Achieving universal health coverage - gender disparities and bias in cancer care and research 🎗

Cancer is a major public health issue that remains one of the leading causes of death around the globe. Sex is an important factor that determines the pathogenesis and prognosis of many diseases, as well as cancer. In general, men have a higher risk of malignancy compared to women for majority of cancers. Such disparities can be due to hormonal differences, water and lipid composition, and differences in immune system function.  

However, not all gender-related differences in cancer incidence and mortality rates can be explained by anatomical and biological differences alone. There are other factors, such as social and economic inequalities, power imbalances and discrimination, that are impacting women’s health and access to good quality healthcare in more ways than one would think.  

Discrimination and prejudice against women in healthcare, the gender gap in research participants, defunding scientific research addressing women’s health, are a few examples of the many barriers that are obstructing our achievement of UN’s Sustainable Development Goal 3: good health and wellbeing for all. This blog particularly aims to discuss challenges surrounding the achievement of Goals 3.4 - Reduce Mortality from Non-communicable diseases and promote mental health, and 3.8 - Achieve universal health coverage.  

Quality vs. Access of healthcare  

By now, most of us women are familiar with how women’s pain and issues are often dismissed by healthcare professionals; over 80% of women have had their pain dismissed by a doctor. Evidence shows that women’s symptoms remain more often unexplained than men’s. Women are seen as too emotional, too sensitive, and hysterical, which may be contributing to the way professionals interpret, or ignore, women’s physical pain and decide not to investigate its cause further.  

This phenomenon, called medical misogyny, indicates how women experiencing pain are told that it’s normal, often being left to live with undiagnosed, and therefore untreated conditions for years. Such systemic biases must be a product of poor awareness, lack of education of medical professionals, and lack of scientific research. This is particularly true for issues regarding women's reproductive health. 

Unfortunately, medical misogyny may be a problem in cancer care as well.  

With a disease like cancer, time is of the essence: the earlier a diagnosis is made, the better chance at survival the patient has. Yet there is evidence that women often experience diagnostic and treatment delays. For instance, a study on bladder and renal cancer diagnosis in English primary care found that women would have three or more pre-referral consultations compared to men, meaning that they would have longer time periods between seeing their GP and being referred to a hospital. This may be due to doctors interpreting the importance of haematuria (i.e. blood in the urine) differently in men and women.  

Such diagnostic delays are not limited to urological cancers; they have also been observed in cases of pancreatic cancer, rectal cancer, and lung cancer. Interestingly, despite men being almost three times more likely to develop bladder cancer, it is unclear why women are more likely to die from it. This paradox raises questions, especially considering that women with (advanced) bladder cancer receiving chemotherapy in clinical trials do not seem to have worse survival than men. In fact, the same study concluded that women are less likely to receive systemic chemotherapy for advanced bladder cancer, but the reason behind this difference in treatment decision is unknown.  

Taken together, these findings highlight a complex picture: while women face significant barriers in timely diagnosis and equitable treatment, they generally have better survival rates after a cancer diagnosis compared to men. This suggests that addressing gender disparities in cancer care could lead to improved outcomes not only for women, but for men as well. 

There are other critical aspects of a woman’s life that are often overlooked when developing a treatment plan, ultimately lowering the quality of care she receives. 

A study looking at caregivers of cancer patients in the US, found that men with cancer are more likely to have their spouse to be their caregiver, whereas women with cancer are more likely to be cared for by a child. Furthermore, women with cervical cancer are 40% more likely to be divorced by their partner compared to healthy women. These findings highlight a troubling disparity in the social expectations women are subjected to, and the level of emotional and practical support available to them outside of clinical settings. 

The support a woman receives beyond the hospital should be a key consideration when designing her treatment plan; this includes her familial, emotional, and financial setting, as well as her caregiving network. Such social aspects of a patient's living situation should be integrated into the clinical decisions, so that all the patients’ needs are met during such a difficult time. 

This is especially relevant when considering SDG goal 3.4, which aims to “Reduce Mortality from Non-communicable diseases and promote mental health”. Research shows that women in cancer care experience more anxiety than their male counterparts, suggesting that mental health management strategies should have a gender-specific approach to improve outcomes. 

