The advantage of women in cancer survival: An analysis of EUROCARE-4 data A. Micheli a, * , R. Ciampichini a , W. Oberaigner b , L. Ciccolallo c , E. de Vries d , I. Izarzugaza e , P. Zambon f , G. Gatta c , R. De Angelis g , the EUROCARE Working Group a Descriptive Epidemiology and Health Planning Unit, Fondazione IRCCS ‘Istituto Nazionale dei Tumori’, Via Venezian 1, 20133 Milan, Italy b Cancer Registry of Tyrol, Innsbruck, Austria c Evaluative Epidemiology Unit, Department of Preventive and Predictive Medicine, Fondazione IRCCS ‘Istituto Nazionale dei Tumori’, Milan, Italy d Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands e Cancer Registry of Basque Country, Vitoria-Gasteiz, Spain f Veneto Tumour Registry, Istituto Oncologico Veneto IRCCS, Padova, Italy g National Centre of Epidemiology, Surveillance and Health Promotion, Cancer Epidemiology Unit, Istituto Superiore di Sanita ` , Rome, Italy ARTICLE INFO Article history: Received 14 July 2008 Received in revised form 5 November 2008 Accepted 7 November 2008 Available online 26 December 2008 Keywords: Gender differences Cancer survival EUROCARE Sex hormones 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 (sal- ivary 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 determi- nant 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. Ó 2008 Elsevier Ltd. All rights reserved. 1. Introduction Women have a longer life expectancy than men 1 and better survival of chronic diseases like cardiovascular disease 2 and cancer. 3–5 The EUROCARE-2 study analysed survival in 1 mil- lion 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 atten- tive 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 data- set 8,9 which contains standardised population-based infor- mation on about 3 million cancer cases from 82 cancer 0959-8049/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejca.2008.11.008 * Corresponding author: Tel.: +39 02 23903559; fax: +39 02 23903528. E-mail address: andrea.micheli@istitutotumori.mi.it (A. Micheli). EUROPEAN JOURNAL OF CANCER 45 (2009) 1017 – 1027 available at www.sciencedirect.com journal homepage: www.ejconline.com