Purpose: Cancer susceptibility and mortality are higher in males, and the mutational and transcriptomic landscape of cancer differs by sex. The current assumption is that men are at higher risk of epithelial cancers as they expose more to carcinogens and accumulate more damage than women. We present data showing women present less aggressive primary cutaneous squamous cell carcinoma (cSCC) and early strong immune activation.
Methods: We explored clinical and molecular sexual disparity in immunocompetent and immunosuppressed primary cSCC patients (N=738, N=160), advanced stage cSCC (N=63, N=20) andFVB/N mice exposed to equal doses of DMBA, as well as in human keratinocytes by whole exome, bulk and single cell RNA sequencing.
Results: We show cSCC is more aggressive in men, and immunocompetent women develop mild cSCC, later in life. To test if sex drives disparity, we exposed male and female mice to equal doses of carcinogen, and found males present more aggressive, metastatic cSCC than females. Critically, females activate cancer immune-related expression pathways and CD4 and CD8 T cell infiltration independently of mutations, a response that is absent in prednisolone treated animals. In contrast, males increase the rate of mitosis and proliferation in response to carcinogen. Women’s skin and keratinocytes also activate immune-cancer fighting pathways and immune cells at ultraviolet radiation-damaged sites. Critically, a compromised immune system leads to high-risk, aggressive cSCC specifically in women.
Conclusions: This work shows the immune response is sex biased in cSCC,and highlights female immunity offers greater protection than male immunity.