The “nexus of women, power, and cancer” is the subject of investigation by The Lancet Commission in September 2023. Through an intersectional feminist lens, the Commission investigates the “prevailing asymmetries of power” in relation to cancer across 3 domains:
- Decision making
In this article we unpack some of the findings and recommendations presented by the Commission in its publication, particularly as they pertain to the cancer vaccine community. If you have time to read it here, do let us know what you think.
Linguistic and theoretical fine points
Before we explore the publication in full, we will consider the definitions that are used throughout.
“The terms sex and gender are distinguished throughout this Commission with sex referring to a set of biological attributes associated with physical and physiological features (such as chromosomes, gene expression, immunological profile, hormonal milieux, and sexual or reproductive anatomy). Gender, as a social construct, refers to norms, roles, and behaviours that are considered appropriate for women and men in a given society.”
The authors reflect that gender identity, referring to the “feelings and identity of one’s gender”, can “deviate from the sex assigned at birth”. Although it would be preferable not to conflate the terms, many sources used by the Commission use the terms sex and gender “interchangeably”. Furthermore, they are “most often only binary”.
The publication also establishes a series of commitments within the umbrella of an intersectional feminist approach. The phrase was initially used in 1989 by American “civil rights activist, feminist, and legal scholar”, Professor Kimberlé Crenshaw. For the Commission it articulates a “prism for seeing the way in which various forms of inequality often operate together and exacerbate each other”.
“An intersectional feminist approach recognises that patriarchy and colonialism is embedded in society and institutions, forming visible and invisible gender hierarchies overlaying other power dynamics, resulting in discriminations, alienation, and marginalisation.”
With the understanding that this approach “recognises and seeks to disrupt power dynamics”, the Commission commits to:
- Promote transformative action towards gender equality, equity, and social justice
- Centre women’s bodies, realities, and voices to capture their real-life experiences in relation to cancer
- Reflect the plurality of women’s experiences and the multiple intersecting dimensions of inequalities
- Integrate an anti-racist and decolonial approach to all its work
- Challenge the way cancer research is funded, conducted, and reported, and by whom, and foster interdisciplinary inclusive research and policy that transcends biomedical worldviews
- Shift the culture of cancer away from individual blame by recognising the role of structural, social, and commercial determinants of health affecting cancer risks and outcomes in women
- Address asymmetries of power by encouraging reflexivity, humility, and inclusiveness in approaches to cancer research, control, and care
The burden of cancer
“The topic of women and cancer spans broad terrain, beyond women’s cancers and the biomedical aspects of any type of cancer that women in all their diversities might experience. It is inclusive of the ways in which sex and gender influence exposures to cancer risk factors, interactions with the cancer health system, and specific challenges faced by health-care professionals, advocates, and caregivers.”
Cancer is a “top 3” cause of premature mortality in women, with 2.3 million women dying prematurely from cancer each year. The authors claim that 1.5 million premature deaths “could be averted” by primary prevention or early detection strategies, and 800,000 deaths could be averted by “optimal cancer care”. In 2020, 9.23 million women were diagnosed with cancer, and 4.43 died of cancer. These numbers are projected to increase by 2040; 13.3 million women will be diagnosed with cancer and 7.1 million women will die of cancer.
Within these increasing rates of diagnosis and death, the greatest burden is expected to be borne by lower-income countries. However, the risk of death from cancer is “similar globally”, regardless of where a woman lives.
The five leading cancer types in women, in terms of incidence, are breast, colorectal, lung, cervical, and thyroid cancer. Combined these five contribute to more than half of the total number. For cancer deaths, the same top four – breast lung, colorectal, and cervical, were the leading causes in 2020, with stomach cancer coming 5th. These comprised 54% of the total mortality burden.
“The true burden of cancer in women has gone largely unrecognised and has far-reaching consequences for families and society more broadly.”
Although the numbers laid out in the report give an insight into the significant effects that cancer has on women, the Commission demands more research and sustainable funding to ensure that data are collected and reported. Then, it is expected, the “current and future impact of cancer” can be “accurately described”.
