The advantage of women in cancer survival: An analysis of EUROCARE-4 data

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Abstract

We analysed 1.6 million population-based EUROCARE-4 cancer cases (26 cancer sites, excluding sex-specific sites, and breast) from 23 countries to investigate the role of sex in cancer survival according to age at diagnosis, site, and European region. For 15 sites (salivary glands, head and neck, oesophagus, stomach, colon and rectum, pancreas, lung, pleura, bone, melanoma of skin, kidney, brain, thyroid, Hodgkin disease and non-Hodgkin’s lymphoma) age- and region-adjusted relative survival was significantly higher in women than men. By multivariable analysis, women had significantly lower relative excess risk (RER) of death for the sites listed above plus multiple myeloma. Women significantly had higher RER of death for biliary tract, bladder and leukaemia. For all cancers combined women had a significant 5% lower RER of death. Age at diagnosis was the main determinant of the women’s advantage, which, however, decreased with increasing age, becoming negligible in the elderly, suggesting that sex hormone patterns may have a role in women’s superior ability to cope with cancer.

Introduction

Women have a longer life expectancy than men1 and better survival of chronic diseases like cardiovascular disease2 and cancer.3, 4, 5 The EUROCARE-2 study analysed survival in 1 million European cancer cases diagnosed in 1985–1989; it found that sex was a predictor of survival, and suggested women had a biological advantage over men in coping with cancer.6 Other evidence supports the idea that women are more attentive to their health than men indicating a cultural rather than biological advantage.7 Nevertheless, neither biological nor cultural factors have been clearly established as responsible for the longevity and survival advantage of women. If cultural factors were important then interventions to reduce the male disadvantage might be proposed; if biological factors were important, then studies to better understand the bases of these differences would be useful.

We analysed the latest release of the EUROCARE-4 dataset8, 9 which contains standardised population-based information on about 3 million cancer cases from 82 cancer registries (CRs) in 23 European countries.10 Our aim was to further examine the role of sex in determining cancer survival, investigating whether the female advantage was present in all ages, cancer sites and European regions, and hence suggest possible reasons for the survival differences between the sexes.

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Patients and methods

We considered 1,668,872 cancer patients (40% women) diagnosed between 1995 and 1999 in European adults (15–99 years).8, 9 For 13 participating countries (Austria, Denmark, England, Finland, Iceland, Ireland, Malta, Norway, Sweden, Scotland, Wales, Northern Ireland and Slovenia) the entire population is covered by cancer registration; the other 10 countries (Belgium, the Czech Republic, France, Germany, Italy, The Netherlands, Poland, Portugal, Spain, and Switzerland) are represented by CRs

European pool: Crude analyses (column b, Table 2)

Crude 5-year relative survival for all cancers combined was significantly higher in women than men by 4.9 percentage points. The advantage for women was significant for 11 of the 26 cancer sites. For liver, biliary tract, bladder and leukaemia, women had a significant survival disadvantage.

European pool: Age specific analyses (columns e and f, Table 2)

Overall, less women than men were considered in the study in all age groups, but the proportion varied with cancer site and age, being highest at 47%, in both the youngest (15–44 years) and oldest categories

Discussion

We have found that women had a survival advantage for most cancers. In the age-adjusted univariate analyses on the European pool, women had significantly better survival for 17/26 sites, and only for biliary tract, larynx and bladder was survival significantly worse in women (Table 2). In the analysis by region, the women’s advantage was significant in all regions for six sites. Although the women’s disadvantage for biliary tract, bladder and leukaemias was pervasive, for no site was a

Conclusions

Our previous study on the prognostic role of sex in cancer survival investigated 1 million EUROCARE-2 cases.6 Multivariable analysis showed that the relative risk of dying was 2% lower in women after adjusting for age, case-mix and country population (not regional population as in the present study).6 The women’s advantage was most evident in the young, reduced in middle age, and reversed in the oldest patients when men had better prognoses.6 We concluded that women might be intrinsically more

Conflict of interest statement

None declared.

EUROCARE-4 Working Group

Austria: W Oberaigner (Tyrol Cancer Registry); M Hackl (Austrian National Cancer Registry); Belgium: E Van Eycken; Martine Verstreken (Flemish Cancer Registry), Czech Republic: J Holub, L Jurickova (West Bohemia Cancer Registry); Denmark: HH Storm; G Engholm (Danish Cancer Society, Dept. Cancer Prevention & Documentation); Finland: T Hakulinen (Finnish Cancer Registry); France: A Belot (FRANCIM); G Hédelin, M Velten (Bas-Rhin Cancer Registry); I Tron, E Le Gall (Bretagne Childhood Cancer

Acknowledgment

This study was carried out under the auspices of the European Cancer Health Indicator Project (EUROCHIP-3) and supported by the Compagnia di San Paolo, Torino, Italy. We thank Don Ward for help with the English.

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