Global Health Equity: Women, Power, and Cancer: A Lancet Commission

Social Determinants of Health in Cancer Care

In this episode, guest host, Dr. Christopher Cross, Director of Global Health Equity Strategies at ASCO moderates a discussion with the Dr. Ophira Ginsburg Co-Author of the Lancet Commission on women, power, and cancer and Dr. Julie Gralow, an advisor to the Commission. Dr. Ginsburg and Dr. Gralow share their insight into social determinants of health in cancer and prevention among women and global efforts underway to advance health equity.

TRANSCRIPT The guest on this podcast episode has no disclosures to declare.

Dr. Christopher Cross: Welcome to ASCO's Social Determinants of Health in Cancer Care Podcast. I'm Dr. Christopher Cross, Director of Global Health Equity Strategies at ASCO.

I'm joined by Dr. Ophira Ginsburg, Senior Advisor for Clinical Research Center for Global Health at the National Cancer Institute, and Dr. Julie Gralow, Chief Medical Officer, and Executive Vice President of ASCO.

In this episode, we will discuss social determinants of health, focusing on women, cancer, and prevention. Thank you both for being a part of our podcast, we're excited to have you on.

Dr. Ophira Ginsburg: Thanks so much. My pleasure.

Dr. Julie Gralow: Thanks, Chris.

Dr. Christopher Cross: So, we'd like to start the conversation with asking our guests, how do you define social determinants of health and cancer care?

Dr. Ophira Ginsburg: Well, social determinants of health, according to the World Health Organization, I'm sure as you know, is really looking at a person's background that leads them to health inequities or health inequality. So, it has to do with the conditions under which people are born, how they develop, grow, live, work, age, and all the sort of forces and systems that shape their daily living conditions.

With respect to the interaction of women and cancer with respect to the social determinants of health, as we put forward in our commission report, really, gender has an influence on all of these factors. And not just gender, but the other intersectional aspects of a person's identity that can serve to compound and influence in a negative way their opportunities to understand what their risks of cancer are, to avoid those risks, to seek and obtain respectful, prompt, timely quality cancer health services.

And this also influences the way in which women interact with the health systems for cancer as care providers, whether it's clinicians, et cetera, or also, is the unpaid caregivers, as we sometimes call them, informal workforce. There's nothing informal about it.

Dr. Julie Gralow: And I would agree with the Ophira's definition. I think of it as the environment in which people are born, live, learn, and work, and how it impacts health.

And so, that can include economic stability, education access and quality, healthcare access and quality, the neighborhood and the environment in which the person lives. And then the social community context, the family, the relationships, all of those can combine to impact health.

Dr. Christopher Cross: Thank you for those responses. What does social determinants of health for women mean at a global level, Dr. Ginsburg?

Dr. Ophira Ginsburg: Global is local. So, we see social determinants of health, and by the way, also commercial determinants of health, which would be wrong not to include in this discussion as greatly impacting the aspects of opportunities to seek and prevent cancer, et cetera, everything we just discussed; this happens also on a global level.

So, as we show in our commission report where a woman lives does greatly influence cancer incidents, mortality, survival, and also, very importantly, who that woman is in her community. Whether she's living in a circumstance situation or there are identity factors that render her structurally marginalized will impact also on her lived experience of cancer.

And we have nine stories that highlight and offer some human aspect to what people are going through, whether they're care providers or women living with the experience of cancer on a personal level, the different countries and context in our report.

Dr. Julie Gralow: With respect to social determinants of health and women, particularly at a global level, I think women interact with cancer in so many ways. I mean, the easy way to think about it is women with a diagnosis of cancer, but we've also got women working to reduce their risk of cancer and detecting it early.

We've also got women in the workforce, health professionals, researchers, we've got women as policymakers, and in the home environment, we have women as caregivers. And they are much more frequently the decision makers for everybody in the family with respect to healthcare related issues.

So, women interact with cancer in so many different ways, and those social determinants of health mean that women are more commonly subject to discrimination. It can be discrimination due to their gender, but also, their age, their race, their ethnicity, their socioeconomic status. And as Dr. Ginsburg has pointed out that this can marginalize them.

And these factors can restrict a woman's rights and her opportunities to reduce her risk of getting cancer. And it can be a barrier to early diagnosis to achieving quality cancer care. And we've got this whole (which is really predominantly portrayed in there) unpaid caregiver workforce that is almost all female around the world. And this can hinder a woman's professional development as well.

