Sex Differences in Multiple Myeloma Biology but not Clinical Outcomes: Results from 3894 Patients in the Myeloma XI Trial

BACKGROUND

Sex differences in the incidence and outcomes of several cancers are well established. Multiple myeloma (MM) is a malignant plasma cell dyscrasia accounting for 2% of all new cancer cases in the UK. There is a clear sex disparity in MM incidence, with 57% of cases in males and 43% in females. The mechanisms behind this are not well understood and the impact of sex on patient outcomes has not been thoroughly explored.

PATIENTS AND METHODS

We investigated the association of sex with baseline disease characteristics and outcome in 3894 patients recruited to the phase III UK NCRI Myeloma XI trial, in which treatment exposure to lenalidomide predominated.

RESULTS

Females were significantly more likely to have the molecular lesions t(14;16) and del(17p) and were more likely to meet the cytogenetic classification of high-risk (HiR) or ultra-high-risk disease (UHiR). There was no difference in progression-free survival (PFS) or overall survival (OS) between the sexes in the overall population.

CONCLUSION

Our data suggest that the genetic lesions involved in the initiation and progression of MM may be different between the sexes. Although females were more likely to have the poor prognosis lesions t(14;16) and del(17p), and were more likely to be assessed as having HiR or UHiR disease, this was not associated with reduced PFS or OS. In female patients the trial treatment may have been able to overcome some of the adverse effects of high-risk cytogenetic lesions. MicroAbstract Multiple myeloma (MM) is more common in males compared to females but the reasons behind this are not well understood and the impact of sex on patient outcomes is unclear. This study demonstrates fundamental differences in genetic lesions underlying the biology of MM between males and females. However, we found that progression-free survival and overall survival were the same in both sexes.

The molecular basis of gender disparities in smoking lung cancer patients

AIMS

Gender disparities exist in smoking-related lung cancer epidemiology, but the molecular basis has not been explored so far. We aimed at identifying genes with gender-bias expression pattern in smoking lung cancer patients for understanding the molecular basis of gender bias in smokers using meta-analysis of microarray gene expression data.

MATERIALS AND METHODS

Transcriptome of around 1100 samples from 13 studies were used in the meta-analysis to identify 'Lung Cancer genes specific to Female-Smokers' (LCFS) and 'Lung Cancer genes specific to Male-Smokers' (LCMS). The expression profiles of these genes were validated with an independent microarray report and TCGA-RNA-sequencing data. The molecular interactions, pathway, and other functional annotations were portrayed for the key genes identified.

KEY FINDINGS

We identified 1159 gender-biased genes in smoking lung cancer patients. Of these, 400 and 474 genes showed differential expression in cancerous compared to normal lung of women (LCFS) and men (LCMS), respectively. While many up-regulated LCFS were involved in 'immune responses' including T-cell activation, leukocyte cell-cell adhesion, the LCMS were mainly involved in 'positive regulation of gene expression', signaling pathways including RAS, VEGF, insulin-receptor signaling, and 'cell cycle'.

SIGNIFICANCE

The strategic-method identified genes, particularly, SNX20, GIMAP6, MTMR2, FAM171B, IDH1, MOBP, FBXO17, LPXN and WIPF1, which were consistently differentially expressed in at least 4 studies, and in agreement with RNA-Seq data. Exploring their functions could be beneficial to the gender-based diagnosis, prognosis, and treatment of lung cancer in smokers. The current meta-analysis supports existing knowledge of sexual-dimorphism of immune responses in cancer.

Prognostic significance of sentinel node biopsy status in cutaneous melanoma: a 21-years prospective study from a single institution

AIM

To analyze the accuracy of the sentinel lymphatic node biopsy (SLNB) and to investigate predictive factors for sentinel node (SN) status and prognostic factors for recurrence-free survival (RFS) and disease-specific survival (DSS) in patients with melanoma.

MATERIAL AND METHODS

Between June 1997 and June 2017, 440 consecutive patients, who underwent SLNB by a single surgical team, were prospectively included. Descriptive and survival analysis were performed.

