Sex disparities in cancer mortality and survival

Emerging Evidence for Infectious Causes of Cancer in the United States

Worldwide, infectious agents currently contribute to an estimated 15% of new cancer cases. Most of these (92%, or 2 million new cancer cases) are attributable to 4 infectious agents: Helicobacter pylori, human papillomavirus, and hepatitis B and C viruses. A better understanding of how infectious agents relate to the US cancer burden may assist new diagnostic and treatment efforts. We review US-specific crude mortality rates from infection-associated cancers and describe temporal and spatial trends since 1999. We review the US-specific evidence for infection-cancer associations by reporting available estimates for attributable fractions for the infection-cancer associations. Death due to cancers with established infectious associations varies geographically, but estimates for the US attributable fraction are limited to a few observational studies. To describe the burden of infection-associated cancer in the United States, additional observational studies are necessary to estimate the prevalence of infection nationally and within subpopulations. As infectious associations emerge to explain cancer etiologies, new opportunities and challenges to reducing the burden arise. Improved estimates for the United States would help target interventions to higher-risk subpopulations.

Clinical and therapeutic implications of sex steroid hormone receptor status in urothelial bladder cancer

Studies on the clinical profile of urothelial bladder cancer (UBC) have shown significant gender differences, namely, higher occurrence in males (male-to-female ratio of 3.5:1) and an advanced stage of disease at the time of diagnosis with rapid progression of the disease after initial diagnosis seen more commonly in females. The relationship between gender and UBC is complex and probably influenced by biological and epidemiological factors. Potential contributory factors such as sex steroid hormone pathway, gender difference in environmental carcinogen exposure, metabolic enzyme activity, and disparities in the intensity of diagnostic evaluation could probably explain the demographic trends in UBC. This comprehensive review of Medline publications during the period 2009–2019 attempts to identify the possible role of sex hormone receptors in gender variation and sexual dimorphism in the occurrence and progression of UBC. The clinical implications of identifying sex steroid receptors on factors such as disease prognostication and the therapeutic role of anti-androgens in the prevention and progression of UBC are critically reviewed. There is now significant evidence in literature to suggest the possible role of sex steroid hormone receptor-mediated signals in the genesis and progression of UBC. These receptors include androgen receptors, estrogen receptors, progesterone receptors, and various other orphan receptors. Excessive or reduced expression of these receptors, as well as alterations in their upstream or downstream pathways, correlate well with the clinical and therapeutic outcomes of UBC.

The pVHL neglected functions, a tale of hypoxia-dependent and -independent regulations in cancer

The von Hippel–Lindau protein (pVHL) is a tumour suppressor mainly known for its role as master regulator of hypoxia-inducible factor (HIF) activity. Functional inactivation of pVHL is causative of the von Hippel–Lindau disease, an inherited predisposition to develop different cancers. Due to its impact on human health, pVHL has been widely studied in the last few decades. However, investigations mostly focus on its role in degrading HIFs, whereas alternative pVHL protein–protein interactions and functions are insistently surfacing in the literature. In this review, we analyse these almost neglected functions by dissecting specific conditions in which pVHL is proposed to have differential roles in promoting cancer. We reviewed its role in regulating phosphorylation as a number of works suggest pVHL to act as an inhibitor by either degrading or promoting downregulation of specific kinases. Further, we summarize hypoxia-dependent and -independent pVHL interactions with multiple protein partners and discuss their implications in tumorigenesis.

Annual Report to the Nation on the Status of Cancer, Featuring Cancer in Men and Women Age 20-49 Years

Background

The American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, and North American Association of Central Cancer Registries provide annual updates on cancer occurrence and trends by cancer type, sex, race, ethnicity, and age in the United States. This year’s report highlights the cancer burden among men and women age 20–49 years.

Methods

Incidence data for the years 1999 to 2015 from the Centers for Disease Control and Prevention- and National Cancer Institute–funded population-based cancer registry programs compiled by the North American Association of Central Cancer Registries and death data for the years 1999 to 2016 from the National Vital Statistics System were used. Trends in age-standardized incidence and death rates, estimated by joinpoint, were expressed as average annual percent change.

Results

Overall cancer incidence rates (per 100 000) for all ages during 2011–2015 were 494.3 among male patients and 420.5 among female patients; during the same time period, incidence rates decreased 2.1% (95% confidence interval [CI] = −2.6% to −1.6%) per year in men and were stable in females. Overall cancer death rates (per 100 000) for all ages during 2012–2016 were 193.1 among male patients and 137.7 among female patients. During 2012–2016, overall cancer death rates for all ages decreased 1.8% (95% CI = −1.8% to −1.8%) per year in male patients and 1.4% (95% CI = −1.4% to −1.4%) per year in females. Important changes in trends were stabilization of thyroid cancer incidence rates in women and rapid declines in death rates for melanoma of the skin (both sexes). Among adults age 20–49 years, overall cancer incidence rates were substantially lower among men (115.3 per 100 000) than among women (203.3 per 100 000); cancers with the highest incidence rates (per 100 000) among men were colon and rectum (13.1), testis (10.7), and melanoma of the skin (9.8), and among women were breast (73.2), thyroid (28.4), and melanoma of the skin (14.1). During 2011 to 2015, the incidence of all invasive cancers combined among adults age 20–49 years decreased −0.7% (95% CI = −1.0% to −0.4%) among men and increased among women (1.3%, 95% CI = 0.7% to 1.9%). The death rate for (per 100 000) adults age 20–49 years for all cancer sites combined during 2012 to 2016 was 22.8 among men and 27.1 among women; during the same time period, death rates decreased 2.3% (95% CI = −2.4% to −2.2%) per year among men and 1.7% (95% CI = −1.8% to −1.6%) per year among women.

Conclusions

Among people of all ages and ages 20–49 years, favorable as well as unfavorable trends in site-specific cancer incidence were observed, whereas trends in death rates were generally favorable. Characterizing the cancer burden may inform research and cancer-control efforts.

Microarray expression profiling of long noncoding RNAs in the progesterone-treated lung cancer cells

BACKGROUND

The increasing incidence and unique biological features of lung cancer in women has prompted renewed interest in the role of sex hormones in this disease. We previously showed that progesterone (P4) inhibited lung cancer tumorigenesis and progression. Here, we investigated the effects of P4 on expression of long noncoding RNAs (lncRNAs) and target mRNAs in lung cancer cells.

METHODS

We performed high-throughput microarray and bioinformatics analysis to identify differentially expressed lncRNAs and mRNAs in the untreated and the P4-treated A549 human lung cancer cells.

RESULTS

In total, 692 lncRNAs and 268 mRNAs were significantly differentially expressed in the P4-treated A549 cells compared to the untreated A549 cells (> 2-fold change, p < 0.05). Of the lncRNAs, 82 and 610 were up-regulated and down-regulated, respectively. Gene ontology, pathway and network analyses showed that many of the mRNAs were involved in the regulation of classical pathways, including Notch signaling. Differential expression of a lncRNA signature composed of NONHSAT000264, FR075921, FR324124, linc-TRIM58, RP1-93H18.7, RP11-120 K9.2, RP11-134F2.2 and NONHSAG024980 was validated by quantitatuve reverse transcriptase-polymerase chain reaction analysis.

CONCLUSIONS

This is the first report of differentially expressed lncRNAs in the P4-treated lung cancer cells. The results suggest that lncRNAs could serve as potential therapeutic targets for P4-sensitive lung cancer.

