In, J Rodrorron Ont.ok~~y &d Ph.n Vol. 27. PP. 293-301 Printed in the U.S.A. All nghts reserved.

0360-3016/93 $6.00 t .I0 Copyright 62 1993 Pergamon Press Ltd.

??Clinical Original Contribution

POOR SURVIVAL OF BLACK PATIENTS IN CARCINOMA OF THE ENDOMETRIUM

HASSAN AZIZ, M.D.,‘, MARVIN ROTMAN, M.D.,‘, FAZAL HUSSAIN, M.D.,‘, GLENDA SMITH, M.D.,‘, EVA CHAN, PH.D.,~, KWANG CHOI, M.D.,‘, CHUL SOHN, M.D.,‘,

JOSHUA HALPERN, M.D.,‘, DAVID SCHWARTZ, M.D., *, ISAMETTIN ARAL, M.D., ‘,

RACHEL FRUCHTER, PH.D.~ AND, ELI SERUR, M.D.2

‘Department of Radiation Oncology, ‘Department of Gynecology and Obstetrics, 3Scientific Computer Center, State University of New York, Health Science Center at Brooklyn.

Purpose: To compare the prognostic factors and survivals of black and white patients with endometrial carcinoma. Methods and Materials: A retrospective study was undertaken of a total of 290 patients with endometrial carcinoma who were treated similarly at the Health Science Center at Brooklyn and Kings County Hospital Center from 1975 and 1990. One hundred and thirty-six of 290 (47.2%) were black and 135/290 (46.9%) were white. Well-known prognostic factors affecting endometrial carcinoma were studied in black and white group of patients. Their overall survival and comparison of survival in each prognostic group were also estimated using multi-variate analysis. Results: Fifty-four percent of white patients had Stage I disease, compared to 45.9% in black patients. In Stage II, 51.6% were white and 48.4% were black, and in Stage III, 88.89% were black and 11.1% were white patients (p = 0.034). Fifty six percent Grade 1 patients were white and 44% were black. In Grade 2,53.3% were white and 46.7% were black and in Grade 3 disease, 70.5% were black and 29.5% were white (p = 0.008). Up to the inner third of myometrial invasion had occurred in 60.6% of white patients and 39.4% in black patients. The middle third of the myometrium was invaded in 60.7% of white patients, and 39.3% of black patients. Thirty-seven percent of outer third of myometrial invasion was found in white patients and 63% in black patients (p = 0.038). Seventy-two percent of positive lymph nodes were found in black patients and 28.0% in white patients (p = 0.01). Sixty-one percent of patients with positive peritoneal cytology were black as compared to 38.7% in white patients (p = 0.017). The overall ten-year correcCed survival for white and black patients was 72% and 40%, respectively (p = 0.0003). Survivals comparisons, when stratified by tace and each prognostic group, showed statistically significant overall survival differences in favor of white patients. Conclusion: Black patients with endometrial carcinoma have poor survival. Low socio-economic status (SES) would not explain these findings. More research is required to determine the cause of poor survival in black patients with endometrial carcinoma.-

Carcinoma of endometrium, Racial differences.

INTRODUCTION

Including both black and white females, it is estimated that in the USA in 1993, there will be 3 1,000 new cases of endometrial carcinoma, making it the most common malignancy of the female genital tract. In the same year, 5700 deaths will occur among both races (10). However, there are marked differences in the incidence and mor- tality from carcinoma of the endometrium in black and white populations (2).