RESULTS

119 of 440 patients (26%) had positive SN. SLNB's false-negative rate was 6.3%. Breslow thickness, Clark´s level, ulceration and histological subtype were statistically significant predictive factors of SN metastases. In a multivariate analysis, positive SN (HR = 2.21, p = 0.01), deeper Breslow thickness (HR = 2.05, p = 0.013), male gender (RR = 2.05, p = 0.02), and higher Clark's level (HR = 2.30, p = 0.043) were significantly associated with decreased RFS; and positive SN (HR = 2.58, p < 0.001), deeper Breslow thickness (HR = 2.57, p = 0.006) and male gender (HR = 1.93, p = 0.006) were associated with lower DSS.

CONCLUSION

SLNB is a reliable and reproducible procedure with high sensitivity (93.7%). Positive SN metastases, Breslow thickness and male gender were statistically associated with poorer outcomes. Male gender was an independent prognostic factor of tumor thickness or SN status.

Brazilian Women With Lung Cancer Have a Higher Overall Survival Than Their Male Equivalents: A Cohort Study

BACKGROUND

Lung cancer is the principal cause of cancer-related deaths worldwide; however, there has been controversy as to whether there is a difference in survival rate according to gender in Brazil. The aim of the present study, therefore, was to compare the epidemiologic and clinical profile and the overall survival of patients with lung cancer according to gender.

PATIENTS AND METHODS

A retrospective cohort study was performed involving 1283 patients diagnosed with lung cancer between 2006 and 2014 at a single cancer center. Survival analysis was conducted using Kaplan-Meier statistics. A log-rank test was used to assess differences between survival curves, and Cox proportional hazards regression analysis was performed to quantitate the relationship between gender and overall survival.

RESULTS

Compared with men, women were more frequently younger (P < .001), nonsmokers (P = .007), diagnosed with adenocarcinoma (P < .001), had early stage disease (P < .001), received surgery or surgery in combination with chemotherapy (P < .001), and had a better survival rate (P < .001). The median overall survival rate was higher in women (14.2 vs. 10.5 months in men; P < .001). Cox regression-adjusted analysis shows that women were 16% less likely to die than men (hazard ratio, 0.84; 95% confidence interval, 0.72-0.98; P = .03).

CONCLUSIONS

A higher overall survival rate was found in women with lung cancer as compared with men with lung cancer in Brazil.

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.

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.

Differences in cancer survival by sex: a population-based study using cancer registry data

PURPOSE

Few large-scale studies have investigated sex differences in cancer survival and little is known about their temporal and age-related patterns.

METHODS

We used cancer registry data for first primary cancers diagnosed between 1982 and 2015 in Victoria, Australia. Cases were followed until the end of 2015 through linkage to death registries. Differences in survival were assessed for 25 cancers using the Pohar-Perme estimator of net survival and the excess mortality rate ratio (EMRR) adjusting for age and year of diagnosis.

RESULTS

Five-year net survival for all cancers combined was lower for men (47.1%; 95% CI 46.9-47.4) than women (52.0%; 95% CI 51.7-52.3); EMRR 1.13 (95% CI 1.12-1.14; p < 0.001). A survival disadvantage for men was observed for 11 cancers: head and neck, esophagus, colorectum, pancreas, lung, bone, melanoma, mesothelioma, kidney, thyroid, and non-Hodgkin lymphoma. In contrast, women had lower survival from cancers of the bladder, renal pelvis, and ureter. For the majority of cancers with survival differences, the EMRR decreased with increasing age at diagnosis; for colorectal, esophageal, and kidney cancer, the EMRR increased with time since diagnosis.

CONCLUSION

Identifying the underlying reasons behind sex differences in cancer survival is necessary to address inequalities, which may improve outcomes for men and women.

Pretreatment subcutaneous adipose tissue predicts the outcomes of patients with head and neck cancer receiving definitive radiation and chemoradiation in Taiwan