The NIH National Cancer Institute describes the continuum of cancer control as a “useful framework”, despite its oversimplification. It has been in use since “at least the mid-1970s” and describes the following stages: aetiology, prevention, early detection, diagnosis, treatment, survivorship, end of life.
The Commission states that entry into the continuum of care is a varied occurrence, which can involve screening programmes or seeking health services in response to symptoms. From there, the detection, interpretation, and management of symptoms are determined by a “complex interplay of individual, contextual, sociocultural, economic health system, and policy factors”.
Key factors that affect stages within the continuum can be organised by the different levels of the Social Ecological Model proposed by Brofenbrenner. The Social Ecological Model suggests that health behaviours influence and are influenced by the social environment with five levels of influence: individual, interpersonal, organisational, community, and public policy. This is explored in the figure below.
For the purposes of understanding the Commission’s implications for the vaccine community, we will assume that a patient has decided to seek care and consider the stages that follow. However, we encourage you to read the report for more on the “perceived need for cancer care” if it is of interest. The first consideration offered in the report is access, and barriers to care.
“Once a woman recognises a need to seek care, gender norms can influence her decision regarding when and where to seek care.”
Before encountering barriers, the “anticipated barriers” come into play. Women are “more likely” to anticipate barriers or reflect on a past bad experience with a health-care provider. Once “perceived barriers” are overcome, gender norms can be identified.
“Gender norms combine with the ability of individuals to seek care on the basis of their financial resources, time availability, and power to act.”
Beyond gender norms, safety concerns and fear of physical violence are “important barriers”.
Who is behind treatment?
Section 4 of the Commission explores “new analyses” in the context of “intersectional biases” that affect health providers, researchers, caregivers, and advocates.
“One of the most important factors influencing gender equity and equality in the health workforce is broad representation of women among leaders at every level.”
An analysis of leadership at the Union for International Cancer Control (UICC) member organisations found that “although the organisations in North America, South America, and Oceania appear to have fostered gender-balanced oncology leadership”, this is not the case for leadership roles in Asia, Africa, and Europe. Furthermore, the researchers considered “gender balance according to type of organisation”, with men “overrepresented as leaders of hospitals, treatment centres, and research institutes”, while women are “overrepresented as leaders of patients support groups, public charities, or advocacy groups”.
This imbalance has a “detrimental effect” on the career trajectory of health personnel. The authors consider the metaphors of the glass ceiling and leaky pipeline. For women in the cancer workforce (as in others), “frequent and severe experiences of gender-based discrimination” inform mental health, perception of workplace safety, job satisfaction, and career development. These are “usually perpetrated” by men, whether colleagues or patients.
“To maximise the potential of the oncology workforce, gender equity and equality, as well as organisational culture transformation, must be promoted if diverse talent is to be retained and nurtured.”
“Academic career success is often measured in terms of grant funding awards, peer-reviewed publications, and promotion to professorial ranks – processes that are inherently discriminative to women.”
The Commission states that data reflect clear disparities in research roles; women are “more likely to be performing experiments”, whereas men are “more likely to be associated with designing experiments”. Men are also “more often in prominent authorship positions”. Furthermore, topics that are “disproportionately studied by women” are “generally published in lower impact journals and cited less often”. Editorial boards also reflect poor gender balance.
Authorship is another area of concern for the Commission. To establish a “global overview of women’s contributions” to cancer research publications they conducted a bibliometric analysis of first and last authors of cancer research papers processed for the Web of Science: Core Collection for 2009 and 2019. First authorship among women increased 41.6% and last authorship increased by 12%, but the percentage of women as first and last authors varied between countries and world regions.
Where do vaccines come in?
Women are implicated or involved throughout the continuum of vaccine demand, development, and deployment. Below are some recommendations from the report that relate to treatment, research, and approach that we consider relevant to the vaccine community but do read the full list if you are interested.
Let us know if you think this Commission adds value to the cancer vaccine community. Do you agree with the findings and recommendations? How does it engage with your experience of cancer, from a personal or professional capacity?
If this article was of interest to you, consider watching our interview with Dr Nora Disis in which she reflects that vaccines are a “levelling field”. Do you agree that access barriers can be overcome through better vaccine development? For more like this, don’t forget to subscribe.