Malignant pleural effusion survival prognostication in an Asian population

BACKGROUND AND OBJECTIVE

LENT and PROMISE scores prognosticate survival in patients with MPE. Prognostication guides the selection of interventions and management. However, the predictive value of these scores and their refinements (modified-LENT) in Asians remain unclear. We aim to evaluate the performance of LENT, modified-LENT and clinical PROMISE scores; identify predictors of survival; and develop an alternative prognostication tool should current scores lack accuracy.

METHODS

Retrospective medical record review of an Asian pleuroscopy database from 2011 to 2018 of patients with MPE was conducted. The prognostic capability of current available scores were evaluated using C-statistics. Demographic and clinical variables as predictors of survival were assessed, and an alternative model was developed using logistic regression.

RESULTS

In 130 patients, the C-statistics for modified-LENT was not significantly different from LENT (0.59 (95% CI: 0.52-0.67) vs 0.56 (95% CI: 0.49-0.63); P = 0.403). In 57 patients, the PROMISE C-statistics was 0.72 (95% CI: 0.53-0.91). In our alternative prognostication model (n = 147), Sex, Eastern Cooperative Oncology Group status, Leukocyte count, EGFR mutation, Chemotherapy and primary Tumour type (SELECT) were predictors of 90-day mortality (C-statistic = 0.87 (95% CI: 0.79-0.95)). SELECT sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios using a predicted probability of 90-day mortality cut-off point of 10% were 0.91, 0.68, 0.34, 0.98, 2.83 and 0.13, respectively.

CONCLUSION

The LENT, modified-LENT and PROMISE scores have poor accuracy of survival prognostication in Asian patients with MPE undergoing pleuroscopy. The proposed SELECT prognostication model is accurate at identifying patients with high probability of survival at 90 days.

The impact of sex and gender on immunotherapy outcomes

Immunotherapies are often used for the treatment, remission, and possible cure of autoimmune diseases, infectious diseases, and cancers. Empirical evidence illustrates that females and males differ in outcomes following the use of biologics for the treatment of autoimmune diseases, e.g., rheumatoid arthritis (RA), infectious diseases, e.g., influenza, and solid tumor cancers. Females tend to experience more adverse reactions than males following the use of a class of biologics referred to as immunotherapies. For immunotherapies aimed at stimulating an immune response, e.g., influenza vaccines, females develop greater responses and may experience greater efficacy than males. In contrast, for immunotherapies that repress an immune response, e.g., tumor necrosis factor (TNF) inhibitors for RA or checkpoint inhibitors for melanoma, the efficacy is reportedly greater for males than females. Despite these differences, discrepancies in reporting differences between females and males exist, with females have been historically excluded from biomedical and clinical studies. There is a critical need for research that addresses the biological (i.e., sex) as well as sociocultural (i.e., gender) causes of male-female disparities in immunotherapy responses, toxicities, and outcomes. One-size-fits-all approaches to immunotherapies will not work, and sex/gender may contribute to variable treatment success, including adherence, in clinical settings.

Pharmacologic Activation of the G Protein-Coupled Estrogen Receptor Inhibits Pancreatic Ductal Adenocarcinoma

BACKGROUND & AIMS

Female sex is associated with lower incidence and improved clinical outcomes for most cancer types including pancreatic ductal adenocarcinoma (PDAC). The mechanistic basis for this sex difference is unknown. We hypothesized that estrogen signaling may be responsible, despite the fact that PDAC lacks classic nuclear estrogen receptors.

METHODS

Here we used murine syngeneic tumor models and human xenografts to determine that signaling through the nonclassic estrogen receptor G protein-coupled estrogen receptor (GPER) on tumor cells inhibits PDAC.

RESULTS

Activation of GPER with the specific, small molecule, synthetic agonist G-1 inhibited PDAC proliferation, depleted c-Myc and programmed death ligand 1 (PD-L1), and increased tumor cell immunogenicity. Systemically administered G-1 was well-tolerated in PDAC bearing mice, induced tumor regression, significantly prolonged survival, and markedly increased the efficacy of PD-1 targeted immune therapy. We detected GPER protein in a majority of spontaneous human PDAC tumors, independent of tumor stage.

CONCLUSIONS

These data, coupled with the wide tissue distribution of GPER and our previous work showing that G-1 inhibits melanoma, suggest that GPER agonists may be useful against a range of cancers that are not classically considered sex hormone responsive and that arise in tissues outside of the reproductive system.

Sex Differences in Cancer Incidence and Survival: A Pan-Cancer Analysis

BACKGROUND

Sex plays an important role in the incidence, prognosis, and mortality of cancers, but often is not considered in disease treatment.

METHODS

We quantified sex differences in cancer incidence using the United States Cancer Statistics (USCS) public use database and sex differences in cancer survival using Surveillance, Epidemiology, and End Results (SEER) public use data from 2001 to 2016. Age-adjusted male-to-female incidence rate ratios (IRR) with 95% confidence intervals (CI) were generated by primary cancer site, race, and age groups. In addition, age-adjusted hazard ratios with 95% CI by sex within site were generated.

RESULTS

In general, cancer incidence and overall survival were lower in males than females, with Kaposi sarcoma (IRR: 9.751; 95% CI, 9.287-10.242; P < 0.001) having highest male-to-female incidence, and thyroid cancers (HR, 1.774; 95% CI, 1.707-1.845) having largest male-to-female survival difference. Asian or Pacific Islanders had particularly high male-to-female incidence in larynx cancers (IRR: 8.199; 95% CI, 7.203-9.363; P < 0.001), relative to other races. Among primary brain tumors, germ cell tumors had the largest male-to-female incidence (IRR: 3.03; 95% CI, 2.798-3.284, P < 0.001).

CONCLUSIONS

Overall, incidence and survival of cancer vary significantly by sex, with males generally having lower incidence and survival compared with females. Male-to-female incidence differences were also noted across race and age groups. These results provide strong evidence that the fundamental biology of sex differences affects cancers of all types.

IMPACT

This study represents the most recent and comprehensive reporting of sex differences in cancer incidence and survival in the United States. Identifying disadvantaged groups is critical as it can provide useful information to improve cancer survival, as well as to better understand the etiology and pathogenesis of specific cancers.

CD44 Gene Polymorphisms as a Risk Factor for Susceptibility and Their Effect on the Clinicopathological Characteristics of Lung Adenocarcinoma in Male Patients

Lung adenocarcinoma is a subtype of lung cancer with high morbidity and mortality. CD44 is instrumental in many physiological and tumor pathological processes. The expression of unique single nucleotide polymorphisms (SNPs) contributes to protein dysfunction and influences cancer susceptibility. In the current study, we investigated the relationship between CD44 polymorphisms and the susceptibility to lung adenocarcinoma with or without epidermal growth factor receptor (EGFR) gene mutations. This study included 279 patients with lung adenocarcinoma. In total, six CD44 SNPs (rs1425802, rs11821102, rs10836347, rs13347, rs187115, and rs713330) were genotyped using a real-time polymerase chain reaction. We found no significant differences in genotype distribution of CD44 polymorphisms between EGFR wild-type and EGFR mutation type in patients with lung adenocarcinoma. We observed a strong association between CD44 rs11821102 G/A polymorphism and EGFR L858R mutation (odds ratio (OR) = 3.846, 95% confidence interval (CI) = 1.018–14.538; p = 0.037) compared with the EGFR wild-type group. In the subgroup of male patients with lung adenocarcinoma harboring the EGFR wild-type, both CD44 rs713330 T/C (OR = 4.317, 95% CI = 1.029–18.115; p = 0.035) and rs10836347 C/T polymorphisms (OR = 9.391, 95% CI = 1.061–83.136; p = 0.019) exhibited significant associations with tumor size and invasion. Data from the present study suggest that CD44 SNPs may help to predict cancer susceptibility and tumor growth in male patients with lung adenocarcinoma.

