Absolute risk of endometrial carcinoma during 20-year follow-up among women with endometrial hyperplasia

Abstract

PURPOSE The severity of endometrial hyperplasia (EH)-simple (SH), complex (CH), or atypical (AH)-influences clinical management, but valid estimates of absolute risk of clinical progression to carcinoma are lacking. Materials and METHODS We conducted a case-control study nested in a cohort of 7,947 women diagnosed with EH (1970-2002) at one prepaid health plan who remained at risk for at least 1 year. Patient cases (N = 138) were diagnosed with carcinoma, on average, 6 years later (range, 1 to 24 years). Patient controls (N = 241) were matched to patient cases on age at EH, date of EH, and duration of follow-up, and they were counter-matched to patient cases on EH severity. After we independently reviewed original slides and medical records of patient controls and patient cases, we combined progression relative risks (AH v SH, CH, or disordered proliferative endometrium [ie, equivocal EH]) from the case-control analysis with clinical censoring information (ie, hysterectomy, death, or left the health plan) on all cohort members to estimate interval-specific (ie, 1 to 4, 5 to 9, and 10 to 19 years) and cumulative (ie, through 4, 9, and 19 years) progression risks. Results For nonatypical EH, cumulative progression risk increased from 1.2% (95% CI, 0.6% to 1.9%) through 4 years to 1.9% (95% CI, 1.2% to 2.6%) through 9 years to 4.6% (95% CI, 3.3% to 5.8%) through 19 years after EH diagnosis. For AH, cumulative risk increased from 8.2% (95% CI, 1.3% to 14.6%) through 4 years to 12.4% (95% CI, 3.0% to 20.8%) through 9 years to 27.5% (95% CI, 8.6% to 42.5%) through 19 years after AH. CONCLUSION Cumulative 20-year progression risk among women who remain at risk for at least 1 year is less than 5% for nonatypical EH but is 28% for AH.

Fig 1.

Absolute risk of subsequent endometrial carcinoma by endometrial hyperplasia (EH) type at index biopsy over intervals of 1 to 4, 5 to 9, and 10 to 19 years. Vertical bars indicate 95% CIs. Data points are plotted at the mean time to diagnosis within each time interval. Size of data points is proportional to the number of case patients diagnosed with endometrial carcinoma during that time interval. AH, atypical hyperplasia; DPEM, disordered proliferative endometrium.

Fig 2.

Cumulative risk of subsequent endometrial carcinoma by endometrial hyperplasia (EH) type at index biopsy. Vertical bars indicate 95% CIs. Data points are plotted at the mean time to diagnosis within each time interval. Size of data points is proportional to the number of case patients diagnosed with endometrial carcinoma during that time interval. AH, atypical hyperplasia; DPEM, disordered proliferative endometrium.