We aimed to determine whether body composition assessment before treatment can predict outcomes in patients with head and neck cancer (HNC). All 881 patients with locoregional head and neck cancer treated with curative intent radiotherapy (RT) between 2005 and 2012 were retrospectively investigated. Body composition was analyzed via pre-RT planning computed tomography (CT) images. Subcutaneous adipose tissue (SAT) and skeletal muscle (SM) indices were measured cross-sectionally at the level of the third thoracic vertebra. Overall survival (OS), locoregional control (LRC), and distant metastasis-free survival (MFS) were analyzed by body composition index and body mass index (BMI). Survivors were followed up for a median of 4.68 years. The SAT indices in female patients were significantly higher than those in males (P < 0.001). The median SAT and muscle indices were 18.6 and 34.3 cm² /m² for women and 6.19 and 51.74 cm² /m² for men, respectively. The 5- and 10-year MFS, LRC, and OS rates were 83% and 82.1%, 73.4% and 71.4%, and 66.4 and 57.6%, respectively. Higher pretreatment SAT index was associated with MFS (hazard ratio [HR]: 0.65; P = 0.015), LRC (HR: 0.758; P = 0.047), and OS (HR: 0.604; P < 0.001). Higher pretreatment BMI was associated with MFS (HR: 0.642; P = 0.031) and OS (HR: 0.615; P < 0.001). The pretreatment SM index had no significant effect on MFS, LRC, and OS. Multivariate analysis revealed that T-stage, N-stage, lesion sites, age, and RT treatment days are independent factors associated with OS; T-stage, N-stage, and lesion sites are independent factors associated with MFS; and N-stage, smoking history, and betel quid chewing history are independent factors associated with LRC. A higher CT-assessed SAT index predicts superior MSF, LCR, and OS in patients with curative HNC, whereas SM does not predict survival or locoregional control.

Cancer survival in adult patients in Spain. Results from nine population-based cancer registries

INTRODUCTION

With the aim of providing cancer control indicators, this work presents cancer survival in adult (≥15 years) patients in Spain diagnosed during the period 2000-2007 from Spanish cancer registries participating in the EUROCARE project.

METHODS

Cancer cases from nine Spanish population-based cancer registries were included and analysed as a whole. All primary malignant neoplasms diagnosed in adult patients were eligible for the analysis. Cancer patients were followed until 31 December 2008. For each type of cancer, 1-, 3- and 5-year observed and relative survival were estimated by sex, age and years from diagnosis. Furthermore, age-standardized 5-year relative survival for the period 2000-2007 has been compared with that of the period 1995-1999.

RESULTS

Skin melanoma (84.6 95% CI 83.0-86.2), prostate (84.6% 95% CI 83.6-85.6) and thyroid (84.2% CI 95% 82.0-86.6) cancers showed the highest 5-year relative survival, whereas the worst prognosis was observed in pancreatic (6% 95% CI 5.1-7.0) and oesophageal (9.4% 95% CI 7.9-11.1) cancers. Overall, survival is higher in women (58.0%) than in men (48.9%). The absolute difference in relative survival between 2000-2007 and 1995-1999 was positive for all cancers as a whole (+4.8% in men, +1.6% in women) and for most types of tumours. Survival increased significantly for chronic myeloid leukaemia, non-Hodgkin's lymphoma and rectum cancer in both sexes, and for acute lymphoid leukaemia, prostate, liver and colon cancers in men and Hodgkin's lymphoma and breast cancer in women. Survival patterns by age were similar in Europe and Spain. A decline in survival by age was observed in all tumours, being more pronounced for ovarian, corpus uteri, prostate and urinary bladder and less for head and neck and rectum cancers.

CONCLUSION

High variability and differences have been observed in survival among adults in Spain according to the type of cancer diagnosed, from above 84% to below 10%, reflecting high heterogeneity. The differences in prognosis by age, sex and period of diagnosis reveal opportunities for improving cancer care in Spain.

Challenges of early detection of oral cancer: raising awareness as a first step to successful campaigning

In Germany, ∼ 13,000 people are found to have oral and pharyngeal cancer every year. Awareness and knowledge about this cancer remain insufficient, particularly amongst elderly people. A campaign for early detection was launched in Northern Germany in April 2012. The first step of the campaign was to increase awareness about oral cancer. Prior to a pre-campaign evaluation at the campaign start, March 2012 and an intermediate-campaign evaluation, November 2012, a sample representative for the population aged 50 ≥ years (target group; N = 500) was drawn for a first process evaluation. The surveys were conducted by means of telephone interviews including questions on behaviour, knowledge and sociodemographic/socioeconomic aspects and target group-oriented questions on issue, media and campaign material awareness. The process evaluation showed an increase in issue awareness from 25 to 40% (P < 0.001) and the media awareness increased by over 10% (P < 0.001). The results suggested that particularly women, the core age group (60-79 years) and the educationally disadvantaged group might benefit from the campaign. Awareness about the issue 'oral cancer' was already significantly increased 7 months after the campaign start. The highest general and media-related increase in awareness was achieved in the target group.