The period from 1969 to 1972 saw a drastic increase in endometrial carcinoma largely due to longer life ex- pectancy. At the same time, there was also an unexplained

increase in younger age group. In certain geographical areas of the country, this increase had exceeded 10% per year between 1969 and 1973 (46). However, during the period from 1973 to 1989, the incidence of endometrial carcinoma in white population had declined by 30% where as the incidence in the black population remained un- changed. The mortality for both the races in the same period decreased by 24%, the preexisting differences in survival between the groups however still exist, i.e., 6.0 per 100,000 deaths for the black patients in 1985- 1989 as compared to 3.4 per 100,000 for white patients (2). Poorer survival in black patients with endometrial car- cinoma has already been reported by several authors ( 12,

Reprints requests to: Hassan Aziz, M.D., Radiation Oncology, State University of New York, 450 Clarkson Ave., Box 1211, Brooklyn, N.Y. 11203.

Acknowledgements-The skillful secretarial assistance pro-

vided by Ms. Elizabeth Rivera in the preparation of this manu- script is gratefully acknowledged by the authors.

Accepted for publication 6 July 1993.

293

294 1. J. Radiation Oncology 0 Biology 0 Physics

Table 1. Pathology

Volume 27, Number 2, I993

Table 3. FIG0 clinical system

Pathology No. of patients % Stage No. of patients %

Adenocarcinoma 193 66.6 Papillary adenocarcinoma 64 22.1 Adenoacanthoma 21 7.2 Clear cell 6 2.1 Adenosquamous 6 2.1 Total 290 100.0

38,4 1) including the American Cancer Society (2). These studies have indicated only advanced stages of the disease in black patients as a reason of their poor survival rate.

This retrospective study was undertaken to ascertain the prognostic factors, including grade, stage, depth of myometrial invasion, status of lymph nodes and perito- neal cytology that differ between black and white patients with endometrial carcinoma.

Methods and Materials A total of 290 patients treated for endometrial carci-

noma at the SUNY-Health Science Center at Brooklyn and Kings County Hospital Center between 1975 and 1990 were included in this study. 136/290 patients (47.2%) were black, mostly from Kings County Hospital and 135/ 290 (46.9%) were white, mostly from the SUNY-Health Science Center. Fifteen out of 290 (5.2%) were Hispanics and the racial origin of four patients was not known. The mean age was 63 years in the range of 28-95 years (stan- dard deviation 10.6). Age specific comparison by race was done by arbitrarily dividing patients into young (< 60 years) and old (> 60 years) groups in accordance with the median age. The majority of patients, 257/290 (88.7%), had adenocarcinoma including the papillary variety. Ad- enoacanthoma was the next most common tumor 2 l/ 290 (7.2%). Clear cell carcinoma was 6/290 (2.1%) and adenosquamous variety was 6/290 (2.1%) (Table 1).

Black and white patients had similar treatments. 2 17/

Table 2. Modalitv of treatment

Modality of treatment No. of

patients %

TAH-BSO + external RT and vaginal insertion cylinderfovoids 203 70.0

TAH-BSO and vaginal insertion cylinder/ ovoids only 14 4.8

TAH-BSO only 50 17.25 RT alone 14 4.8 RT + chemotherapy 3 1.0 TAH-BSO and hormonal therapy 3 1.0 Chemotherapy alone 1 0.36 Refused treatment 2 0.69 Total 290 100.0

TAH-BSO = transabdominal hysterectomy - bilateral sal- pingo-oophorectomy.

IA 107 40.1 IB 105 39.3

II 31 Il.6 III 9 3.4 IV 12 4.5 Unknown 26 9.0 Total 290 100.0

290 (74.8%) had received TAH-BSO (total abdominal hysterectomy and bilateral salpingo-oophorectomy) and postoperative radiation. 50/290 (17.25%) had received TAH-BSO only. Fourteen of 290 (4.8%) were treated with radiation only, while 3/290 ( 1%) were treated with TAH- BSO and hormonal therapy. 2/290 (0.68%) had refused any treatment (Table 2).

Until 1979, external radiation to the pelvis was given using anterior and posterior ports only. Later, all patients were treated with four-field box technique, giving a total dose of 4500 cGy with Cobalt 60 or with the 4MV linear accelerator. This was followed by one cylinder/avoids as a boost dose to the vaginal mucosa to a total vaginal sur- face dose in the range of 6500-7000 cGy. As a primary modality, radiation was used in the same fashion. If only postoperative vaginal cylinder/avoids were used, 7000 cGy was delivered to the vaginal mucosa as surface dose in two insertions.

