# Nationwide analysis on sex differences in diagnosis, treatment and survival of rectal cancer

## TL;DR

This study finds that women with rectal cancer are more likely to be diagnosed at advanced stages but have slightly better survival after surgery compared to men.

## Contribution

The study provides new insights into sex-based differences in rectal cancer diagnosis, treatment, and survival using nationwide real-world data.

## Key findings

- Women were more likely to present with advanced-stage (cT4) rectal tumors compared to men.
- Women had better 5-year survival after surgery compared to men.
- Asymptomatic patients showed no sex-based differences in treatment or survival.

## Abstract

Limited literature is available comparing sexes in rectal cancer. This nationwide study using real-world data was performed to evaluate sex-based differences in diagnosis, treatment and survival outcomes in rectal cancer.

Data from the Netherlands Cancer Registry were analyzed for patients diagnosed with rectal adenocarcinoma between 2015 and 2019. Patient and tumor characteristics, treatment strategies, response to neoadjuvant therapy, and survival outcomes were compared between sexes.

The cohort consisted of 22251 patients (37.1% women, 62.9% men). Women more frequently presented with cT4 tumors (16% vs. 11%, P < 0.001) but no differences were observed in nodal status, distant metastases, use of neoadjuvant (chemo) radiotherapy and radicality in resections between sexes. In the total study population, 5-year survival did not differ significantly (63.6% in women vs. 61.6% in men, P=0.23). However, in surgically treated patients, survival was higher in women (77.4% vs. 75.0%, P=0.019). Female sex was an independent predictor for survival in surgically treated patients (HR 0.90; 95% CI 0.82–0.98). In the subgroup of patients who were asymptomatic at the time of diagnosis [n=1320], there were no sex-based differences in presentation, treatment, or survival (5-year overall survival: 78.8% vs. 80.4%, P=0.45).

Sex-based differences exist in rectal cancer presentation and outcome. Women are more likely to present a more advanced T-stage. Despite this, women have a better overall survival after surgical treatment. In contrast, men and women undergoing treatment for asymptomatic rectal cancer have comparable outcomes.

The online version contains supplementary material available at 10.1186/s13293-026-00863-3.

Rectal cancer affects both men and women, but it is unclear whether the disease develops or progresses differently between the sexes. Understanding these differences could help improve diagnosis, treatment, and outcomes for all patients.

In this nationwide study from the Netherlands, we analyzed information from over 22,000 people diagnosed with rectal cancer between 2015 and 2019. About one-third of the patients were women. We found that women were more likely than men to have locally advanced tumors at diagnosis. Despite this, men and women received similar treatments, including surgery, radiation, and chemotherapy.

Overall, long-term survival was similar for men and women. However, among patients who underwent surgery, women lived slightly longer than men. When we looked specifically at patients whose cancer was detected before they developed symptoms, for example, through national screening programs, there were no differences between men and women in how the cancer presented, how it was treated, or how long they lived.

These results suggest that women are diagnosed with more advanced rectal tumors but still have slightly better survival after surgery. The findings also highlight the importance of early detection of rectal cancer, as patients diagnosed before symptoms appear have much higher survival rates. Understanding sex-based differences in rectal cancer may help refine screening strategies and improve care for both men and women.

The online version contains supplementary material available at 10.1186/s13293-026-00863-3.

Tumor presentation: Women were more likely to present with advanced-stage tumors (cT4), with 16% of women diagnosed with cT4 compared to 11% of men. However, no significant differences in nodal or metastatic status were observed between sexes

No treatment differences: There were no significant sex-based differences in treatment strategies, including rates of surgical treatment, neoadjuvant chemoradiotherapy, and radical resections.

Survival Outcomes: Overall, women had a slight survival advantage after surgical treatment, with a 5-year survival of 77.4% compared to 75.0% in men (P=0.019). Female sex was an independent predictor for better survival in surgically treated patients

Asymptomatic patients: Among asymptomatic patients, there were no significant differences between men and women.

Importance of early detection: The study highlighted the critical role of early detection in improving survival outcomes, as asymptomatic patients had significantly better survival than symptomatic ones, regardless of sex

The online version contains supplementary material available at 10.1186/s13293-026-00863-3.