Dr. Christopher Cross: When you were talking, Dr. Gralow, it made me think of hearing about the story of the former First Lady Rosalynn Carter. Her father passed away when she was around 13 or 14 from cancer, and she said she had to become the caregiver as like the oldest sibling.

And talking about that in wake of her passing, in her advocacy for mental health and caregiving, I think is right along this conversation that people may not be experts as you two are, but they have lived experiences where they've had to step into these roles. And so, thank you for bringing to light the global context.

Like you were saying, Dr. Ginsburg, local is global, and I think this is something that everybody can relate to.

Now, let's get into the work that you both are doing. Can you tell our audience about Women, power, and cancer: A Lancet Commission and your role and any of the key findings you may want to highlight?

Dr. Ophira Ginsburg: Yeah, I'm happy to take that one on. To start with, I was very fortunate to have a conversation with the editor-in-chief of the Lancet, Dr. Richard Horton, several years ago now, three years ago actually.

And we at that time, were making kind of note of where we were at some three years after the publication of a three-part series called Health, Equity, and Women's Cancer that was published in the Lancet that was specifically oriented around breast and cervical cancer, and the difficulties and challenges women have in obtaining equitable access to care.

And to some extent, we commented on what we don't know about, for example, the children that are left behind when a woman dies of one of these cancers. And we emphasized the importance of more research in that area.

This led to my pitching proposal for a commission, and this was approved, and we published an initial commentary (Richard and myself) in July of 2020 that led to the commission that we now have as a major report in the Lancet that was published on September 27th, and excited to speak about that.

I might just emphasize a couple of key data points in the report that I think the listeners would be interested to know. Well, for the first time, we were able to show the number of women's lives that could be saved if just four risk factors were addressed.

So, we found that 1.3 million women's lives would be saved if tobacco, alcohol, obesity, and infections could be controlled. Now, why is this important for women? Well, it's important for men as well, and I know people often ask, “Why did you focus on women?” We can get to that if people are interested.

But to emphasize the importance of the preventability and lack thereof, we know what is contributing to a large proportion of cancer in women, but what many people don't know is what the numbers actually show with respect to premature mortality and how that relates to maternal orphans, that I just mentioned that hadn't been really addressed before.

So, when you look at the number of men and women with cancer, it's roughly equal. It's almost 50/50. Now, men are more likely to die of cancer than women. About 44% of all cancer deaths occur in women, so it's not that much less.

But when you look at the number of women experiencing cancer under the age of 50, in 2020 alone, of the 3 million adults diagnosed with cancer, two in three were women. That was a data point hiding in plain sight, we produced that. That was published in advance of this report in the Lancet Oncology with a few of us on the commission.

And then in the commission report, we really dug into the preventability of premature deaths, and we found that 1.5 million women could be spared, a death under the age of 70 due to cancer if everyone had access to primary prevention and early detection strategies that we know work and we know exist. And another 800,000 women's lives could be saved premature deaths below the age of 70 if every woman everywhere diagnosed with cancer had access to optimal care.

In 2020 alone, 1 million children lost their mothers due to cancer, just that year. And when we looked at the prevalence, so the number of kids who were without their mothers who were still children in 2020, it's seven and a half million.

This was work done by our colleagues at IARC, Dr. Valerie McCormack group, and many of us were on that report as well. So, these are big numbers and I think that's what's gotten people talking about this.

Dr. Julie Gralow: I was fortunate to be invited by Dr. Ginsburg early in the formation of this commission to serve as an advisor on the commission. I did not serve as a commissioner itself, but at a high level, tried to see what I could do to support the gathering of information and the discussions that led to the recommendations that came out of it.

And in my advisor role, I am working hard to promote this commission, to get the word out. It's really been interesting to see the engagement across the board with media, with policymakers, cancer center directors, the NCI director who now, is our NIH director, actually wrote an editorial as part of this Monica Bertagnolli.

I have been thrilled to see the uptake of it. And part of my job as an advisor is to continue to get that message out and frankly to help us respond to the recommendations that came out of this report.

Dr. Ophira Ginsburg: Absolutely. I'm just going to add to that by saying thank you, Dr. Gralow, for being such a key advisor on this work. Really, this kind of work takes a village.

