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Review Open Access

Unveiling sex differences in pancreatic ductal adenocarcinoma: Current evidence and future directions (Review)

  • Authors:
    • Sophie Rauschenberg
    • Elisabeth Orgler‑Gasche
    • Didem Karakas Zeybek
    • Ivonne Regel
    • J.-Matthias Löhr
    • Daniel Öhlund
    • Michael Günther
    • Lina Aguilera Munoz
  • View Affiliations / Copyright

    Affiliations: Department for Internal Medicine I, University Hospital Halle (Saale), D-06120 Halle (Saale), Germany, Department of Medicine II, University Hospital LMU Munich, D-81377 Munich, Germany, Graduate School of Health, Medical Biotechnology, Acibadem University, 34752 Istanbul, Turkey, Department of Clinical Sciences, Karolinska Institute, 18288 Stockholm, Sweden, Department of Diagnostics and Intervention (Oncology) and Wallenberg Centre of Molecular Medicine, Umeå University, 90187 Umeå, Sweden, Institute of General Pathology, Medical University of Innsbruck, A-6020 Innsbruck, Austria, Department of Pancreatology and Digestive Oncology, Beaujon University Hospital, 92110 Clichy, France
    Copyright: © Rauschenberg et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
  • Article Number: 35
    |
    Published online on: January 15, 2026
       https://doi.org/10.3892/ijo.2026.5848
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Abstract

Pancreatic ductal adenocarcinoma (PDAC) is the seventh leading cause of cancer‑related death worldwide in both men and women. While sex‑specific differences are increasingly recognized as critical determinants of health and disease, particularly in oncology, they remain markedly underexplored in PDAC. Emerging evidence suggests that sex differences influence numerous aspects of PDAC, including treatment response and prognosis. This knowledge gap represents a notable barrier to the development of effective, personalized therapeutic strategies for both sexes. The present review provides a comprehensive overview of the current knowledge on sex‑based differences in PDAC, encompassing epidemiology, risk factors, chemotherapy pharmacokinetics and toxicity, prognosis, therapeutic response, immune interactions, tumor microenvironment, tumor microbiota and molecular biomarkers.

View Figures

Figure 1

Overview of sex-related hormonal and
genetic differences for PDAC. Estrogens significantly shape immune
functions, including innate immune responsiveness through TLRs and
the regulation of cytokine production. In PDAC, estrogens influence
transcriptional subtypes and further modulate the TME by promoting
the differentiation of CAFs toward a more tumor-suppressive
phenotype. Conversely, estrogens can also affect TAMs, driving them
toward a more immunosuppressive state. Notably, TAMs in women show
greater plasticity following neoadjuvant chemoradiation with
gemcitabine, which is associated with improved survival. By
contrast, androgens are linked to carcinogenesis and cachexia.
Notably, the effects of estrogens are not restricted to women; men
can also produce estrogen locally within the tumor tissue,
similarly promoting CAF differentiation toward a more
tumor-suppressive TME. PDAC, pancreatic ductal adenocarcinoma; TME,
tissue microenvironment; ERE, estrogen response element; ARE,
androgen response element; AR, androgen receptor; TAM,
tumor-associated macrophage; CAF, cancer-associated fibroblasts;
TLR, Toll-like receptor; CDKN2B, cyclin-dependent kinase inhibitor
2B; TFF1, trefoil factor 1; KDM6A, lysine demethylase 6A; GLI2,
zinc finger protein 2; EFNB2, ephrin B2; BICD1, bicaudal D cargo
adaptor 1; LAMA3, laminin α3; ELOVL6,
elongation-of-very-long-chain-fatty acids 6; SALL4, Sal-like
protein 4.

Figure 2

Structured overview of sex-related
differences in PDAC. The left panel summarizes aspects associated
with female patients, including epidemiological patterns, relevant
risk factors, prognostic considerations, immune-related features
and molecular characteristics. The right panel presents the
corresponding male-associated domains, following the same thematic
categories for direct comparison. The lower section synthesizes
overarching implications for future research, highlighting the need
to integrate sex as a biological variable in study design and
translational investigations. *trends have been shown,
but further studies are needed. PDAC, pancreatic ductal
adenocarcinoma; TAM, tumor-associated macrophage; AR, androgen
receptor; CDKN2B, cyclin-dependent kinase inhibitor 2B.
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Copy and paste a formatted citation
Spandidos Publications style
Rauschenberg S, Orgler‑Gasche E, Karakas Zeybek D, Regel I, Löhr J, Öhlund D, Günther M and Aguilera Munoz L: <p>Unveiling sex differences in pancreatic ductal adenocarcinoma: Current evidence and future directions (Review)</p>. Int J Oncol 68: 35, 2026.
APA
Rauschenberg, S., Orgler‑Gasche, E., Karakas Zeybek, D., Regel, I., Löhr, J., Öhlund, D. ... Aguilera Munoz, L. (2026). <p>Unveiling sex differences in pancreatic ductal adenocarcinoma: Current evidence and future directions (Review)</p>. International Journal of Oncology, 68, 35. https://doi.org/10.3892/ijo.2026.5848
MLA
Rauschenberg, S., Orgler‑Gasche, E., Karakas Zeybek, D., Regel, I., Löhr, J., Öhlund, D., Günther, M., Aguilera Munoz, L."<p>Unveiling sex differences in pancreatic ductal adenocarcinoma: Current evidence and future directions (Review)</p>". International Journal of Oncology 68.3 (2026): 35.
Chicago
Rauschenberg, S., Orgler‑Gasche, E., Karakas Zeybek, D., Regel, I., Löhr, J., Öhlund, D., Günther, M., Aguilera Munoz, L."<p>Unveiling sex differences in pancreatic ductal adenocarcinoma: Current evidence and future directions (Review)</p>". International Journal of Oncology 68, no. 3 (2026): 35. https://doi.org/10.3892/ijo.2026.5848
Copy and paste a formatted citation
x
Spandidos Publications style
Rauschenberg S, Orgler‑Gasche E, Karakas Zeybek D, Regel I, Löhr J, Öhlund D, Günther M and Aguilera Munoz L: <p>Unveiling sex differences in pancreatic ductal adenocarcinoma: Current evidence and future directions (Review)</p>. Int J Oncol 68: 35, 2026.
APA
Rauschenberg, S., Orgler‑Gasche, E., Karakas Zeybek, D., Regel, I., Löhr, J., Öhlund, D. ... Aguilera Munoz, L. (2026). <p>Unveiling sex differences in pancreatic ductal adenocarcinoma: Current evidence and future directions (Review)</p>. International Journal of Oncology, 68, 35. https://doi.org/10.3892/ijo.2026.5848
MLA
Rauschenberg, S., Orgler‑Gasche, E., Karakas Zeybek, D., Regel, I., Löhr, J., Öhlund, D., Günther, M., Aguilera Munoz, L."<p>Unveiling sex differences in pancreatic ductal adenocarcinoma: Current evidence and future directions (Review)</p>". International Journal of Oncology 68.3 (2026): 35.
Chicago
Rauschenberg, S., Orgler‑Gasche, E., Karakas Zeybek, D., Regel, I., Löhr, J., Öhlund, D., Günther, M., Aguilera Munoz, L."<p>Unveiling sex differences in pancreatic ductal adenocarcinoma: Current evidence and future directions (Review)</p>". International Journal of Oncology 68, no. 3 (2026): 35. https://doi.org/10.3892/ijo.2026.5848
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