer within 5 years after hysterectomy (2% and 6%, respectively). After multivariate analysis, only LUS involvement remained significantly associated with this risk. Patients with EC and associated ovarian cancer were more likely to be younger and have superficially invasive EC, family history of HNPCC-related tumors, and family history of breast or ovarian cancer. After multivariate analysis, only age younger than 50 years (odds ratio [OR], 4.27; 95% confidence interval [CI], 1.49-12.21) and family history of breast or ovarian cancer (OR, 3.95; 95% CI, 1.60-9.72) were significantly related to risk of having ovarian cancer associated with EC. No significant risk factors were identified for development of an associated breast cancer after EC.

CONCLUSIONS

Young age, family history of malignancy, and LUS involvement may indicate the need for more intensive preventive strategies for colorectal cancer and for evaluating the risk of synchronous ovarian cancer in patients with EC.

Secondary cancer prevention during follow-up for endometrial cancer

OBJECTIVE

To conduct a population-based study of incidence and screening rates for secondary breast and colorectal cancers after endometrial cancer and to assess implications for follow-up.

METHODS

This was a retrospective population-based study from administrative databases. The inception cohort included all women diagnosed with endometrial cancer in Ontario, Canada from 1996 to 2000, without a previous history of breast or colorectal cancer. We ascertained 5-year recurrence and overall survival rates and practitioner type during follow-up. Primary outcomes were age-standardized incidence and screening rates of breast and colorectal cancer during follow-up compared with the general female population.

RESULTS

There were 3,473 women in the cohort. The 5-year recurrence rate was 15.0% and overall survival was 79.3%. Family physicians were most often involved in follow-up care. Age-standardized incidence rates of breast and colorectal cancer were 0.5% and 0.7%, respectively, compared with 0.5% (P=.76) and 0.2% (P<.001) in the general population. Age-standardized screening rates for these cancers were 64.0% and 30.0%, respectively, compared with 31.0% (P<.008) and 15.0% (P<.001) in the general population. Women aged older than 70 years and those with the lowest income were least likely to have secondary cancer screening.

CONCLUSION

Women with endometrial cancer have a comparable risk of breast cancer but higher risk of colorectal cancer compared with the general population. Follow-up after endometrial cancer should include counseling and uptake of secondary cancer prevention strategies, which will contribute to maximizing long-term survivorship for these women.

LEVEL OF EVIDENCE

II.

Progression from normal breast pathology to breast cancer is associated with increasing prevalence of mouse mammary tumor virus-like sequences in men and women

Mouse mammary tumor virus (MMTV)-like sequences have been found in up to 40% of breast cancer samples but in <2% of normal breast tissue samples from Australian women studied by our group. Screening of a larger and more diverse cohort of female breast cancer samples has now shown a correlation of MMTV-like sequences with the severity (grade) of breast cancer. Thirty-two percent (43 of 136) of female breast cancer samples were positive for MMTV-like sequences when screened using PCR. A significant gradient of MMTV positivity was observed with increasing severity of cancer from 23% of infiltrating ductal carcinoma (IDC) grade I tumors to 34% of IDC grade II tumors (P = 0.00034) and 38% of IDC grade III tumors (P = 0.00002). We also report for the first time the detection of MMTV-like sequences in 62% (8 of 13) of male breast cancer samples and 19% (10 of 52) of male gynecomastia samples screened. MMTV-like sequences were demonstrated in various premalignant breast lesions of females, including fibroadenoma (20%) and fibrocystic disease (28%) samples, at a significantly higher prevalence than that seen in normal breast tissue (1.8%; P = 0.00001). Study of a longitudinal cohort of female breast cancer patients indicated that MMTV was co-incident with tumor but was not present when tumor was absent on histology. These results support the association of MMTV-like sequences with development of breast tumors in men and women and suggest association of MMTV with increasing severity of cancer.

Increased Risk for Hereditary Nonpolyposis Colorectal Cancer-Associated Synchronous and Metachronous Malignancies in Patients with Microsatellite Instability-Positive Endometrial Carcinoma Lacking MLH1 Promoter Methylation

PURPOSE

The aim of this study was to evaluate number and types of synchronous and metachronous malignancies in patients with endometrial carcinoma with and without microsatellite instability (MSI).

EXPERIMENTAL DESIGN

From a series of 413 endometrial cancer patients, we identified 94 patients with MSI-positive (MSI+) cancers and grouped them by tumor MLH1 promoter methylation status. These 94 patients were matched by year of surgery to 94 patients with MSI-negative (MSI-) endometrial cancers from the same series. Medical records were reviewed for clinicopathologic information including rates and types of synchronous and metachronous malignancies. Hereditary nonpolyposis colorectal cancer (HNPCC)-associated second and third cancers were analyzed for MSI and MSH2, MSH6, and MLH1 expression for comparison with the corresponding endometrial cancers.

