The intersection of women and cancer spans broad terrain. It encompasses wide-ranging impacts including the influence of gender on exposure to cancer risk factors, the biomedical effects of cancer and cancer treatment that women might experience differently to men, as well as the indirect effects of cancer on psychological, emotional, social and economic health and well-being – the latter extending to children, families and society. It is inclusive of the very real gender inequities experienced by what is a predominantly female healthcare workforce.
To explore the relationship between gender, power and cancer, The Lancet Commission on women and cancer is taking an intentionally broad, intersectional feminist approach to its investigation. It is important to note that despite the Commission’s title, our work is inclusive of all genders insofar as to explore how one’s gender identity might contribute to a person’s marginalised identities, which can influence cancer risk and cancer outcomes. First, we need to acknowledge that despite some progress in recent years, more than 300,000 women each year die from cervical cancer; 9 in 10 of whom were living in a low- or middle-income country (LMIC). Meanwhile, breast cancer incidence and mortality continue to rise at alarming rates, particularly in LMIC, where access to early diagnosis and effective cancer treatment can be profoundly inequitable.
We must also acknowledge and address the myriad ways in which stigma, cancer myths, and cultural taboos can contribute to the delays many women face all along the care pathway. Moreover, these barriers are relevant not only for women with breast or gynaecological cancers, but can also impact women with colorectal, lung, and other cancers, often thought of as primarily diseases of men. In addition, some cancer risk factors appear to impact risk for women at a lower level of exposure, such as with alcohol. Epidemiological data indicate that even modest drinking in women is associated with an increased risk of certain cancers (Am J Prev Med 2014;46(3 Suppl 1):S16-25; Lancet Oncol 2021;22(8):1071-1080), and alcohol consumption is clearly on the rise among women in many LMICs, including China and India (Lancet 2019;393(10190):2493-2502). On the other hand, overweight and obesity – another important if under-recognised modifiable risk factor for many cancers (e.g. postmenopausal breast cancer, uterine, colorectal, gallbladder, and renal cancers) – already affects women far more than men, and is on the rise in many LMICs (Lancet 2020;396(10243):11-13).
I mention the above examples of alcohol consumption and overweight/obesity (linked to poor dietary habits and to some degree, sedentary lifestyles) purposefully here. These are but two exposures associated with plenty of ‘blame and shame’, especially for women. One of our tasks with this Commission is to look beyond our own individual, personal responsibility to what I believe is a rather cynical deflection of blame away from the food and beverage industries. We might also press for change from our respective governments, among whose responsibilities include evidence-informed public health policymaking, and the protection of the public from known, avoidable harms. Of course, the ‘commercial determinants of health’ impact people of all genders, but it is worth investigating how cultural messaging around women’s empowerment, associated with tobacco and alcohol marketing directed at women, plays a role in the growing burden of some cancers in women and rising rates of consumption in some LMICs.
Regarding the broader knock-on effects, the impact to whole communities of a woman’s death from cancer, often in the prime of life, is still underappreciated, although evidence speaks for itself. Two-thirds of all cancer cases among adults under the age of 50 occur in women (Lancet Oncol. 2021 Feb;22(2):166-167), while a mother's death from breast or cervical cancer increases the risk of childhood death, an effect that is greater in LMICs (Cancer. 2019 Jan 1;125(1):109-117). A multi-country study in sub-Saharan Africa found that 1 in 2 women who died of breast cancer were younger than age 50, and for every 100 maternal deaths, 210 children became maternally orphaned (JAMA Oncol 2021;7(2):285-289). When we consider the social and economic impacts of a woman’s death from cancer, it becomes clear that what may initially be regarded as a woman’s, or a family’s, problem is in fact a societal catastrophe (Lancet. 2017 Feb 25;389(10071):847-860).
In the broader remit of the Commission, we are also exploring how women in the oncology workforce are disadvantaged. In many countries, including high-income and, increasingly, middle-income countries, gender balance is being achieved in medical training. However, with progress up the academic or clinical ladder, the balance moves back again towards men. In recent years, some women have reached leading positions including major professional societies, but they are still the exception rather than the rule. Redressing the balance requires a disruption of the existing patriarchal system, the structural oppression in terms of race, ethnicities and gender that was originated when society accepted the male voice as the dominant one. However, rather than apportioning blame, we can begin by accepting that we have all, to some extent, internalised the system and have practised unconscious bias against women in our professional lives. Men and women alike need to engage in more of a feminist construct that reflects true gender equality, by ensuring that more equitable opportunities are built into the framework of the power structures in oncology. This needs to happen at every level of training and in every facet of the healthcare and research workforce. We must develop and implement policies to help to level the playing field for women in the oncology workplace; we need to see cooperation within the healthcare sector rather than competition for limited resources.
Finally, we are exploring a feminist approach to our economics analyses as a means to better value the burden of cancer in women and the contributions of women caring for people with cancer, in the formal and informal sectors. It is our hope that the data we generate, and the recommendations we present in our main report in The Lancet – to be published in 2023 – will drive real-world actions to mitigate gender-related power imbalances and inequities in cancer control globally.
Special Session – Women for Oncology Forum: Gender equity: a broader perspective, 21.9.2021, h. 15:05 – 16:05, Channel 1