All patients were staged clinically according to standards of International Federation of Gynecologists and Obste- tricians (FIGO) into Stages IA, IB, II, III, AND IV (30). Tumor grade was assessed from pathology reports and categorized as 1, 2, or 3 based upon histologic character- istics, cellular atypia and differentiation. Stage (Table 3), Grade (Table 4), depth of myometrial invasion (Table 5), lymph node involvement, and peritoneal cytology were analyzed for both black and white patients separately using multivariate analysis. With each prognostic factor, survival differences were estimated using the Kaplan and Meier method (32) and the Log rank test (37), unless otherwise specified. All survivals were calculated excluding death from other causes. Chi square test or Fishers exact tests were employed as necessary to determine the significance in the distribution of characteristics between the racial groups. The data analysis was carried out using the SAS statistical software package (3).

Table 4. Grade

Grade

1 2 3

Total

No. of patients %

136 48.6 98 35.0 46 16.4

280 100.0

Poor survival of black patients in carcinoma ??H. AZIZ et al. 295

Table 5. Depth of myometrial invasion Table 7. Grade Black vs. white

Inner l/3 Mid l/3 Outer l/3 No invasion

No. of patients

66 56 40 26

N= 188

%

35 30 21 14

Blacks Whites

Grade No. % No. %

1 55 43.1 71 56.3 126 100 2 43 46.1 49 53.3 92 100 3 31 70.5 13 29.5 44 100

p = 0.008 N = 262

RESULTS

Of the sample population, 47.2% (N = 136) were blacks and 46.9% (N = 135) were white, with a mean age of 63 years (std. dev 10.6) in the range of 28 to 95 years. Mean age at menarche was 13 years (std. dev. 1.9) in the range of 7 to 18 years and the mean age at menopause was 49.4 years (std. dev 6.6) in the range of 20 to 87 years. Out of 83 patients, we were able to get sexual history, average number of sexual partners was 2.7 with a range of 0 to 15 and out of 100 patients , mean age at first coitus was 19.7 years, with a range of 13 to 37 years, Most of the patients (N = 274) were obese with a mean weight of 174 pounds (std. dev 45.44) in the range of 83 to 338 pounds. Among black patients 92/ 129 (7 1.3%) were obese as com- pared to 76/122 (62.3%) in white group of patients. Twenty-two out of 123 ( 17.9%) black and 22/ 130 ( 16.9%) white patients were diabetic.

disease was more predominant in white patients. Ninety- two of 262 (35.1%) had Grade 2 tumor, of these 43/92 (46.7%) were blacks and 49/92 (53.3%) were white pa- tients. Forty-four out of 262 ( 16.6%) had Grade 3 disease. Of these, 31/44 (70.5%) were blacks while only 13/44 (29.5%) were whites (p = 0.008, Chi square test) as shown in Table 7.

Myometrial invasion

Stage One hundred ninety-six of 250 (78.4%) patients had

Stage I disease. Ninety of 196 (45.9%) of Stage I patients were black, while the rest, 106/ 196 (54.1%), were white patients. Thirty-one of 250 (12.4%) had Stage II disease. Of these, 15/3 1 (48.4%) were found in black patients, while 16/3 1 (5 1.6%) occurred in white patients. 23/250 (9.2%) had Stage III disease. Eighteen of 23 (78.3%) of these were in black patients and the remaining 5/23 (2 1.7%) of Stage III disease were found in white patients (p = 0.034, Exact test) as shown in Table 6.

