Thank you for the opportunity to respond to this letter. We would also like to thank Dr Elshaikh for his interest and thoughtful comments in response to our paper that shows the correlation between adult comorbidity evaluation 27 score (ACE-27) and survival in patients with endometrial cancer (EC).

A large prospective population study of US adults showed that excess body weight was associated with a higher risk of death from any cancer. EC specifically had the highest relative risk of death associated with increasing body mass index (BMI) when compared with any other obesity-related or nonrelated cancer. Compared with women with a normal BMI, the relative risk of death was increased 2.5- to 3-fold for women with a BMI of 30-40 kg/m ² and 6-fold for a BMI >40 kg/m ² . Therefore, inclusion of BMI in the list of comorbidities that are used to calculate the ACE-27 score allows for quantification of the burden of obesity in addition to other medical conditions that are common in this population.

The study referenced by Dr Elshaikh states that 70-90% of patients with type I EC are obese. However, that cohort included treated and untreated patients with BMI >30 kg/m ² and was limited to grade 1-2 cancers. Our study is limited to surgically treated patients. It does not include young obese women who were treated with progestational therapy to preserve fertility or older patients who were treated with progestational or radiation therapy to prevent the high risk of surgical morbidity and death. We also included patients with grade 3 endometrioid, serous, and clear cell histologic conditions, which are not associated with obesity. Therefore, the statistic mentioned in the aforementioned study does not pertain to the population that was discussed in our article. Last, ACE-27 score was affected only by a BMI of >38 kg/m ² , resulting in a score of ≥2 depending on other comorbidities. As a result, an ACE-27 score of ≥2 could be due to obesity with a BMI of >38 kg/m ² ; 40% of our patients met this criteria.

The ACE-27 score used in our study documented comorbid conditions at the time of initial EC diagnosis or first evaluation at our institution. Longitudinal assessment of comorbidity was not performed in our analysis. We agree that comorbidities in this population increases with age and that subsequent evaluation of ACE-27 may reveal a different comorbidity score, but the purpose of this study was to determine factors that are associated with recurrence and death at the time of cancer diagnosis. It may also be true that the impact of comorbidity could be illustrated if we looked at a more uniform group of patients. However, the generalizability and power to detect a clinically important difference would be diminished.