We have 21 commissioners, 10 mentees from across the world. More than half of our commissioners are living in a lower middle-income country. Most of those in high-income countries actually were raised and trained in a low and middle-income country.

We have four men among us, but we have our advisory board, and also, a seven-person patient advocacy committee that I don't want to forget to mention, who really held our feet to the fire and ensured that their voices were not just heard, but they helped to co-create the content, as did very much our advisors like Dr. Gralow.

Dr. Christopher Cross: I also want to add my thanks to your thanks Dr. Ginsburg, for all the work that both you and Dr. Gralow are doing at the commission.

So, I want to set the stage here for the audience. In the first half, I think we talked about really laying the landscape globally around social determinants of health broadly. Then it sounds like we really focused on the disproportionate burden of caregiving across globally.

Now, Dr. Ginsburg, you've mentioned these four key areas around if we address them, it would have a marketed effect of impact. I just wanted to reiterate those. You've mentioned tobacco, alcohol, obesity, and infection.

You talk about sort of a mindset or an approach that I think underscores these things that we've already mentioned. Could you talk a little bit more about how important is feminism in addressing and achieving equity at a global scale for women affected by cancer?

Dr. Ophira Ginsburg: Oh, I'm so glad you asked that. It was something that, to be honest, very early on as we came together as a commission on Zoom, because it was mostly during the worst part of the pandemic, we questioned amongst ourselves whether we should use the word feminism. And it was actually to his credit that Dr. Richard Horton, the editor-in-chief said, “Absolutely, you should.”

And we thought about it from our various countries where we were all living. Some felt a little nervous about it, said, “Well, maybe we won't be taken seriously, maybe we'll get backlash. It'll take away from the key messages, et cetera.”

And then we decided as we decided everything by consensus, which by the way is a feminist approach — that the fact that we were debating it meant we had to say it. That's exactly it. And so, sure enough, every time we're asked this, it's actually easier each time to reflect on what do we actually mean by feminism here?

Well, one way they define it, and I think it's Mary Wollstonecraft who said, “Feminism is not about women having power over men, it's about women having power over ourselves. This is where power comes in, the asymmetries of power that prevail.”

In the report as people will read, we looked at three domains of this: knowledge, understanding what our risks are, understanding our role in society, and understanding anything about cancer, our decision-making as we show in the very elaborate section on health systems where women in many situations, in many countries, not just in the global south, don't really have decision-making power over their own health. And then the third being asymmetries of power with respect to economics.

And in fact, it was an intersectional feminist approach that we ultimately decided was most useful here. And we have a conceptual framework, sort of one of those diagrams people can look at and think about, “How does that impact on my own interaction with the cancer health system, whether I'm living with cancer, looking after somebody with cancer, I'm a cancer health provider, a researcher, policymaker, or a combination of these in fact.”

Dr. Julie Gralow: Dr. Ginsburg, I have a question for you related to some of what you've just said. For the first couple of years of the commission's workings, it was called the Commission on Women & Cancer. And as you were getting to the finish line and ready to launch it, you added that word “power.” So, it's the Lancet Commission on Women, Power, and Cancer.

How did that come about and what's been the reaction to adding that word power in?

Dr. Ophira Ginsburg: In fact, there was a commentary written in response to the three-part series I mentioned earlier: Health, Equity and Women's Cancer by then President of Chile, Dr. Michelle Bachelet, who went on to become the UN Human Rights Commissioner.

And she wrote a commentary in response to our three-part series called Women, Power, and the Cancer Divide. And it really spoke to me. I remember keeping that in my head all this time, it's several years, that was 2017, actually.

And we ultimately realized that power was really at the center of this important aspect of inequality and inequity. And if we could recognize where the power differentials are, it would help inform the solutions that we bring forward in our 10 recommendations.

So, at the end of the day, we had that placeholder, women and cancer report, and our editor, our handling editor, Dr. Vania Wisdom said, “Why don't we just call it Women, Power, and Cancer?” And we all laughed. Of course, it was fighting in plain sight.

Dr. Christopher Cross: This is all just fantastic. And to me as a researcher myself, I see the benefit of this approach you've articulated in a way of, it's led to the disaggregation of subtypes of cancer that affect women and even other groups.