Sixty-six of 162 (40.7%) had inner third myometrial invasion only. Of these, 40/66 (60.6%) belonged to the white group of patients and 26166 (39.4%) were found in black patients. Fifty-six of 162 (34.6%) had invasion of the middle third of myometrium. In this group 34/56 (60.7%) were found in white patients and the rest, 22/56 (39.3%) in black patients. Forty of 162 (24.7%) had in- vasion of the outer third of the myometrium. Twenty- five of 40 (62.5%) of these were found in black patients, while 15/40 (37.5%) occurred in white patients (p = 0.038, Chi square test) as shown in Table 8.

Lymph node involvement Only 24/264 (9.1%) had positive lymph nodes either

in the pelvis or in the periaortic area. Of these 18/24 (75%) were found in blacks, and 6/24 (25%) in white patients. This proportion is significantly different from the black and white proportion of the no lymph node involvement group patients (p = 0.01).

Grade Of 126/262 (48.09%) had Grade 1 disease. The rate of

Grade 1 disease in black patients was 55/ 126 (43.7%), and in white patients was 7 l/ 126 (56.3%). Similarly, Grade 2

Peritoneal cytology Peritoneal cytology was evaluated in 168 patients.

Thirty-one of 168 (18.5%) had positive peritoneal cytol- ogy. Nineteen out of 31 (61.3%) patients with positive cytology were found in blacks as compared to 12/3 1

Table 6. Stage Black vs. white

Blacks Whites Total

Stage No. % No. % No. %

I 90 45.9 106 54.1 196 100 I1 15 48.4 16 51.6 31 100

III 8 88.9 1 11.1 9 100 IV 8 100 0 0 8 100

(p = 0.034, Exact test) N = 244

Table 8. Invasion of myometrium black vs. white

Blacks Whites Total Depth of invasion No. % No. % No. %

Inner l/3 26 39.4 40 60.6 66 100 Mid l/3 22 39.3 34 60.7 56 100 Outer l/3 25 62.5 15 37.5 40 loo

p = 0.038 N= 162

Total

No. %

296 1. J. Radiation Oncology 0 Biology 0 Physics Volume 27. Number 2, 1993

0.04 , , , , , , , , , , , . , , , , , , , , 0 20 40 60 80 100 120 140 160 I80

SURVIVAL MONTHS

(LOGRANK TEST P=O.OOOl)

Fig. 1. Overall survival of all patients.

(38.7%) being positive in white patients. This proportion is not significantly different from the black and white pro- portion of the negative cytology patients (p = 0.107).

Overall survival The overall corrected IO-year survival for all patients

both blacks and whites, including all stages was 57% (Fig 1). When broken down by stages, the lo-year corrected survival for Stage I was 70% and for Stage II was 30%, and the median survival for Stage III and IV was 12 months (Fig 2). The overall corrected lo-year survival for white patients was 72% as compared to 40% for the black patients (p = 0.0003) (Fig. 3). The overall survival for both blacks vs. whites less than 60 years of age (p = 0.002), and for blacks vs.whites more than 60 years of age (p =

0.003) was significantly lower in black patients as com- pared to white patients. Survival comparison stratified by both age and race indicates that the younger than 60 years of age group of black patients had the worse survival rate.

Stage The corrected 1 O-year survival for Stage I black patients

was 58% as compared to 74% for the white patients (p = 0.06). Survival for Stage II white patients was 50% at 10 years and for black patients 12% for the same period. In Stage III, median survival for blacks patients was 11 months as compared to 3 months in white patients (there was only one white patient in Stage III). In Stage IV, me- dian survival for black patients was 9.5 months, whereas in Stage IV, there were no white patients. Overall survival

0.0 C II D . , , , , , , , , , , ,,,,,,, ‘,,,,,

0 20 40 60 80 100 120 140 160 180 SURVIVAL MONTHS A: STAGE I

6: STAGE II (LOGRANK TEST P=O.OOOl) C: STAGE III

D: STAGE IV

Fig. 2. Overall survival of black and white patients by stage.

