Gender inequalities and discrimination may adversely impact women’s rights and opportunities to avoid cancer risk factors and impede their ability to seek and obtain timely diagnoses and quality cancer care, according to The Lancet Commission on Women, Power, and Cancer published by Ginsburg et al in The Lancet. Further, gender inequalities may hinder women’s professional advancement as leaders in cancer research, practice, and policymaking—which, in turn, could perpetuate the lack of women-centered cancer prevention and care.
Overview of Gender Inequities
“The impact of a patriarchal society on women’s experiences of cancer has gone largely unrecognized. Globally, women’s health is often focused on reproductive and maternal health, aligned with narrow antifeminist definitions of women’s values and roles in society, while cancer [care] remains wholly underrepresented,” emphasized lead study author Ophira Ginsburg, MD, Senior Advisor for Clinical Research at the Center for Global Health at the National Cancer Institute and Co-Chair of The Lancet Commission on Women, Power, and Cancer.
Approximately 1.3 million women of all ages died in 2020 as a result of four major risk factors for cancer: tobacco, alcohol, obesity, and infections. The burden of cancer on women caused by these four risk factors has been widely underrecognized. For instance, a previous study from 2019 found that only 19% of women attending breast cancer screenings in the UK were aware that alcohol is a major risk factor for breast cancer.
“Discussion about cancer in women often focus on ‘women’s cancers,’ such as breast [cancer] and cervical cancer—but about 300,000 women under [the age of] 70 die each year from lung cancer and 160,000 from colorectal cancer: two of the top three causes of cancer death among women, globally. Furthermore, for the past few decades, in many high-income countries, deaths from lung cancer in women have been higher than deaths from breast cancer,” revealed senior study author Isabelle Soerjomataram, PhD, Deputy Branch Head of Cancer Surveillance at the International Agency for Research on Cancer and Co-Chair of The Lancet Commission on Women, Power, and Cancer. “The tobacco and alcohol industry target marketing of their products specifically at women; we believe it’s time for governments to counteract these actions with gender-specific policies that increase awareness and reduce exposure to these risk factors,” she added.
Methods and Findings
In The Lancet Commission on Women, Power, and Cancer, an international, multidisciplinary team of investigators—including patient advocates and scholars specializing in gender studies; human rights; law; economics; social sciences; and cancer epidemiology, treatment, and prevention—analyzed how women experience cancer and developed recommendations for policymakers, governments, civil societies, and health- and social-care systems.
In a recent study, published by Frick et al in The Lancet Global Health alongside the The Lancet Commission on Women, Power, and Cancer, investigators used the GLOBOCAN 2020 database from the International Agency for Research on Cancer to examine cancer mortality. The investigators estimated that 5.3 million patients aged 30 to 69 years died of cancer in 2020—2.3 million of whom were women. They argued that 1.5 million premature cancer deaths among women per year could be prevented by eliminating exposures to key risk factors or through early detection and diagnosis, and that a further 800,000 lives could be saved each year if all women had access to optimal cancer care.
Greater scrutiny of the causes and risk factors for cancer among women may also be needed, since they are often less understood compared with the causes and risk factors for cancer among men. There is growing evidence to suggest there may be a link between commercial products predominantly used by women—such as certain types of breast implants, skin lighteners, and hair relaxers—and the increased risk of cancer.
“While men are at higher risk for most cancer types that develop in both sexes, women have approximately the same burden from all cancers combined, with 48% of cancer cases and 44% of cancer deaths worldwide occurring in women. [Among] the 3 million adults diagnosed with cancer under the age of 50 in 2020, two out of three were women. Cancer is a leading cause of mortality in women, and many die in their prime of life, leaving behind an estimated 1 million children in 2020 alone,” explained co–study author Verna Vanderpuye, MD, a senior consultant at the Korle Bu Teaching Hospital in Ghana and Co-Chair of The Lancet Commission on Women, Power, and Cancer. “There are important factors specific to women which contribute to this substantial global burden; by addressing these through a feminist approach, we believe this will reduce the impact of cancer for all,” she stressed.
Globally, women tend to be disadvantaged in terms of education and employment opportunities and are more likely to have fewer financial resources to help cope with cancer-related financial challenges. An analysis of a study involving patients from eight countries in Asia discovered that almost 75% of women with cancer reported catastrophic expenditures in the year following their diagnosis, with 30% or more of their annual household income spent on cancer-related expenses such as medical costs and complementary medicine.