The importance of inclusivity in scientific research 

Throughout history, biomedical research has focused on using male physiology as the medical standard, and in oncology this has led to the importance of sex and gender differences being underestimated. Scientist and healthcare professionals have been using a dangerous “nonsexual” approach in cancer research, with women often being under-represented in clinical trials. An analysis of The Cancer Genome Atlas, found that only 2.5% of their published articles addressed sex differences in cancer in a meaningful way. All of this leads to the assumption that treatments will have the same outcomes in everyone, which s is simply not true; an example is how women receiving radiation therapy are twice as likely to develop solid tumours post-radiation exposure compared to men, for reasons that are unknown. 

Unfortunately, it seems as though the lack of gender awareness in research and treatment strategies will become more popular; terms like “women” have been recently censored in official documents such as research proposals in certain regions (among over 350 other terms). Censoring entire communities from research can only eventually lead to the misrepresentation and mis-generalisation of research findings, which will of course disproportionately affect minorities and, in this case, women.  

Scientific research tailored towards women specifically is vital and has unfortunately been lacking, even prior to the recent censorship rules. To this day, women suffer due to conditions such as Endometriosis; a long-term chronic condition that continues to be under-researched and poorly understood, with inconsistent diagnosis and management strategies, yet affecting around 178 million women around the globe. 

Poor representation in research of entire groups of people can only lead to those communities not receiving the proper care. Cancer research involving patients of nonconforming gender identities is either misleading, due to sex and gender labels often being used incorrectly in scientific research or completely lacking due to the absence of funding and initiatives. This, in addition to censoring diverse labels, makes it impossible to assess the differences and inequalities in healthcare for gender minorities. The result? Patients of gender minorities, such as transgender and non-binary people, have lower rates of cancer screening and increased cancer mortality. 

Conclusions 

In a world moving towards a Precision or Personalised Medicine approach, it is essential that we consider a patient’s sex and gender, as well as other factors, when planning their cancer treatment and management.  

The intersection of multiple social factors must be considered for us to advance towards the achievement of SDG 3.8; race, ethnicity, and socioeconomic status are all factors that can influence cancer care and disparities. African American women in the US experience longer delays in diagnosis of breast cancer compared to White women, and although they are less likely to be diagnosed with breast cancer, they are more likely to die of the disease compared to White women. In the UK, Black women are almost twice as likely to receive a late-stage diagnosis compared to White British women. African American and Black patients have the lowest survival rate of any other racial group for most cancers. Cervical cancer and breast cancer disproportionately affect women in low and middle-income countries as well as in poor and marginalised groups. Black patients with Hodgkin Lymphoma with low socioeconomic status from rural areas, have worse 5-year survival rates compared to White patients with high socioeconomic status in metropolitan neighbourhoods.
Universal healthcare access means that medical information and the availability of care should not be determined by one’s gender identity, race, income, or geographic location, but it should rather be guaranteed as a human right. Only by addressing these inequalities can we move closer to achieving equitable cancer outcomes and fulfilling SDG Target 3.8. 

Unfortunately, these issues go so far beyond the world of cancer and oncology. Thus, we call for all healthcare workers, doctors, and researchers to look at their own biases and ensure they include women and gender minorities in their research and studies.  

A more gender aware perspective of cancer is essential in research, treatment strategies, clinical trials, and global health, and it is needed for us to reach the SDG 3 targets, specifically 3.4 and 3.8, which advocate for good health and wellbeing for all. More research should also investigate the reasons behind these gender differences in cancer survival. 

Want to learn more?  

• European Cancer Organisation has created a report on Women and Cancer with important statistics and information.  

• The UK Biobank is currently running a project with the University of British Columbia on Sex and Gender Disparities in Cancer Incidence and Survival.  

• Royal College of Radiologists is committing to ten action points to improve cancer care for sexual and gender minorities. 

• City Cancer Challenge Foundation announces a $10 million initiative called Cities Taking Action for Gender Equity in Cancer Care (2024-2030). 

• AstraZeneca is funding an initiative called The Powering Breast Cancer Progress grant programme, aiming to improve health outcomes for underserved patient populations. 

• Cancer Research UK Manchester Centre ran a seminar on Improving cancer care in the LGBTQ+ community, highlighting how cancer risk in the LGBTQ+ community can be different to that in non-LGBTQ+ people.