Poor survival of black patients in carcinoma ??H. AZIZ et al. 297

(3 Z 0.8 - 1 _ a.___ ____ ‘,_, > .________^_________ ____ -- __________ a - I 0.6 - v) .

ei E 0.4 -

0.0 , , I ,,,,,,,,,,.,‘,.,.,,,‘,.,,,‘,‘,

0 20 40 60 80 too 120 MO 160 180

SURVIVAL MONTHS

(LOGRANK TEST P=O.O003) ----Whites - Blacks

Fig. 3. Overall survival of black and white patients.

comparison stratified by race and Stage showed that in Stage I and 11, black patients have worse survival as com- pared to white patients (p =O.OOOl), as shown in Figure 4 and Table 9.

by race and grade showed that black patients of all grades survive poorly (p = O.OOOl), as shown in Figure 5 and Table 10.

Grade Myometrial invasion When patients were analyzed for survival stratified by

race and grade, black patients with Grade 1 had worse survival than Grade 1 white patients. The corrected lo- year survival of white Grade 1 patients was 89% against 54% for black patients. In Grade 2 corrected IO-year sur- vival for white patients was 52% and 28% for black pa- tients. Median survival in Grade 3 black patients was 18.5 months while median survival of white patients in Grade 3 was 21 months. Overall survival comparison stratified

The 10 year corrected survival of black patients with no invasion or only inner third of myometrial invasion was 58% as compared to 78% in white patients. Surpris- ingly, both groups of patients with middle third invasion of myometrium had similar survival of 7 1% at 10 years. With outer third invasion of myometrium the corrected 5 year survival of white patients was 29% and for black patients 20% (p = 0.0001) as shown in Table 11 and Fig- ure 6.

0 20 40 60 80 100 120 I40 160 180 SURVIVAL MONTHS A. STAGE I BLACKS

8: STAGE I WHITES (LOGRANK TEST P=O.OOOl) C: STAGE II BLACKS

D: STAGE II WHITES E: STAGE III BLACKS F: STAGE III WHITES G, STAGE IV BLACKS H: STAGE IV WHITES

Fig. 4. Survival by stage in black and white patients.

298 1. J. Radiation Oncology 0 Biology 0 Physics Volume 27, Number 2, 1993

Table 9. Survival by stage black vs. white Table 10. Survival by grade black vs. white

Blacks Whites

5 Yrs 10 yrs 5 Yrs 10 yrs Stage N % % N % %

I 50 63 58 55 78 74 II 13 25 12 11 50 50

III 5 0 0 1 0 0 IV 8 0 0 0 0 0

(p = 0.000 1, Exact test) N= 143

Blacks Whites

5 Yrs 10 yrs 5 yrs 10 yrs Grade N % % N % %

1 35 64 54 39 92 89 2 27 33 28 29 56 52 3 18 24 0* 5 0** 0***

0, = 0.0001, Exact test) N= 153

Maximum: *93 months; +37 months; $37 months.

Lymph Nodes and Peritoneal Cytology Most of the patients who had positive lymph nodes

were blacks (72%) and their survival was not significantly lower than white patients (28%) with positive lymph nodes (p = 0.4). Similarly, most of the patients with positive peritoneal cytology were black (6 1.3%), as compared to white (38.7%), but their survival was not significantly dif- ferent (p = 0.19).

among blacks accounts for an excessive mortality. None of these studies have compared survivals with other well- known prognostic groups (15, 24, 25, 39, 45). In this ret- rospective study, we have not only compared the numbers of poor prognostic factors in each racial group, but have also compared survivals in each prognostic group.

DISCUSSION

At present, carcinoma of the endometrium is the most common tumor of the female genital tract (10); as such, it has become one of the most important subjects being discussed in the recent oncologic literature (1, 16,22,23). Although the incidence of endometrial carcinoma in white patients may be 30% less for 1985- 1989, than in 1973, it is still considerably higher for white patients, being 23.3 per 100,000, while the rate for blacks is 14.8 per 100,000. The incidence in black patients, however for years has remained constant with a steady difference in mortality, that is, 6.0 per 100,000 for blacks and 3.4 per 100,000 for whites (2).