RESULTS

The MSI+ and MSI- cohorts were similar with regard to age, race, grade, and histology. Twenty-eight MSI+ endometrial cancers (29.8%) were MLH1 unmethylated. Rates of synchronous and metachronous cancers were also similar in the MSI+ and MSI- groups at 20 and 23%, respectively. However, patients with MSI+ MLH1 unmethylated endometrial cancers had an excess of HNPCC-associated second and third cancers compared with those with MSI+ MLH1 methylated and MSI- endometrial cancers (18% versus 4.5%, P = 0.034, and 2.1%, P = 0.002). Six of seven second tumors from 5 patients with MSI+ MLH1 unmethylated endometrial cancers showed concordant MSI and mismatch repair protein expression status.

CONCLUSIONS

Our observation that patients with MSI-positive MLH1 unmethylated endometrial carcinoma are at increased risk for HNPCC-associated synchronous and metachronous malignancies suggests inherited cancer susceptibility. These patients and their families may warrant more intense cancer surveillance.

Subsequent primary malignancies after endometrial carcinoma and ovarian carcinoma

BACKGROUND

Population-based data on subsequent neoplasms after women are diagnosed with endometrial and ovarian carcinomas are limited, particularly regarding specific histologic tumor types.

METHODS

The nationwide Swedish Family-Cancer Database of 10.2 million individuals, which includes 19,128 invasive endometrial carcinomas and 19,440 ovarian carcinomas, was used to calculate standardized incidence ratios (SIRs) and 95% confidence intervals (95% CIs) for second primary carcinomas. SIRs were calculated for specific follow-up periods. Data on histopathologic types also were used.

RESULTS

An excess of subsequent malignancies after women were diagnosed with endometrial carcinoma was noted at 11 sites. The highest SIRs were recorded for synchronous or metasynchronous ovarian carcinomas (SIR, 55.77; 95% CI, 48.82-63.43) and carcinomas of the small intestines (SIR, 14.71; 95% CI, 4.64-34.59). Primary ovarian carcinoma was followed by an increased risk of developing endometrial carcinoma, and the risks of developing many other malignancies also were increased after women were diagnosed with endometrial carcinoma, including intestinal malignancies, renal cell carcinoma, bladder carcinoma, squamous cell skin carcinoma, connective tissue malignancies, and leukemia. When ovarian endometrioid histology was diagnosed synchronously with primary endometrial carcinoma, the SIR was 140; when endometrial carcinoma was the subsequent neoplasm, the SIR was 87. A small familial component was found in the cooccurrence of endometrial carcinoma and ovarian carcinoma.

CONCLUSIONS

The current data show a strong clustering of endometrial carcinomas and ovarian carcinomas, particularly involving tumors of endometrioid morphology. The patterns of second neoplasms also suggest that hereditary nonpolyposis colorectal carcinoma may contribute to the association between endometrial and ovarian malignancies. Increased risks for connective tissue tumors and leukemia may signal a response to treatment, and an increased risk for squamous cell skin carcinoma may signal a depressed immune function.

Survival after relapse in patients with endometrial cancer: results from a randomized trial

OBJECTIVE

The aim of this study was to determine the rates of local control and survival after relapse in patients with stage I endometrial cancer treated in the multicenter randomized PORTEC trial.

METHODS

The PORTEC trial included 715 patients with stage 1 endometrial cancer, either grade 1 or 2 with deep (>50%) myometrial invasion or grade 2 or 3 with <50% invasion. In all cases an abdominal hysterectomy was performed, without lymphadenectomy. After surgery, patients were randomized to receive pelvic RT (46 Gy) or no further treatment.

RESULTS

The analysis was done by intention-to-treat. A total of 714 patients were evaluated. At a median follow-up of 73 months, 8-year actuarial locoregional recurrence rates were 4% in the RT group and 15% in the control group (P < 0.0001). The 8-year actuarial overall survival rates were 71 (RT group) and 77% (control group, P = 0.18). Eight-year rates of distant metastases were 10 and 6% (P = 0.20). The majority of the locoregional relapses were located in the vagina, mainly in the vaginal vault. Of the 39 patients with isolated vaginal relapse, 35 (87%) were treated with curative intent, usually with external RT and brachytherapy, and surgery in some. A complete remission (CR) was obtained in 31 of the 35 patients (89%), and 24 patients (77%) were still in CR after further follow-up. Five patients subsequently developed distant metastases, and 2 had a second vaginal recurrence. The 3-year survival after first relapse was 51% for patients in the control group and 19% in the RT group (P = 0.004). The 3-year survival after vaginal relapse was 73%, in contrast to 8 and 14% after pelvic and distant relapse (P < 0.001). At 5 years, the survival after vaginal relapse was 65% in the control group compared to 43% in the RT group.