Lung cancer survival in Germany: A population-based analysis of 132,612 lung cancer patients

OBJECTIVES

Lung cancer is the most common cancer-related death worldwide. In Germany it accounts for 25% of cancer deaths in men, and 14% in women. The aim of this study is to provide an overview of 5-year relative survival by sex, age, histology, and tumour stage in Germany representing a population of 26.7 million people.

MATERIALS AND METHODS

The study is based on a pooled German dataset including data from 12 population-based cancer registries covering around one third of the German population. A total of 132,612 patients diagnosed with lung cancer from 2002 to 2010 were included in the analysis. Survival estimates for the time period 2007-2010 were calculated using period analysis. Differences in survival between sexes were tested for statistical significance by model-based period analysis (poisson regression model). The relative excess risk (RER) of death (women vs. men) was extracted from the model with the p value for the difference in RER.

RESULTS

The overall age adjusted 5-year relative survival was 15.5% (standard error (SE) 0.2) for men and 20.3% (SE 0.3) in women. Survival differed markedly according to age (men: <60 years 18.5% vs. 80+ years 8.4% and women 23.7% vs. 10.6%, respectively), histology (largest difference between histological groups: men 25.7 and women 44.4% points) and stage (men: UICC Ia 62.9%, vs. UICC IV 4.6% and women 75.2% vs. 7.0%, respectively). Our study showed survival advantages for women compared to men, most notably in younger aged patients (RER 0.83, p<0.0001), patients with adenocarcinoma (RER 0.80, p<0.0001), and patients with lower stage cancer (RER 0.62, p<0.0001).

CONCLUSIONS

This study presents up-to-date survival estimates for lung cancer in Germany. Compared to other European countries survival was relatively high. Women showed higher survival than men independent of age, histology and stage. The reasons for the survival differences require further clarification.

Oncotyrol--Center for Personalized Cancer Medicine: Methods and Applications of Health Technology Assessment and Outcomes Research

BACKGROUND

The Oncotyrol - Center for Personalized Cancer Medicine is an international and interdisciplinary alliance combining research and commercial competencies to accelerate the development, evaluation and translation of personalized healthcare strategies in cancer. The philosophy of Oncotyrol is to collaborate with relevant stakeholders and advance knowledge "from bench to bedside to population and back". Oncotyrol is funded through the COMET Excellence Program by the Austrian government via the national Austrian Research Promotion Agency (FFG). This article focuses on the role of health technology assessment (HTA) and outcomes research in personalized cancer medicine in the context of Oncotyrol.

METHODS

Oncotyrol, which currently comprises approximately 20 individual projects, has four research areas: Area 1: Biomarker and Drug Target Identification; Area 2: Assay Development and Drug Screening; Area 3: Innovative Therapies; Area 4: Health Technology Assessment and Bioinformatics. Area 4 translates the results from Areas 1 to 3 to populations and society and reports them back to Area 3 to inform clinical studies and guidelines, and to Areas 1 and 2 to guide further research and development.

RESULTS

In a series of international expert workshops, the Oncotyrol International Expert Task Force for Personalized Cancer Medicine developed the Methodological Framework for Early Health Technology Assessment and Decision Modeling in Cancer and practical guidelines in this field. Further projects included applications in the fields of sequential treatment of patients with chronic myeloid leukemia (CML), benefit-harm and cost-effectiveness evaluation of prostate cancer screening, effectiveness and cost-effectiveness of multiple cervical cancer screening strategies, and benefits and cost-effectiveness of genomic test-based treatment strategies in breast cancer.

CONCLUSION

An interdisciplinary setting as generated in Oncotyrol provides unique opportunities such as systematically coordinating lab and bench research, product development, clinical studies and decision science/HTA and transparent joint planning of research and development with a partnership of researchers, manufacturers and health policy decision makers. However, generating a joint research and legal framework with numerous partners from different sectors can be challenging, particularly in the starting period of such an endeavor. The journey to translational personalized medicine through multidisciplinary collaborations may still be long and difficult, but it is evident that it must be continued to turn vision into reality.

Sex differences in cancer survival in Estonia: a population-based study

BACKGROUND

In Estonia, women have much longer life expectancy than men. The aim of this study was to examine sex differences in cancer survival in Estonia and to explore the role of age at diagnosis, stage at diagnosis and tumour subsite.