The most important prognostic factors such as stage, grade, degree of myometrial invasion, lymph node in- volvement, and the presence of positive peritoneal cytol- ogy were analyzed for all patients. In black patients, a statistically significant higher number of patients were found with higher stage, grade, and with greater degree of myometrial invasion.

As expected, with more black patients in higher stages, grades, and higher degree of myometrial invasion, more black patients were found with positive lymph nodes and positive peritoneal cytology.

Several studies (12, 38, 41) have shown that in endo- metrial carcinoma, a greater number of high-stage patients

All prognostic factors (1, 15, 16, 25) being adversely affected in black patients, their overall IO-year corrected survival was considerably poorer being 72% for whites as compared to 40% for black patients (p = 0.0003) (Fig. 3). When survival for the two racial groups was calculated, stratified by stage, grade, and depth of myometrial inva- sion, survival was significantly higher for white patients in all prognostic groups (Figure 2-6 and Tables 9-l 1).

0 20 40 60 80 100 120 140 160 180

SURVIVAL MONTHS

(LOGRANK TEST i-0.0001) A: GRADE I BLACKS B: GRADE I WHITES C: GRADE II BLACKS D: GRADE II WHITES E: GRADE Ill BLACKS F, GRADE III WHITES

Fig. 5. Survival by grade in black and white patients.

Poor survival of black patients in carcinoma ??H. AZIZ ef al. 299

Table 11. Survival by invasion of myometrium black vs. white

Blacks Whites

Myometrial 5 Yrs 10 yrs invasion N % % N 5 Yrs 10 yrs

Upto inner l/3 26 12 58 40 80 78 Middle l/3 22 71 71 34 71 71 Outer l/3 25 20 * 15 29 t

(p = 0.000 1, Exact test) N= 162

Maximum: *93 months; +80 months.

Patients with positive lymph nodes and positive peri- toneal cytology, the majority of whom were black patients, had significantly poor survival. Although all age groups of black patients had poorer survival as compared to their white counterparts (13), the younger group of black pa- tients, that is, ~60 years of age when compared to the same age group of whites had the worst survival of all age groups (p = 0.002).

For several decades, a greater incidence of cancer in most anatomical sites and a higher mortality rate among blacks has been well known. In 1950, Henschke et al. (26) had already pointed out an increased rate of cancer and mortality among the black population. The incidence of cancer in the black population in this country, including all sites described by the American Cancer Society (2) in 1988 was 402 per 100,000 and for whites 2 13 per 100,000. The overall 5-year survival for black patients for all sites is 38% as compared to 53% for whites.

Many authors (2, 12, 38, 41) have made attempts to explain the disproportionate distribution of increased in- cidence and mortality among blacks. The National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) incidence data has been extensively used (7, 28)

for comparison against So&o-Economic Status (SES) of a given population for a specific cancer site. Low SES seems to be responsible for the greater mortality in sites such as cancer of the cervix, esophagus, lung, pancreas, and stomach (38). Carcinoma of the endometrium, colon, breast, and of ovaries have long been known to occur more commonly in patients with high SES (12, 38, 47). A low SES would not explain a greater incidence of en- dometrial carcinoma. A greater incidence of endometrial carcinoma may be explained as a result of greater life expectancy (19, 46). However, hormonal effect may also be responsible for the greater incidence of endometrial carcinoma (48). Greater degree of estrogenic stimulation of the endometrium may occur in early menarche and late menopause (3 1). Obesity and ingestion of estrogens during menopause may also account for a substantial number of cases. There is evidence that development of early menarche and late menopause at present is on the increase ( 12) with subsequent increase for developing en- dometrial carcinoma. Several authors have reported on the relationship of estrogen therapy in postmenopausal women and increased risk for developing endometrial carcinoma (35, 48). Obesity is associated with increased estrogen production secondary to increased peripheral aromatization. Further obesity may alter the metabolism of estrogen in a way which results in retention of unop- posed estrogenic activity. Obesity, therefore, is a well-rec- ognized risk factor (4) for the development of endometrial carcinoma.

