Cancer affects men and women differently. But these differences are not always reflected in their research and treatment. A report published in the scientific journal The Lancet urges an intersectional gender approach when it comes to this disease. The commission in charge of the report, composed of an international team, proposes a set of ten actions, with the general recommendation that sex and gender be included in all policies and guidelines related to cancer.
"This commission was created to investigate the intersection between social inequalities, the status of women in society and cancer," Karla Unger, a researcher in Health Systems at Mexico's National Cancer Institute and one of the study's authors, said in an email. "Those who occupy positions of power decide what is prioritized, financed and studied," he denounces, referring to a highly masculinized sector. While acknowledging recent advances, she denounces that women with cancer continue to experience "various forms of discrimination" that must be eradicated.
The study has been carried out in countries with very different realities, but Unger believes that this does not detract from its value, but reinforces his thesis. The expert repeats in many of her assertions that these are situations that occur "also in high-income countries" to highlight the global nature of the problem. The report stresses that, "regardless of geographic region or economic resources," women are more likely than men to lack the knowledge and power to make informed health care decisions.
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Access to accurate health information and quality health services would be at the heart of the analysis. The report notes that 1.5 million women's deaths could be prevented through primary prevention or early detection strategies, and another 800,000 if all women had access to optimal cancer care. It does not specify data regarding men.
It also analyzes the role of women in health and care related to cancer, concluding that it is they, for the most part, who become unpaid caregivers when a family member suffers from cancer. And, conversely, they are significantly underrepresented as leaders in research and policy organizations.
Incomplete studies
When talking about cancer and women, the debate usually focuses on those that affect them specifically, such as breast cancer and uterine cancer. "Breast cancer is the most common and cervical cancer is the only completely avoidable cancer," says the expert. It is normal that they have so much media focus. But in this commission other types of cancer that affect both sexes have been included, with the intention of identifying social differences between them. "There are studies that report that women are diagnosed at more advanced stages than men in colorectal cancer, bladder cancer and urinary tract cancer," he explains. "Longer times between presentation to the physician and final diagnosis have also been reported for women compared to men for various types of cancer: lung, colorectal, bladder, pancreas, and urothelial [bladder]."
The report stresses the need to differentiate between gender and sex, something that is not always done. Sex refers to biological attributes such as chromosomes, gene expression, or reproductive anatomy. Gender, on the other hand, is a social construct that encompasses roles and drivers that are considered socially appropriate for women or men. "These terms are not interchangeable," Unger says. "But in the research we did, most of the available data used sex and gender interchangeably, usually binarily: male or female. One of the main recommendations we make in the Commission is to ensure the collection of data disaggregated by sex, gender, and other sociodemographic factors on a routine basis in health statistics."
Dr. Elena Élez is an oncologist at Vall d'Hebron University Hospital and head of the Colorectal Cancer Group at the Vall d'Hebron Institute of Oncology. He has not participated in this study, but his team has made reports along the same lines and is very much in agreement with their conclusions. It highlights the breadth of the report and the fact that it takes into account all stages, from research to dealing with the patient. Élez gives two concrete examples of how differentiating between men and women when we talk about cancer can help. "For example, when we do studies and in the models we use mice," he says in a telephone conversation. "Many times the authors do not look at something as simple as specifying whether they are mice or mice. And this has a very important impact. There are differences in how each drug affects by sex."
"On the other hand, in medicines, there are usually data on side effects included. We should still differentiate between men and women and see the impact this has," he adds. There is scientific literature that supports this idea. An American study published in the Journal of Clinical Oncology reveals that, after receiving cancer treatment, women have a 34% higher risk of developing serious symptomatic adverse effects than men. Especially if the treatment is immunotherapy: before drugs such as cisplatin or pembrolizumab were approved, they had a 49% higher risk of sequelae than them.
"There is a clear male bias in the way we look at the world," says Ana Porroche Escudero, an anthropologist and researcher in Lancaster University's Division of Health Research. "That's why I welcome the fact that the article mentions the importance of investigating environmental and occupational factors in cancer incidence." When it comes to understanding how cancer affects men and women, biological but also environmental differences must be taken into account. Family burdens, how to respond to pain, how to follow medical prescriptions, how often check-ups are made.
Porroche misses "greater emphasis on denouncing the role of the social determinants of health in incidence," but celebrates that studies like this focus on the intersection between power, cancer and women, a debate that, he believes, has not been fully addressed in biomedical environments. "Patriarchy dominates cancer research and policymaking," he says. "Leadership positions are dominated by men and male thinking, this applies to the management of health services such as research teams, committees responsible for subsidizing research and editing scientific journals," he laments.
Dr. Élez is less critical. "Luckily, at least in our [Spanish] context, we have a health system that always tries to do the best for the patient, that works at the level of evidence, and applies the best possible treatment to the patient," he says. "But you have to understand how we approach this, you have to change even the way we talk." Élez also includes these conclusions in the need to individualize the treatment of patients, "the way to approach cancer is very different depending on how the patient is, depending on whether they are men or women, young or old." In short, you have to go towards an individualized and specific treatment.
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