Coronary Artery Calcium as a Synergistic Tool for the Age- and Sex-Specific Risk of Cardiovascular and Cancer Mortality: The Coronary Artery Calcium Consortium

Background

Coronary artery calcium (CAC) is a predictor for the development of cardiovascular disease (CVD) and to a lesser extent cancer. The age‐ and sex‐specific relationship of CAC with CVD and cancer mortality is unknown.

Methods and Results

Asymptomatic patients aged 40 to 75 years old without known CVD were included from the CAC Consortium. We calculated sex‐specific mortality rates per 1000 person‐years’ follow‐up. Using parametric survival regression modeling, we determined the age‐ and sex‐specific CAC score at which the risk of death from CVD and cancer were equal. Among the 59 502 patients included in this analysis, the mean age was 54.9 (±8.5) years, 34% were women, and 89% were white. There were 671 deaths attributable to CVD and 954 deaths attributable to cancer over a mean follow‐up of 12±3 years. Among patients with CAC=0, cancer was the leading cause of death, the total mortality rate was low (women, 1.8; men, 1.5), and the CVD mortality rate was exceedingly low for women (0.3) and men (0.3). The age‐specific CAC score at which the risk of CVD and cancer mortality were equal had a U‐shaped relationship for women, while the relationship was exponential for men.

Conclusions

The age‐ and sex‐specific relationship of CAC with CVD and cancer mortality differed significantly for women and men. Our age‐ and sex‐specific CAC score provides a more precise estimate and further facilitates the use of CAC as a synergistic tool in strategies for the prediction and prevention of CVD and cancer mortality.

Long-Term Employment Outcomes among Female Cancer Survivors

Advances in early detection and treatment have led to a growing population of female cancer survivors, many of whom are of working age. We examined the relationship between cancer and long-term (>5 years) employment outcomes in a nationally representative sample of working-age women in the United States. Data from nine waves of the Health and Retirement Study were used to examine employment status and weekly hours worked among cancer survivors (n = 483) and women without cancer (n = 6605). We used random slope regression models to estimate the impact of cancer and occupation type on employment outcomes. There was no difference in employment status between cancer survivors and women without cancer at baseline; however, during follow-up, cancer survivors were more likely to be employed than women without cancer (odds ratio (OR) = 1.33, 95% confidence interval (CI): 1.11–1.58). Among 6–10-year survivors, professional workers were less likely (OR = 0.40, 95% CI: 0.21–0.74) to be employed than manual workers. Among >10-year survivors, professional workers averaged fewer weekly hours worked (−2.4 h, 95% CI: −4.4–−0.47) than manual workers. The impact of cancer on long-term employment outcomes may differ by occupation type. Identifying the occupation-specific mechanisms associated with the return to work will be critical to developing targeted strategies to promote employment in the growing female cancer survivor population.

Sex differences in cancer mechanisms

We now know that cancer is many different diseases, with great variation even within a single histological subtype. With the current emphasis on developing personalized approaches to cancer treatment, it is astonishing that we have not yet systematically incorporated the biology of sex differences into our paradigms for laboratory and clinical cancer research. While some sex differences in cancer arise through the actions of circulating sex hormones, other sex differences are independent of estrogen, testosterone, or progesterone levels. Instead, these differences are the result of sexual differentiation, a process that involves genetic and epigenetic mechanisms, in addition to acute sex hormone actions. Sexual differentiation begins with fertilization and continues beyond menopause. It affects virtually every body system, resulting in marked sex differences in such areas as growth, lifespan, metabolism, and immunity, all of which can impact on cancer progression, treatment response, and survival. These organismal level differences have correlates at the cellular level, and thus, males and females can fundamentally differ in their protections and vulnerabilities to cancer, from cellular transformation through all stages of progression, spread, and response to treatment. Our goal in this review is to cover some of the robust sex differences that exist in core cancer pathways and to make the case for inclusion of sex as a biological variable in all laboratory and clinical cancer research. We finish with a discussion of lab- and clinic-based experimental design that should be used when testing whether sex matters and the appropriate statistical models to apply in data analysis for rigorous evaluations of potential sex effects. It is our goal to facilitate the evaluation of sex differences in cancer in order to improve outcomes for all patients.

Survival-associated alternative splicing signatures in non-small cell lung cancer

Alternative splicing (AS) is fundamental to transcriptome and proteome richness, and data from recent studies suggested a critical association between AS and oncogenic processes. To date, no systematic analysis has been conducted on AS from the perspective of different sexes and subtypes in non-small-cell lung cancer (NSCLC). Thus, we integrated the information of NSCLC patients from The Cancer Genome Atlas (TCGA) and evaluated AS profiles from the perspectives of sex and subtype. Eventually, a total of 813 and 1020 AS events were found to be significantly related to the overall survival (OS) of lung adenocarcinoma (LUAD) and lung squamous cell carcinoma (LUSC) patients. Four prognostic prediction models performed well at 1, 3, and 5 years, with an area under the receiver operating characteristic (ROC) curve (AUC) greater than 0.75. Notably, we explored the upstream splicing factors (SFs) and downstream regulatory mechanisms of the OS-associated AS events and verified four differentially expressed alternative splicing (DEAS) events via qPCR. These findings can provide important guidance for subsequent studies. In addition, we also constructed nomograms to facilitate early screening by clinicians and to determine patient outcomes in NSCLC.

Transgender individuals' cancer survivorship: Results of a cross-sectional study

BACKGROUND

Transgender individuals' cancer prevalence and transgender cancer survivors' health needs have received scarce attention. The current study compared transgender and cisgender individuals' cancer prevalence and described the health needs of transgender cancer survivors.

METHODS

The authors used Behavioral Risk Factor Surveillance System data on 95,800 cisgender and transgender individuals who self-reported a cancer diagnosis. Using multiple logistic regression, they estimated cancer prevalence and calculated odds ratios with 95% confidence intervals of physical, psychological, overall health, and health behaviors of transgender survivors compared with cisgender survivors.

RESULTS

After adjusting for confounders, transgender men had a significantly higher (>2-fold) number of cancer diagnoses compared with cisgender men, but not cisgender women. Cancer prevalence among gender nonconforming individuals and transgender women was not significantly different from that of cisgender men and cisgender women. Gender nonconforming survivors had significantly greater physical inactivity, heavy episodic alcohol use, and depression compared with cisgender men and cisgender women. Transgender men survivors were significantly more likely to report poor physical health and greater medical comorbidities and were less likely to report smoking compared with cisgender men and cisgender women. Transgender women survivors were significantly more likely to report diabetes compared with cisgender men and cisgender women and were more likely to report cardiovascular disease compared with cisgender women.

CONCLUSIONS

Clinicians should be aware of the higher prevalence of cancer among transgender men and a potential survivorship bias among transgender individuals. Transgender survivors have considerable variation in their risk profile. Clinicians and health services can target gender nonconforming survivors' depression and health behaviors to improve survival and should address the complex comorbidities of transgender men and transgender women.

Impact of gender on survival in patients with laryngeal squamous cell carcinoma: a propensity score matching analysis

BACKGROUND

In the world, there are approximately 160,000 cases of laryngeal cancer newly diagnosed every year and 95% of the cases are squamous cell carcinoma (LSCC). We conduct this study to investigate the influencing factors in LSCC.

METHOD

We used cohort of LSCC cases form the Surveillance, Epidemiology, and End Results (SEER) database (1973-2014) to investigate the relationship between gender and survival. We conducted 1:1 propensity matching to mimic randomized controlled trials. Using the matched group, we investigate the effect of gender on cancer-specific survival (CSS) and overall survival (OS).