“Gender norms mean women are often expected to prioritize the needs of their families at the expense of their own health, sometimes leading to the postponement of seeking health care. This can be exacerbated as gender norms also exclude men from participating in childcare in many settings, meaning it’s hard for a mother to find childcare while they seek care for their own health needs,” underlined co–study author Nirmala Bhoo-Pathy, MD, of the Universiti Malaya and the Queen’s University Belfast.
The investigators detailed that sexism within health-care systems in the form of unconscious gender biases and discrimination can lead to suboptimal care for women. Multiple previous studies have found that women with cancer are more likely to report inadequate pain relief and have a greater risk of undertreatment of pain compared with men.
These gender biases may be intensified when the patient with cancer is also part of a marginalized ethnic or indigenous group or has a diverse sexual orientation or gender identity. A recent national survey in the United States found that Black women of diverse sexual orientation and gender identity reported higher intersectional stigmas than any other group, and that stigmas were associated with a 2.4-fold increased risk of delays for seeking breast cancer care in comparison with White, heterosexual, cisgender women.
Gender inequalities in society may also impact the cancer workforce as well as patients and caregivers—with women significantly underrepresented in leadership positions. An analysis of leadership of the Union for International Cancer Control (UICC) member organizations discovered that, although the organizations in North America, South America, and Oceania appeared to have roughly equal numbers of male and female leaders across cancer organizations, women’s representation in leadership positions remained substantially lower in Asia, Africa, and Europe. Additionally, among the 184 UICC member organizations classified as hospitals, treatment centers, or research institutes globally, just 16% of them were led by women.
“A key, yet often underestimated, part of the oncology workforce is cancer advocates who are mostly women and represent the population most affected by cancer. Policymakers [as well as] academic and medical institutions must fully recognize the value of patient advocates and integrate them into all aspects of the cancer care continuum. Advocates should not merely be added to a grant or article out of necessity, but [must be] considered as valuable as their clinical counterparts—a meaningful contributor and equal partner—and compensated as such,” suggested co–study author Carolyn Taylor, BFA, Founder and Executive Director of Global Focus on Cancer.
Next Steps
To address these issues, the investigators called for a feminist approach to cancer care that aims to eliminate gender inequalities and transform health systems, cancer workforces, as well as research ecosystems into more inclusive and responsive environments that take into consideration the needs of women in all their diversities—therefore reducing the global burden of cancer. The investigators highlighted the significance of including sex and gender in all cancer-related policies and guidelines, making them responsive to the needs and aspirations of all women—whether they be patients, caregivers, or researchers.
They also stressed the need for new strategies designed to boost women’s awareness of cancer risk factors and symptoms along with increasing equitable access to early cancer detection and diagnosis. Through training programs and leadership, they indicated it may be possible to create accessible and responsive health systems that provide respectful, quality cancer care for women in all their diversities. Further, to ensure that women have equal representation in leadership positions within the cancer workforce, there must be fair access to cancer research resources, leadership, and funding opportunities for women.
“Our Commission exposes the asymmetries of power [that] influence women’s experiences of cancer and makes the recommendations required to advance an intersectional feminist approach that would reduce the impact of cancer for all. In a society where women’s autonomy is infringed, it’s imperative that researchers, policymakers, organizations, and health-care providers do all they can to meet women’s diverse and unique needs during their experiences of cancer care,” underscored co–study author Shirin Heidari, PhD, President of GENDRO and a senior researcher at the Gender Centre at The Geneva Graduate Institute.
Conclusions
“Our Commission highlights that gender inequalities significantly impact women’s experiences with cancer. To address this, we need cancer to be seen as a priority issue in women’s health and call for the immediate introduction of a feminist approach to cancer,” Dr. Ginsburg reiterated.
“Achieving gender equality in the context of cancer research and care will require broad implementation of the recommendations in The Lancet Commission on Women, Power, and Cancer, including the overarching priority action that sex and gender be included in all cancer-related policies and guidelines, so they are responsive to the needs and aspirations of women in all of their diversities. This is something we can and should all support. Improved outcomes for women translate into benefits for households, communities, societies, and the world,” concluded Monica Bertagnolli, MD, Director of the National Cancer Institute, who was not involved in the Commission.
Disclosure: For full disclosures of the Commission authors, visit thelancet.com.