The endometrial carcinoma occurring as a result of higher estrogenic activity is usually well differentiated ( 18). The hormonal effect as an etiological factor would not explain the presence of a higher number of black patients with high grade tumor. A low SES would only explain the presence of higher number of black patients with higher stage of the disease. Whether untreated low grade

0 20 40 60 80 100 120 140 160 180

Fig. 6. Survival by myometrial invasion in blacks and whites.

SURVIVAL MONTHS A: UP TO INNER l/S SLACKS

(LOGRANK TEST P=O.OOOl) 6: UP TO INNER 113 WHITES C. UP TO INNER l/2 SLACKS D. UP TO INNER 112 WHITES E: UP TO OUTER 113 SLACKS F: UP TO OUTER l/S WHITES

300 I. J. Radiation Oncology 0 Biology 0 Physics Volume 27, Number 2, 1993

tumor as it progresses in stage becomes undifferentiated remains a matter of controversy. Hill er al. (27) have re- ported on the possibility of such a change in the event of tumor progression without treatment. It is obvious that at present no explanation is available for the presence of greater number of patients with undifferentiated carci- noma in the black group of patients. It is possible however, that because of low SES that leads to tumor progression it may also lead to dedifferentiation of the tumor. This explanation for poor survival in black patients may be simple and will only stand when stage-to-stage, grade- to-grade survivals are similar in both blacks and whites which is not the case in our group of black patients.

vival of black patients with endometrial carcinoma in each group of well-known prognostic factors, except for ad- vanced stages cannot be exclusively explained by low SES of the black patients. It may indicate a genetic difference between the two racial groups or there may be profound effects of poor environmental and social factors on the differentiation of the tumor, its progression, and its sub- sequent optimal treatment.

In anatomic sites such as carcinoma of the prostate, Aziz et al. (5) and Dayal et al. ( 17) have reported similar survivals for similar stages and grades. An increased rate of mortality among black patients of carcinoma of the prostate gland was evident on the basis of a higher number of patients with higher stages and higher grades among black patients. Here again, the presence of low SES would explain the presence of a higher number of higher stages, but would not explain the presence of more patients with high grades. Later Hussain et al. (29) in 1992 again showed a greater number of black patients with high grade car- cinoma of the prostate and effectively related it to smok- ing. No such evidence is available in case of endometrial carcinoma.

Many authors (6,42,44) report worse survival for black cancer patients when stage and grade remain the same in both racial groups. Our finding of significantly worse sur-

From this study, it is not obvious why there are greater numbers of poor prognostic features in black patients with endometrial carcinoma. Low SES would only explain part of the problem such as greater number of patients with high stage disease, especially in black patients (12,20, 33, 40). Low SES, leading to delay in treatment and progres- sion of disease, also changes an initial low grade tumor to higher grade is controversial. Pap smear with its low yield in detecting early endometrial carcinoma also cannot be relied upon ( 12). At this time, an effective program for intervention (8, 9, 20) cannot be drawn. However, risk factors for developing endometrial carcinoma should be targeted for intervention. Women who are infertile and/ or obese (43) should be kept under observation, preferably with removal of endometrial tissue for biopsy at meno- pause. Estrogens alone should be avoided for alleviation of the symptoms of menopause and should be combined with progesterones (2 1,34) to avoid hyperplasia of the en- dometrium (11, 14, 36). Environmental or social factors which may be independent of low SES should be looked into to find any possible factors influencing the prognosis of black patients.

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