RESULT

In total, 47881 patients were brought into an unmatched cohort and 17985 cases were brought into a matched cohort. Using the matched group, we conducted a survival analysis. The 1-year, 3-year, and 5-year CSS and OS rates were better in female patients and the subgroup analysis showed the same trend. Cox regression analysis showed gender was an independent prognostic indicator for LSCC patients.

CONCLUSION

Gender is an independent prognostic indicator for LSCC patients. Male patients are a high-risk population.

Association of Patient Sex With Efficacy of Immune Checkpoint Inhibitors and Overall Survival in Advanced Cancers: A Systematic Review and Meta-analysis

Importance

Sex-associated differences in immune response are known, but a meta-analysis suggested men, compared with women, derive greater value from immunotherapy for advanced solid-organ malignant neoplasms. However, methodologic concerns and subsequent trials have placed these results in doubt.

Objective

To perform an updated, comprehensive meta-analysis that assesses the efficacy of immunotherapy in advanced cancers according to patient sex.

Design, Setting, and Participants

A systematic review of studies (n = 23) indexed in MEDLINE (PubMed), Embase, and Scopus from inception of these databases to October 2, 2018, was conducted. Randomized clinical trials that compared immunotherapy with standard of care in the treatment of advanced solid-organ malignant neoplasms were included if overall survival was reported as an outcome and if data stratified by patient sex were available. Observational studies, editorials, commentaries, review articles, non-peer-reviewed publications, studies that compared various immunotherapy regimens, studies that reported other measures of oncologic response, and studies that reported subgroup analyses for 1 sex only were excluded.

Main Outcomes and Measures

Overall survival, with a test for heterogeneity between women and men, to assess the null hypothesis that no difference in the survival advantage of immunotherapy exists by patient sex.

Results

This meta-analysis included 23 randomized clinical trials that reported on 9322 men (67.9%) and 4399 women (32.1%); the age of most patients was in the 70s. An overall survival benefit of immunotherapy was found for both men (hazard ratio [HR], 0.75; 95% CI, 0.69-0.81; P < .001) and women (HR, 0.77; 95% CI, 0.67-0.88; P = .002). Random-effects meta-analysis of study-level differences in response to immunotherapy demonstrated no statistically significant difference between the sexes (I2 = 38%; P = .60). Subgroup analyses according to disease site, line of therapy, class of immunotherapy, study methodology, and representation of women recapitulated these findings.

Conclusions and Relevance

Stratified analyses demonstrated no statistically significant association of patient sex with the efficacy of immunotherapy in the treatment of advanced cancers using overall survival as the outcome.

Differences in cancer survival by area-level socio-economic disadvantage: A population-based study using cancer registry data

Despite overall improvements in cancer survival due to earlier diagnosis and better treatment, socio-economically disadvantaged people have lower cancer survival than more advantaged people. We aimed to examine differences in cancer survival by area-level socio-economic disadvantage in Victoria, Australia and assess whether these inequalities varied by year of diagnosis, age at diagnosis, time since diagnosis and sex. Cases diagnosed with a first primary cancer in 2001–2015 were identified using the Victorian Cancer Registry and followed to the end of 2016. Five-year net survival and the excess risk of death due to a cancer diagnosis were estimated. People living in more disadvantaged areas had lower five-year survival than residents of less disadvantaged regions for 21 of 29 cancer types: head and neck, oesophagus, stomach, colorectum, anus/anal canal, liver, gallbladder/biliary tract, pancreas, lung, melanoma, connective/soft tissue, female breast, ovary, prostate, kidney, bladder, brain and central nervous system, unknown primary, non-Hodgkin lymphoma, multiple myeloma and leukemia. The observed lower survival in more deprived regions persisted over time, except head and neck cancer, for which the gap in survival has widened. Socio-economic inequalities in survival decreased with increasing age at diagnosis for cancers of connective/soft tissue, bladder and unknown primary. For colorectal cancer, the observed survival disadvantage in lower socio-economic regions was greater for men than for women, while for brain and central nervous system tumours, it was larger for women. Cancer survival is generally lower for residents of more socio-economically disadvantaged areas. Identifying the underlying reasons for these inequalities is important and may help to identify effective interventions to increase survival for underprivileged cancer patients.

Aging and aging-associated diseases: a microRNA-based endocrine regulation hypothesis

Although there are numerous hypotheses explaining the nature of aging and associated processes, two concepts are dominant: (i) aging is a result of cell-autonomous processes, such as the accumulation of DNA mutations, aberrant methylations, protein defects, and shortening of telomeres, leading to either inhibition of cellular proliferation and death of non-dividing terminally differentiated cells or tumor development; (ii) aging is a result of a central program that is switched on at a specific stage of organismic development. The microRNA-based endocrine regulation hypothesis combines the two above concepts by proposing central regulation of cell death occurrences via hypothalamus-pituitary gland (PG)-secreted miRNA hormones, the expression and/or secretion of which are regulated by sex hormones. This hypothesis explains such well-known phenomena as inverse comorbidity of either cancer or Alzheimer’s (AD) and other neurodegenerative diseases; higher AD morbidity and lower frequency of many common types of cancer in women vs. men; higher risk of early AD and lower risk of cancer in subjects with Down syndrome; longer life expectancy in women vs. men and much lower sex-dependent differences, if any, in other mammals; increased lifespans due to hypophysectomy or PG hypofunction; and parabiotic effects of blood or plasma transfusions between young and old animals.

Sex Differences in the Blood Transcriptome Identify Robust Changes in Immune Cell Proportions with Aging and Influenza Infection

Sex differences in autoimmunity and infection suggest that a better understanding of molecular sex differences will improve the diagnosis and treatment of immune-related disease. We identified 144 differentially expressed genes, referred to as immune sex expression signature (iSEXS), between human males and females using an integrated multi-cohort analysis of blood transcriptome profiles from six discovery cohorts from five continents with 458 healthy individuals. We validated iSEXS in 11 additional cohorts of 524 peripheral blood samples. When we separated iSEXS into genes located on sex chromosomes (XY-iSEXS) or autosomes (autosomal-iSEXS), both modules distinguished males and females. iSEXS reflects sex differences in immune cell proportions, with female-associated genes showing higher expression by CD4+ T cells and male-associated genes showing higher expression by myeloid cells. Autosomal-iSEXS detected an increase in monocytes with age in females, reflected sex-differential immune cell dynamics during influenza infection, and predicted antibody response in males, but not females.

Molecular Markers in Sex Differences in Cancer

Cancer is one of the common causes of death with a high degree of mortality, worldwide. In many types of cancers, if not all, sex-biased disparities have been observed. In these cancers, an individual's sex has been shown to be one of the crucial factors underlying the incidence and mortality of cancer. Accumulating evidence suggests that differentially expressed genes and proteins may contribute to sex-biased differences in male and female cancers. Therefore, identification of these molecular differences is important for early diagnosis of cancer, prediction of cancer prognosis, and determination of response to specific therapies. In the present review, we summarize the differentially expressed genes and proteins in several cancers including bladder, colorectal, liver, lung, and non-small cell lung cancers as well as renal clear cell carcinoma, and head and neck squamous cell carcinoma. The sex-biased molecular differences were identified via proteomics, genomics, and big data analysis. The identified molecules represent potential candidates as sex-specific cancer biomarkers. Our study provides molecular insights into the impact of sex on cancers, suggesting strategies for sex-biased therapy against certain types of cancers.