CONCLUSION

Survival after relapse was significantly better in the patient group without previous RT. Treatment for vaginal relapse was effective, with 89% CR and 65% 5-year survival in the control group, while there was no difference in survival between patients with pelvic relapse and those with distant metastases. As pelvic RT was shown to improve locoregional control significantly, but without a survival benefit, its use should be limited to those patients at sufficiently high risk (15% or over) for recurrence in order to maximize local control and relapse-free survival.

Stability-variability conflict as a reason for cancer: physical and social aspects

We present an analysis of cancer based on the synthesis of physical and social models of life as the stability-variability conflict (SVC). We showed that the intensity of the SVC increases with an increase in the rate of evolution or progress of species and populations. The probability of oncogenesis depends on this intensity and on the gray zone in the host's homeostasis. An organism and its cells are two interdependent systems which in extreme situations become antagonistic and competitive. The hierarchy of the biosystems (cell, organism, population) does not resolve the SVC and does not decrease the gray zone of this conflict. Cancer develops mainly due to external effects and results in some internal, including genomic, alterations which result in cell death (apoptosis), or cause cells to begin a new stage in their lives, possibly leading to tumors. In this respect, cancer is a rescuer of the cells, although it brings about the death of the host. An increase in the production of tumor-associated proteins in cancer patients is an example of such changes. Cancer can also be analysed in terms of entropy and information. In the context of the SVC, cancer is irreversible deviations from the "golden mean" solution. The golden mean and cancer deviation are considered universal categories of physical and social reflections of the SVC as the quintessence of life.

Clinicopathologic and familial characteristics of endometrial carcinoma with multiple primary carcinomas in relation to the loss of protein expression of MSH2 and MLH1

BACKGROUND

The frequency of synchronous or metachronous multiple primary carcinomas in patients with endometrial carcinoma has been reported to be between 10% and 23% and is highest among all gynecologic carcinomas. However, clinical characteristics and underlying genetic abnormalities in endometrial carcinoma with multiple primary carcinomas has not been well clarified. Endometrial carcinoma is the most commonly associated extracolonic malignancy in hereditary nonpolyposis colorectal carcinoma in which germ line mutations in DNA mismatch repair genes, particularly in MSH2 and MLH1, are known to cause this syndrome. The purpose of the current study was to investigate clinicopathologic and familial characteristics including MSH2, MLH1, and p53 expression in endometrial carcinoma with multiple primary carcinomas, by comparing them to endometrial carcinoma without other primary malignancies.

METHODS

Patients were divided into two groups: 30 patients with synchronous or metachronous multiple primary carcinomas other than endometrial carcinoma and 116 patients with endometrial carcinoma without other primary malignancies. Clinicopathologic characteristics, family history of cancer, and immunohistochemical protein expression of MSH2, MLH1, and p53 expression were investigated in both groups, and 15 endometria from benign disease were used for normal controls in immunohistochemistry.

RESULTS

The frequency of high risk clinicopathologic factors of endometrial carcinoma and 5-year survival rates and the frequency of p53 overexpression were not statistically different between the two groups. However, the loss of MSH2 and/or MLH1 expression was significant in endometrial carcinoma with multiple primary carcinomas, when compared with endometrial carcinoma alone (22 of 30 vs. 31 of 116). In cases with multiple primary carcinomas, particularly those diagnosed before the patient was 55 years of age or those in which the patient had a family history of cancer, the frequency of this loss was especially high (11 of 13 and 10 of 11, respectively).

CONCLUSIONS

The clinical or biologic nature of endometrial carcinoma with multiple primary carcinomas seems to be similar to endometrial carcinoma alone. A high incidence of defective MSH2 and MLH1 protein in endometrial carcinoma with multiple primary carcinomas, however, suggests that abnormalities in the function of MSH2 and MLH1 may play an important role in tumorigenesis for patients with endometrial carcinoma with multiple primary carcinomas and their families.

The importance of family history in young patients with endometrial cancer

Endometrial cancer occurs primarily in postmenopausal women older than 60 years of age. Especially in young patients with endometrial cancer, a positive family history with respect to cancer and/or development of synchronous or metachronous tumors can be indicative of hereditary factors. One genetic disorder, playing an important role in the development of endometrial cancer in young women, is hereditary non-polyposis colorectal cancer (HNPCC). The mean age to develop endometrial cancer because of a mutation in one of the HNPCC-genes is below 50 years. Mutation carriers have a life-time risk of about 50% for endometrial cancer. Especially young patients with endometrial cancer should always be asked for the family history and after primary treatment the family history should regularly be updated during follow-up.