METHODS

Using data from the population-based Estonian Cancer Registry, we examined the relative survival of adult patients diagnosed with nine common cancers in Estonia in 1995-2006 and followed up through 2011. Excess hazard ratios (EHR) of death associated with female gender adjusted for age, stage at diagnosis and tumour subsite were estimated.

RESULTS

A total of 20 828 male and 13 166 female cases were analysed. The main data quality indicators were similar between men and women. Women had more cases with unknown extent of disease at diagnosis. Overall, the age-adjusted 5-year relative survival ratio was higher among women than men for all studied sites, but the difference was significant for cancers of mouth and pharynx (22% units), lung (5% units), skin melanoma (17% units) and kidney (8% units). The increase in survival over time was larger for women than men for cancers of mouth and pharynx, colon, rectum, kidney and skin melanoma. In multivariate analysis, women had a significantly lower EHR of death within five years after diagnosis for five of the nine cancers studied (cancers of mouth and pharynx, stomach, lung, skin melanoma and kidney). Adjustment for stage and subsite explained some, but not all of the women's advantage.

CONCLUSIONS

We found a significant female survival advantage in Estonia for cancers of mouth and pharynx, stomach, lung, kidney and skin melanoma. The differences in favour of women tended to increase over time as from the 1990s to the 2000s, survival improved more among women than among men. A large part of the women's advantage is likely attributable to biological factors, but other factors, such as co-morbidities, treatment compliance or health behaviour, are also probable contributors to gender survival disparities in Estonia and merit further investigation. Our findings have implications for public health, early detection and cancer care in Estonia.

Do female cancer patients display better survival rates compared with males? Analysis of the Korean National Registry data, 2005-2009

Background

Sex differences have been reported in the prognosis of certain cancers. In this study, we investigated whether Korean females display better survival rates compared with male patients for solid tumor sites.

Methods

We analyzed data from the Korean National Cancer Incidence Database from 599,288 adult patients diagnosed with solid cancers between 2005 and 2009. Patients were followed until December 2010. We applied a relative excess risk (RER) model adjusting for year of follow-up, age at diagnosis, and stage at diagnosis.

Results

For all solid cancer sites combined, women displayed an 11% lower risk of death compared to men (RER 0.89; 95% CI 0.88–0.90) after adjusting for year of follow-up, age, stage, and case mix. Women showed significantly lower RERs for the following sites: head/neck, esophagus, small intestine, liver, nasal cavities, lung, bone/cartilages, melanoma of skin, soft tissue, brain and CNS, and thyroid. In contrast, women displayed a poorer prognosis than did men for colorectal, laryngeal, kidney and bladder cancer. However, the survival gaps between men and women narrowed by increase in age; female patients over 75 years of age displayed a 3% higher RER of death compared with males in this age group.

Conclusions

Female cancer patients display an improved survival for the majority of solid tumor sites, even after adjustment for age and stage. Age at diagnosis was the major contributor to the women’s survival advantage.

Gender disparities in the tumor genetics and clinical outcome of multiple myeloma

BACKGROUND

Several cancer types have differences in incidence and clinical outcome dependent on gender, but these are not well described in myeloma. The aim of this study was to characterize gender disparities in myeloma.

METHODS

We investigated the association of gender with the prevalence of tumor genetic lesions and the clinical outcome of 1,960 patients enrolled in the phase III clinical trial MRC Myeloma IX. Genetic lesions were characterized by FISH.

RESULTS

Disparities were found in the prevalence of primary genetic lesions with immunoglobulin heavy chain gene (IGH) translocations being more common in women (50% of female patients vs. 38% of male patients, P < 0.001) and hyperdiploidy being more common in men (50% female vs. 62% male, P < 0.001). There were also differences in secondary genetic events with del(13q) (52% female vs. 41% male, P < 0.001) and +1q (43% female vs. 36% male, P = 0.042) being found more frequently in female myeloma patients. Female gender was associated with inferior overall survival (median: 44.8 months female vs. 49.9 months male, P = 0.020).

CONCLUSIONS

We found gender-dependent differences in the prevalence of the primary genetic events of myeloma, with IGH translocations being more common in women and hyperdiploidy more common in men. This genetic background may impact subsequent genetic events such as +1q and del(13q), which were both more frequent in women. The higher prevalence of lesions associated with poor prognosis in the female myeloma population, such as t(4;14), t(14;16) and +1q, may adversely affect clinical outcome.

IMPACT

These differences suggest that gender influences the primary genetic events of myeloma.