Sex Differences in Cancer Driver Genes and Biomarkers

Cancer differs significantly between men and women; even after adjusting for known epidemiologic risk factors, the sexes differ in incidence, outcome, and response to therapy. These differences occur in many but not all tumor types, and their origins remain largely unknown. Here, we compare somatic mutation profiles between tumors arising in men and in women. We discovered large differences in mutation density and sex biases in the frequency of mutation of specific genes; these differences may be associated with sex biases in DNA mismatch repair genes or microsatellite instability. Sex-biased genes include well-known drivers of cancer such as β-catenin and BAP1 Sex influenced biomarkers of patient outcome, where different genes were associated with tumor aggression in each sex. These data call for increased study and consideration of the molecular role of sex in cancer etiology, progression, treatment, and personalized therapy.Significance: This study provides a comprehensive catalog of sex differences in somatic alterations, including in cancer driver genes, which influence prognostic biomarkers that predict patient outcome after definitive local therapy. Cancer Res; 78(19); 5527-37. ©2018 AACR.

Impact of Patients' Gender on Efficacy of Immunotherapy in Patients With Metastatic Kidney Cancer: A Systematic Review and Meta-analysis

Recent meta-analyses on checkpoint inhibitors in cancer report conflicting data regarding the association of patient gender with inhibitor efficacy. In advanced kidney cancer, checkpoint inhibitors have shown improved outcomes in first- and second-line settings compared with standard of care, but the role of patient gender on treatment outcome is unclear. We aimed to assess the efficacy of immunotherapy according to patient gender in advanced kidney cancer. We performed a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search was performed using PubMed, Scopus, Web of Science, and The Cochrane Library to identify eligible studies published through February 16, 2019. Studies were included if they reported on the differential outcomes of male and female patients with metastatic kidney cancer receiving immunotherapy. Our outcomes of interest were overall survival (OS) or progression-free survival (PFS). Four randomized controlled trials comprising a total of 3664 patients (2715 males and 949 females) met our inclusion criteria. Both men and women with metastatic kidney cancer had an OS and PFS advantage with immunotherapy compared with standard-of-care, but no statistically significant difference between the genders was observed (OS hazard ratio [HR] for men, 0.69; 95% confidence interval [CI], 0.59-0.8; P = .40; HR for women, 0.62; 95% CI, 0.48-0.81; P = .13; PFS HR for men, 0.7; 95% CI, 0.59-0.82; P = .24; HR for women, 0.68; 95% CI, 0.52-0.90; P = .105). In patients with advanced kidney cancer receiving checkpoint inhibitors, there seems to be no association of patient gender with treatment outcome.

Monoclonal Antibodies in Dermatooncology-State of the Art and Future Perspectives

Monoclonal antibodies (mAbs) targeting specific proteins are currently the most popular form of immunotherapy used in the treatment of cancer and other non-malignant diseases. Since the first approval of anti-CD20 mAb rituximab in 1997 for the treatment of B-cell malignancies, the market is continuously booming and the clinically used mAbs have undergone a remarkable evolution. Novel molecular targets are constantly emerging and the development of genetic engineering have facilitated the introduction of modified mAbs with improved safety and increased capabilities to activate the effector mechanisms of the immune system. Next to their remarkable success in hematooncology, mAbs have also an already established role in the treatment of solid malignancies. The recent development of mAbs targeting the immune checkpoints has opened new avenues for the use of this form of immunotherapy, also in the immune-rich milieu of the skin. In this review we aim at presenting a comprehensive view of mAbs' application in the modern treatment of skin cancer. We present the characteristics and efficacy of mAbs currently used in dermatooncology and summarize the recent clinical trials in the field. We discuss the side effects and strategies for their managing.

Sex disparities in cancer

Sex is a key biological factor affecting the development of many cancer types. There are considerable differences between male and female subpopulations in terms of cancer incidence, prognosis and mortality. Recent studies have extensively characterized the sex-biased molecular changes in cancer patients. Further efforts should be made to develop sex-specific cancer prevention and therapeutic strategies.

Sex Differences in Cancer Immunotherapy Efficacy, Biomarkers, and Therapeutic Strategy

Sex differences in innate and adaptive immune responses are known, and women generally mount a stronger immune response than men. Cancer immunotherapy, represented by immune checkpoint inhibitors (ICIs), has revolutionized the treatment of cancer, and sex differences in cancer immunotherapy are just starting to be revealed. Here, we summarize recent research progress concerning sex differences in cancer immunotherapy efficacy. On their own, ICIs tend to be more effective in male cancer patients compared with female patients, while ICIs combined with chemotherapy tend to be more effective in female patients than male patients. Male tumors are usually more antigenic than female tumors, and this is reflected by their increased number of tumor mutations and cancer germline antigens. The biomarker tumor mutational burden (TMB), which reflects tumor antigenicity, is more effective at predicting immunotherapy response for female lung cancer patients than for male patients. In this review, we propose different therapeutic strategies for the different sexes: For male cancer patients, the immune environment should be enhanced, whereas for female cancer patients, tumor antigenicity should be enhanced.

Bladder cancer survival: Women only fare worse in the first two years after diagnosis

OBJECTIVES

It has consistently been shown that women who are diagnosed with bladder cancer have lower survival than men, but the exact mechanism remains unknown. Most studies assumed that the sex-specific mortality ratio is constant over time, possibly resulting in inaccurate estimates in various periods of follow-up. This study aimed to investigate the sex-specific excess mortality in bladder cancer patients and its variation over follow-up time.

METHODS

Observational cohort study. Using data from the population-based Netherlands Cancer Registry, we studied 24,169 patients diagnosed between 2003 and 2014 with histologically confirmed ≥T1 bladder cancer with follow-up until January 2018. We used flexible parametric relative survival models to estimate excess mortality as a function of time for each sex and to explore the effect of covariates on these functions.

RESULTS

Female patients (24%) had worse clinical tumor, node, and metastasis-stage at diagnosis and more often a nonurothelial tumor histology. The excess mortality ratio of sex was not constant over time; in the first two years after diagnosis excess mortality rates for women were higher than for men, but lower thereafter; this applied to both nonmuscle-invasive and muscle-invasive bladder cancer subgroups. Baseline differences in age, tumor, node, and metastasis-stage and histology accounted for only part of the excess mortality gap.

CONCLUSIONS

The assumption of proportional hazards over time leads to underestimation of the excess mortality ratio for women in the first two years and overestimation thereafter, when excess mortality is comparable for women and men. Clinicians should incorporate the initial sex-specific poorer outcome in their considerations regarding prognosis and treatment options for female patients, e.g., more invasive treatment and neo-adjuvant treatment. These findings also point towards a mechanism of micrometastatic disease, warranting assessment of sex-specific efficacy in randomized controlled trials on treatments in this patient population.

Understanding Differences in Cancer Survival between Populations: A New Approach and Application to Breast Cancer Survival Differentials between Danish Regions

Large variations in cancer survival have been recorded between populations, e.g., between countries or between regions in a country. To understand the determinants of cancer survival differentials between populations, researchers have often applied regression analysis. We here propose the use of a non-parametric decomposition method to quantify the exact contribution of specific components to the absolute difference in cancer survival between two populations. Survival differences are here decomposed into the contributions of differences in stage at diagnosis, population age structure, and stage-and-age-specific survival. We demonstrate the method with the example of differences in one-year and five-year breast cancer survival between Denmark’s five regions. Differences in stage at diagnosis explained 45% and 27%, respectively, of the one- and five-year survival differences between Zealand and Central Denmark for patients diagnosed between 2008 and 2010. We find that the introduced decomposition method provides a powerful complementary analysis and has several advantages compared with regression models: No structural or distributional assumptions are required; aggregated data can be used; and the use of absolute differences allows quantification of the survival that could be gained by improving, for example, stage at diagnosis relative to a reference population, thus feeding directly into health policy evaluation.

