Sex-based inequities in non-small cell lung cancer: gaps and opportunities across the care pathway

Nesrine Mejri; Myriam Saadi; Mouna Ben Rejab; Rahma Ayadi; Seif Haddaoui; Ahmed Anas Haouari; Haifa Rachdi; Yosra Berrazaga

doi:10.1007/s12094-026-04449-8

Sex-based inequities in non-small cell lung cancer: gaps and opportunities across the care pathway

Clin Transl Oncol. 2026 Jun 7. doi: 10.1007/s12094-026-04449-8. Online ahead of print.

Authors

Nesrine Mejri^{1

2}, Myriam Saadi³, Mouna Ben Rejab⁴, Rahma Ayadi⁵, Seif Haddaoui³, Ahmed Anas Haouari³, Haifa Rachdi³, Yosra Berrazaga³

Affiliations

¹ Faculty of Medicine Tunis, Medical oncology Department, University Tunis El Manar, Abderrahmen Mami Hospital, Ariana, Tunisia. nesrinemejriturki2@gmail.com.
² Laboratory LR18SP06: Chest Pathology Department, Abderrahmen Mami Hospital, Ariana, Tunisia. nesrinemejriturki2@gmail.com.
³ Faculty of Medicine Tunis, Medical oncology Department, University Tunis El Manar, Abderrahmen Mami Hospital, Ariana, Tunisia.
⁴ Faculty of Medicine Tunis, Radiation oncology Department, University Tunis El Manar, Abderrahmen Mami Hospital, Ariana, Tunisia.
⁵ Faculty of Medicine Tunis, Pathology Department, University Tunis El Manar, Abderrahmen Mami Hospital, Ariana, Tunisia.

PMID: 42251629
DOI: 10.1007/s12094-026-04449-8

Abstract

Background: Sex-related disparities in non-small cell lung cancer (NSCLC) remain incompletely characterized, particularly in low- and middle-income countries. We aimed to evaluate sex-based differences across the entire lung cancer care continuum, from smoking exposure and diagnostic pathways to treatment access and survival outcomes, distinguishing biological susceptibility from healthcare system inequities.

Methods: We conducted a retrospective cohort study of 1031 consecutive patients with histologically confirmed NSCLC managed at two tertiary oncology centers in Tunisia between 2013 and 2023. Smoking exposure, body mass index, age and stage at diagnosis, diagnostic and treatment intervals, access to molecular testing, treatment patterns, and overall survival were compared between women and men. Multivariable regression and interaction analyses were performed.

Results: Women represented 20.7% of the cohort and were younger at diagnosis (median 54 vs. 62 years; p = 0.02) with lower cumulative smoking exposure. After adjustment for smoking intensity and age, sex was not independently associated with stage at diagnosis. Women experienced longer patient intervals (156 vs. 125 days; p = 0.025) and diagnostic intervals (42 vs. 31 days; p = 0.02), whereas treatment intervals were similar. Women were more likely to undergo molecular biomarker testing and to receive targeted therapy. Median overall survival was longer in women (20 vs. 14 months; log-rank p < 0.01), but no sex-by-stage or sex-by-smoking interaction was identified for survival.

Conclusions: Sex-related differences in NSCLC are heterogeneous: biological susceptibility drives earlier onset at lower smoking exposure, while prolonged diagnostic delays and under-representation in screening programs reflect addressable healthcare inequities. Targeted interventions are warranted to improve early detection and diagnostic equity in women.

Keywords: Equity; Lung cancer; Sex; Smoking.