Low colorectal cancer survival in the Mountain West state of Nevada: A population-based analysis

Colorectal cancer (CRC) is the third greatest cancer burden in the United States. The remarkably diverse Mountain West state of Nevada has uncharacteristically high CRC mortality compared to other Western states. We aimed to study the determinants of the CRC excess burden by using data from the Nevada Central Cancer Registry from 2003-2013. Five-year cause-specific age-adjusted survival from colorectal cancer was calculated and stratified by sex, race/ethnicity and region of Nevada. Cox Proportional Hazards regression modelling was used to study the impact of demographic, social, and clinical factors on CRC survival in Nevada, assessing follow-up as accurately as possible. The extent to which differences in survival can be explained by receipt of stage-appropriate treatment was also assessed. 12,413 CRC cases from 2003-2013 in Nevada were analyzed. Five-year CRC survival was low: 56.0% (95% CI: 54.6-57.5) among males and 59.5% (95% CI: 58.0-61.1) among females; significantly lower than national 5-year survival of 65.1% and 66.5%, respectively. Low survival was driven by populous Southern Nevada; after adjustment for all covariates, Southern Nevadans were at 17% higher risk of death than their counterparts in Northwestern Nevada (HR:1.17; 95% CI:1.08-1.27). Many patients did not receive stage-appropriate treatment, although this only partly explained the poor survival, uniformly low for every race/ethnicity in Nevada. The observed disparity for this one state within a single nation merits public health attention; regardless of the state or region of residence, all Americans deserve equal opportunity for optimum health outcomes in the face of a cancer diagnosis. The current study provides baseline information critical to clinicians, public health professionals, and all relevant stakeholders as they attempt to discern why Nevada's outcomes are vastly divergent from its neighboring Western states and make plans for remediation.

The Effect of Mouse Strain, Sex, and Carcinogen Dose on Toxicity and the Development of Lung Dysplasia and Squamous Cell Carcinomas in Mice

In order to translate new treatments to the clinic, it is necessary to use animal models that closely recapitulate human disease. Lung cancer develops after extended exposure to carcinogens. It has one of the highest mutation rates of all cancer and is highly heterogenic. Topical treatment with N-nitrosotris-(2-chloroethyl)urea (NTCU) induces lung squamous cell carcinoma (SCC) with nonsynonymous mutation rates similar to those reported for human non-small cell lung cancer. However, NTCU induces lung cancer with variable efficacy and toxicity depending on the mouse strain. A detailed characterization of the NTCU model is needed. We have compared the effect of three different NTCU doses (20, 30, and 40 mmol/L) in female and male of NIH Swiss, Black Swiss, and FVB mice on tumor incidence, survival, and toxicity. The main findings in this study are (1) NIH Swiss mice present with a higher incidence of SCC and lower mortality compared with Black Swiss and FVB mice; (2) 30 mmol/L NTCU dose induces SCC at the same rate and incidence as the 40 mmol/L dose with lower mortality; (3) female mice present higher grade and incidence of preinvasive lesions and SCC compared with males; (4) NTCU-induced transformation is principally within the respiratory system; and (5) NTCU treatment does not affect the ability to elicit a specific adaptive immune response. This study provides a reference point for experimental designs to evaluate either preventive or therapeutic treatments for lung SCC, including immunotherapies, before initiating human clinical trials.

The estrogen pathway as a modulator of response to immunotherapy

Lung cancer is the leading cause of cancer deaths worldwide, with a 5-year survival rate of about 18%. Thus, there is a great need for novel therapeutic approaches to treat non-small-cell lung cancer (NSCLC). Immune checkpoint inhibitors (ICIs) have improved outcomes for a subset of patients, especially those with high programmed death-ligand 1 expression and/or high tumor mutational burden, but have failed in the majority of patients. Increasing evidence suggests that the estrogen signaling pathway may be a therapeutic target in metastatic NSCLC and that the estrogen pathway may play a role in sex-based responses to ICIs. This report will review the epidemiologic, preclinical and clinical data on the estrogen pathway in NSCLC, its implications in sex-based responses to ICIs and the potential use of antiestrogen therapy in combination with ICIs.

Sex-, feeding-, and circadian time-dependency of P-glycoprotein expression and activity - implications for mechanistic pharmacokinetics modeling

P-glycoprotein (P-gp) largely influences the pharmacokinetics (PK) and toxicities of xenobiotics in a patient-specific manner so that personalized drug scheduling may lead to significant patient's benefit. This systems pharmacology study investigated P-gp activity in mice according to organ, sex, feeding status, and circadian time. Sex-specific circadian changes were found in P-gp ileum mRNA and protein levels, circadian amplitudes being larger in females as compared to males. Plasma, ileum and liver concentrations of talinolol, a pure P-gp substrate, significantly differed according to sex, feeding and circadian timing. A physiologically-based PK model was designed to recapitulate these datasets. Estimated mesors (rhythm-adjusted mean) of ileum and hepatic P-gp activity were higher in males as compared to females. Circadian amplitudes were consistently higher in females and circadian maxima varied by up to 10 h with respect to sex. Fasting increased P-gp activity mesor and dampened its rhythm. Ex-vivo bioluminescence recordings of ileum mucosae from transgenic mice revealed endogenous circadian rhythms of P-gp protein expression with a shorter period, larger amplitude, and phase delay in females as compared to males. Importantly, this study provided model structure and parameter estimates to refine PK models of any P-gp substrate to account for sex, feeding and circadian rhythms.

Role of chemotherapy in 5000 patients with head and neck cancer treated by curative surgery: A subgroup analysis of the meta-analysis of chemotherapy in head and neck cancer

OBJECTIVE

To evaluate the effect of chemotherapy added to a surgical locoregional treatment (LRT) for patients with locally advanced head and neck squamous cell carcinoma (HNSCC).

MATERIALS AND METHODS

We studied the sub-group of trials with surgical LRT included in the meta-analysis on chemotherapy in head and neck cancer (MACH-NC). Data from published and unpublished randomized trials comparing the addition of chemotherapy to LRT in HNSCC patients were sought using electronic database searching for the period 1965-2000, hand searching and by contacting experts in the field. Trials with less than 60 patients, or preoperative radiotherapy or where the type of LRT could not be individually determined were excluded. All individual patient data were checked for internal consistency, compared with published reports, and validated with trialists. Data were pooled using a fixed-effect model. Heterogeneity was assessed using Cochrane test and I² statistic.

RESULTS

Twenty-four trials were eligible (5000 patients). Chemotherapy improved overall survival (HR = 0.92 [95%CI: 0.85-0.99] p = 0.02). There was a significant interaction between treatment effect and timing of chemotherapy (p = 0.08 at pre-specified threshold of 0.10) with a greater effect for concomitant chemotherapy (HR = 0.79, 95%CI: 0.69-0.92). The benefit of chemotherapy was greater in women (HR_women = 0.63, 95%CI: 0.50-0.80) compared to men (HR_men = 0.96, 95%CI: 0.89-1.04; p for interaction = 0.001).

CONCLUSIONS

This analysis confirmed the benefit of concomitant chemotherapy added to surgical LRT. The role of induction therapy as yet to be determined as it did not improve OS. Women may benefit more than men from chemotherapy.

Assessing the Effectiveness of Systemic Therapy after Stereotactic Radiosurgery on Cancer Recurrence and All-Cause Mortality

BACKGROUND

Patients with cancer often present with brain metastases in the setting of controlled extracranial disease, for which they receive stereotactic radiosurgery (SRS) and surgical resection. The role of systemic therapy after SRS is unclear. Brain metastasis indicates active cancer dissemination, and microscopic systemic disease may be present despite absence of gross disease as assessed by conventional imaging modalities.

OBJECTIVE

The aim was to determine if post-SRS systemic therapy reduces the risk of brain relapse, systemic relapse, and death in patients with brain metastases and controlled extracranial disease.

METHODS

We retrospectively reviewed the medical records of 67 patients with controlled extracranial disease who received SRS for brain metastases. Kaplan-Meier analysis and Cox proportional hazards regression were used to assess how post-SRS systemic therapy affected the risk of brain relapse, systemic relapse, and all-cause mortality.

RESULTS

In our sample, 31% of patients received systemic therapy after SRS. Post-SRS systemic therapy did not affect median time to brain relapse (P = 0.43), systemic relapse (P = 0.16), or death (P = 0.33) by univariate analysis. After accounting for confounding factors such as cancer histology and age, post-SRS systemic therapy significantly reduced the risk of brain relapse (hazard ratio [HR], 0.22; P = 0.002) but not systemic relapse (HR, 0.38; P = 0.09) or all-cause mortality (HR, 2.16; P = 0.09).

CONCLUSIONS

Only a minority of patients with brain metastases and controlled extracranial disease receive adjuvant systemic therapy after SRS, but those that do have a reduced risk of brain relapse. Post-SRS systemic therapy may act prophylactically to reduce the risk of intracranial cancer recurrence.

Effect of sex on the efficacy of patients receiving immune checkpoint inhibitors in advanced non-small cell lung cancer

Immune checkpoint inhibitors (ICIs) have shown promising efficacy in the treatment of non‐small cell lung cancer (NSCLC). Sex‐associated dimorphism in immune system response is acknowledged, but the effect of patients’ sex on efficacy of ICIs as treatment in NSCLC still remains controversial. The present study was conducted to investigate the difference in efficacy of NSCLC patients receiving immune checkpoint inhibitors according to the sex. A total of 9583 patients involved 6567 men and 3016 women with advanced lung cancer from 15 randomized controlled trials were included in this study. An overall survival (OS) benefit of immune checkpoint inhibitors was illustrated in both male (HR 0.76, 95% CI 0.71‐0.82) and female (HR 0.73, 95% CI 0.58‐0.91) patients, and a progression‐free survival (PFS) benefit was also found in both men (HR 0.67, 95% CI 0.58‐0.77) and women (HR 0.73, 95% CI 0.56‐0.95) in NSCLC. Both PD‐1/PD‐L1 inhibitors alone and PD‐1/PD‐L1 plus chemotherapy significantly improved the OS and PFS in male patients. Whereas in females, PD‐1 inhibitors or monotherapy significantly benefited the OS but not the PFS, PD‐L1 inhibitors or combination therapy significantly prolonged the PFS but not the OS. No survival benefit was found in both male and female patients from the CTLA‐4 inhibitors. The current study indicated that the magnitude of survival benefit is sex‐dependent and male patients seemed to obtain more consistent and favorable outcomes from ICIs than women patients in NSCLC.

Smoking History Decreases Survival in Patients with Squamous Cell Carcinoma of the Mouth: A Retrospective Study with 15 Years of Follow-up

Background:

The purpose of this study was to evaluate the influence of smoking history on the clinical-pathological, sociodemographic and prognostic characteristics of patients with oral squamous cell carcinoma (SCC).

Materials and Methods:

A retrospective cohort study was carried out with the records of 136 smokers with SCC and 68 nonsmokers with oral SCC who were diagnosed and treated at Haroldo Juaçaba Hospital (2000-2014). Data on patient sex, age, race, education level, tumor location, tumor size, lymph node involvement, distant metastasis, treatment type, marital status, method of health care access (public or private health systems) and overall survival (15 years) were analyzed by the X² test, Mantel-Cox tests and multinomial and Cox logistic regression models (SPSS 20.0, p <0.05).

Results:

Smoking history was directly associated with male sex (p <0.001), low levels of education (p = 0.001), tumors of the mouth and palate (p = 0.001), stage T3/4 tumors (p = 0.014), lymph node metastasis (N+) (p = 0.024), palliative treatment (p = 0.024) and receiving health care through the public health system (p = 0.006), with education level being the only independently associated factor (p = 0.039). Lower survival was observed in patients who were smokers (p = 0,002), with low levels of education (p = 0.001), who had stage T3/4 tumors (p = 0.004), with N+ (p = 0.021), and had received palliative treatment (p = 0.002). Age (>65 years old, p = 0.015) and T staging (T3/4, p = 0.033) decreased the survival of SCC patients regardless of the other factors.

Conclusions:

Smoking history had an independent association with low education level and a history of alcoholism, and survival was negatively associated with older age and larger tumor size, which were more prevalent in smokers.

Sex Differences in Melanoma

PURPOSE OF REVIEW

The goal of this review has been to elucidate the sex differences in cancer incidence and mortality in cutaneous melanoma. We have evaluated biological and behavioral research to determine where the critical questions exist.

RECENT FINDINGS

The most recent findings, through 2015, are exploratory in nature but seem to indicate that the differences are more likely due to biological variations rather than behavioral. While behavioral studies do show that women are more likely than men to seek health care and practice healthy behaviors, these differences are not sufficiently strong to explain the variation in incidence and mortality in cutaneous melanoma. Evolved differences in the immune systems of females and the role of sex steroid hormones in immunomodulation are two promising avenues for research. Studies in mice demonstrate that the newer immunotherapies are more effective in females and sex steroid hormones, such as estrogen receptor beta are inversely associated with tumor aggressiveness while testosterone increases it.

SUMMARY

Our analysis indicates that biological factors need to be investigated more thoroughly to understand the variation in incidence and mortality in cutaneous melanoma. Such understanding could lead to reducing incidence and mortality for both males and females (male incidence is 27.4 per 100,000; female 16.8 per 100,000; male mortality is 3.9 per 100,000; female mortality 1.6 per 100,000). It is most likely that behavioral differences between the sexes cannot account for the preponderance of male mortality. In addition to the important role of genetic factors, it is critical to evaluate further additional biological factors and their interactions with genetics and behavior.

Sex disparities in salivary malignancies: Does female sex impact oncological outcome?

OBJECTIVE

Previous population-based studies in salivary gland carcinomas have described a relationship between female sex and superior oncological outcome.

PATIENTS AND METHODS

Our institutional database of 884 surgically treated patients with salivary gland malignancies from 1985 to 2015 was analyzed for the impact of sex on oncological outcomes. Histologies were classified in three risk groups, low, intermediate and high. Survival outcomes were determined using the Kaplan-Meier method. Hazard ratios for male sex were determined using the Cox proportional hazards model.

RESULTS

Eight hundred sixty-seven patients were identified; median age was 59 years, and 51% had a minor salivary gland malignancy. Female patients were younger (58 versus 60 years; p = 0.040) and had a lower incidence of high-risk histologies (25% versus 40%, p < 0.001) and T3-T4 tumors compared to men (23% versus 31%, p < 0.001). With a median follow-up of 57 months, female patients had a superior 5-year disease-specific survival (DSS) (90% versus 79%; p < 0.001). The unadjusted hazard ratio showed male patients had a 2.15-fold increased risk of death (HR 2.15; 95% CI, 1.50-3.06, p < 0.001). After adjusting for Charlson comorbidity index, tobacco use, histological risk group, and overall pathological stage, males still had a statistically significant increased risk of death (HR 1.48; 95% CI 1.05-2.17; p = 0.047). Subgroup analysis showed DSS for females was significantly better in the high-risk histological group (5-year 68% versus 49%, p = 0.007).

CONCLUSION

Our study shows that sex has an impact on cancer-specific survival and that female sex favors improved survival.

Current trends in the features of male thyroid cancer: Retrospective evaluation of their prognostic value

This study aimed to compare the clinicopathologic characteristics and oncologic outcomes of papillary thyroid cancer (PTC) patients according to sex. Then, we validated prognostic variables to determine whether sex is a significant prognostic factor for PTC.Between January 2007 and December 2010, 1232 men and 7276 women PTC patients underwent surgery. The patient characteristics and 5-year oncologic outcomes were compared. The stepwise Cox proportional hazards model determined the significance of survival variables.Men PTC patients had more lymph node (LN) metastases than women, both in the total (P < .0001) and hemithyroidectomy (P < .0001) patients. Men and women showed similar 5-year recurrence-free survivals, both in total (P = .815) and hemithyroidectomy (P = .148) patients. The tumor size and the number of positive central nodes were associated with tumor recurrence, but not sex.Sex was not an independent prognostic factor for tumor recurrence. Multicenter clinical studies with long-term follow-ups are needed to validate these results.

Testis-specific protein, Y-linked 1 activates PI3K/AKT and RAS signaling pathways through suppressing IGFBP3 expression during tumor progression

The testis‐specific protein, Y‐linked 1 (TSPY1), a newly recognized cancer/testis antigen, has been suggested to accelerate tumor progression. However, the mechanisms underlying TSPY1 cancer‐related function remain limited. By mining the RNA sequencing data of lung and liver tumors from The Cancer Genome Atlas, we found frequent ectopic expression of TSPY1 in lung adenocarcinoma (LUAD) and liver hepatocellular carcinoma (LIHC), and the male‐specific protein was associated with higher mortality rate and worse overall survival in patients with LUAD and LIHC. Overexpression of TSPY1 promotes cell proliferation, invasiveness, and cycle transition and inhibits apoptosis, whereas TSPY1 knockdown has the opposite effects on these cancer cell phenotypes. Transcriptomic analysis revealed the involvement of TSPY1 in PI3K/AKT and RAS signaling pathways in both LUAD and LIHC cells, which was further confirmed by the increase in the levels of phosphorylated proteins in the PI3K‐AKT and RAS signaling pathways in TSPY1‐overexpressing cancer cells, and by the suppression on the activity of these two pathways in TSPY1‐knockdown cells. Further investigation identified that TSPY1 could directly bind to the promoter of insulin growth factor binding protein 3 (IGFBP3) to inhibit IGFBP3 expression and that downregulation of IGFBP3 increased the activity of PI3K/AKT/mTOR/BCL2 and RAS/RAF/MEK/ERK/JUN signaling in LUAD and LIHC cells. Taken together, the observations reveal a novel mechanism by which TSPY1 could contribute to the progression of LUAD and LIHC. Our finding is of importance for evaluating the potential of TSPY1 in immunotherapy of male tumor patients with TSPY1 expression.

Genotypic and Phenotypic Variables Affect Meiotic Cell Cycle Progression, Tumor Ploidy, and Cancer-Associated Mortality in a brca2-Mutant Zebrafish Model

Successful cell replication requires both cell cycle completion and accurate chromosomal segregation. The tumor suppressor BRCA2 is positioned to influence both of these outcomes, and thereby influence genomic integrity, during meiotic and mitotic cell cycles. Accordingly, mutations in BRCA2 induce chromosomal abnormalities and disrupt cell cycle progression in both germ cells and somatic cells. Despite these findings, aneuploidy is not more prevalent in BRCA2-associated versus non-BRCA2-associated human cancers. More puzzlingly, diploidy in BRCA2-associated cancers is a negative prognostic factor, unlike non-BRCA2-associated cancers and many other human cancers. We used a brca2-mutant/tp53-mutant cancer-prone zebrafish model to explore the impact of BRCA2 mutation on cell cycle progression, ploidy, and cancer-associated mortality by performing DNA content/cell cycle analysis on zebrafish germ cells, somatic cells, and cancer cells. First, we determined that combined brca2/tp53 mutations uniquely disrupt meiotic progression. Second, we determined that sex significantly influences ploidy outcome in zebrafish cancers. Third, we determined that brca2 mutation and female sex each significantly reduce survival time in cancer-bearing zebrafish. Finally, we provide evidence to support a link between BRCA2 mutation, tumor diploidy, and poor survival outcome. These outcomes underscore the utility of this model for studying BRCA2-associated genomic aberrations in normal and cancer cells.

Trend and projection of mortality rate due to non-communicable diseases in Iran: A modeling study

Background

Following the epidemiologic and demographic transition, non-communicable disease mortality is the leading cause of death in Iran. Projecting mortality trend can provide valuable tools for policy makers and planners. In this article, we have estimated the trend of non-communicable disease mortality during 2001–2015 and have projected it until 2030 at national and subnational levels in Iran.

Methods

The data employed was gathered from the Iranian death registration system and using the Spatio-temporal model, the trends of 4 major categories of non-communicable diseases (cancers, cardiovascular diseases, asthma and COPD, and diabetes) by 2030 were projected at the national and subnational levels.

Results

The results indicated that age standardized mortality rate for cancers, CVDs, and Asthma and COPD will continue to decrease in both sexes (cancers: from 81.8 in 2015 to 45.2 in 2030, CVDs: 307.3 to 173.0, and Asthma and COPD: from 52.1 to 46.6); however, in terms of diabetes, there is a steady trend in both sexes at national level (from 16.6 to 16.5). Age standardized mortality rates for cancers and CVDs, in males and females, were high in all provinces in 2001. The variation between the provinces is clearer in 2015, and it is expected to significantly decrease in all provinces by 2030.

Conclusion

Generally, the age standardized mortality rate from NCDs will decrease by 2030. Of course, given the experience of the past two decades in Iran, believing that the mortality rate will decrease may not be an easy notion to understand. However hard to believe, this decrease may be the result of better management of risk factors and early detection of patients due to more comprehensive care in all segments of society, as well as improved literacy and awareness across the country.

TNFSF15 promoter polymorphisms increase the susceptibility to small cell lung cancer: a case-control study

BACKGROUND

Tumor necrosis factor superfamily member 15 (TNFSF15) is closely related to tumorigenesis and development. This study aimed to investigate the correlations between TNFSF15 polymorphisms and genetic susceptibility to lung cancer.

METHODS

This case-control study included 209 small cell lung cancer patients (SCLC), 340 non- small cell lung cancer patients (NSCLC) and 460 health controls. TNFSF15-638 A > G and - 358 T > C polymorphisms were genotyped by polymerase chain reaction-restrictive fragment length polymorphism (PCR-RFLP) analysis. Odds ratio (OR) and 95% confidence interval (95% CI) were estimated by unconditional logistic regression.

RESULTS

Our results showed that subjects carrying the TNFSF15-638GG genotype or -358CC genotype were more likely to develop SCLC (-638GG, OR = 1.84, 95%CI = 1.13-2.99; -358CC, OR = 2.44, 95%CI = 1.46-4.06), but not NSCLC (P > 0.05). In stratified analysis, -638GG genotype was related to SCLC among males (OR = 1.95, 95%CI = 1.09-3.45, P = 0.023) and older patients (OR = 2.93, 95%CI = 1.44-8.68, P = 0.006). However, -358CC genotype was associated with SCLC among females (OR = 8.42, 95%CI = 2.22-31.89, P = 0.002) and older subjects with OR (95%CI) of 11.04 (3.57-34.15) (P < 0.001). Moreover, TNFSF15 -358CC was linked with a higher risk of SCLC among non-smokers (OR = 2.54, 95%CI = 1.20-5.35, P = 0.015) but not among smokers (OR = 1.88, 95%CI = 0.92-3.84, P = 0.086).

CONCLUSION

These findings highlight the importance of TNFSF15 polymorphisms in the development of SCLC.