So, you've mentioned disaggregating deaths of women and looking at age as a spectrum, and then underscoring that less than 50 at that age, there's so many other disparities that are dominantly affecting that age group. To me, that underscores the ROI, if you will, the value, the power in using a feminist approach to address cancer research for women.

And now, I got a question for you, Dr. Gralow; you humbly mentioned your role as an advisor on this commission, but I want you to speak to the roles that women are taking, especially physician researchers in these organizations that are pivotal in addressing and achieving global health equity.

Dr. Julie Gralow: Thanks for bringing that up. We haven't really delved into the role of women in the workforce, and there have clearly been inequities there across the world and in the United States.

But I think it's a very exciting time in the United States as we now have a female head of our National Institutes of Health, and we have a female nominee to replace her as the Head of the National Cancer Institute. The CEO of both the American Cancer Society and the National Comprehensive Cancer Network are now women.

We have female presidents of both ACR and ASCO right now. I'm in my role at ASCO as the Chief Medical Officer. I mean, just look at what has happened recently. Now, that doesn't mean that we've solved the problem of equity in the workforce in the United States, much less the rest of the world, but we do have female leaders and we are all committed to hold the door open to those who follow behind us.

And we've actually had some joking about, “Just blow up the door entirely. Why do we have a door that's blocking the women who we're helping promote?” So, I think it's a very exciting time in our workforce in the U.S., and I see it in many other countries too.

I mean, look at some of the commissioners on this Lancet Commission, Dr. Ginsburg, the current president of AORTIC, the African Organization for Research and Training in Cancer, for example, and many others.

Dr. Ophira Ginsburg: Absolutely. I love the way you put that. Yeah, leave the door wide open. We do have tremendous leadership amongst our commissioners. And in fact, the fact that we have all these mentees coming up ranks, it's just great.

AORTIC, the African Organization for Research and Training in Cancer is particularly notable, representing the continent of Africa for having a lot of strong women leaders, including as Dr. Gralow just said, Dr. Miriam Mutebi. She's a breast surgeon based in Nairobi, Kenya, who just came on as the new president of AORTIC.

And we actually held a launch event there. We had the global launch of this commission report September 27th in Geneva, Switzerland at the Graduate Institute. And we had a lot of activity around that launch and media activity.

And just a week and a half or so ago, we had our African regional launch held at the biannual meeting of AORTIC, and that was just phenomenal. I mean, Dr. Gralow was there, I don’t know if you want to say anything, but the panelists were just — I was so pulled over by the depth and the breadths and the scope of the conversation, and the way it was so personal for so many of our commissioners who are from the region.

Dr. Julie Gralow: Yeah, I was at the African launch sitting next to our ASCO president, Dr. Lynn Schuchter, it was her first AORTIC meeting. And she was so impressed with the launch and the talks that went along with it, and the content of this commission that she immediately said, “Okay, we need to feature this prominently at our ASCO annual meeting next June in Chicago.”

So, we are working with Dr. Ginsburg and the commission on what we can do to bring this to North America now in a prominent way.

Dr. Ophira Ginsburg: Yeah, we're very excited about this prospect. I just want to add, we do intend to have regional launches elsewhere and we're working with our colleagues in SLACOM, another one of our valued partners — Society of Medical Oncology from Latin America & the Caribbean led by Dr. Eduardo Cazap was also an advisor to see how best to put together a launch event in that region as well, sometime in the spring.

I might just add, it's not just meant to have another dissemination event and we can have a webinar and have a discussion, which is important, but we can also tailor the data to reflect the unique epidemiology and health systems issues and other aspects that are relevant to achieving the outcomes we want to see in a given region.

So, for example, in Senegal, Dr. Isabelle Soerjomataram, one of the co-chairs, the other being Dr. Verna Vanderpuye, also one of the leaders of AORTIC. Dr. Soerjomataram is at IARC, WHO's cancer agency, and she put together specific data points breaking down what was relevant for the African continent and presented that alongside this panel discussion we were just talking about.

Dr. Christopher Cross: For me, a natural question just follows up … listening to you both talk about all of these advancements and these powerhouses that are moving the needle. What is the hope for in the next maybe 5 to 10 years that we will hope to see, given this change in leadership and this new direction we're going in?

Dr. Ophira Ginsburg: I'll say that with what we just heard from Dr. Gralow regarding the leadership currently between the NIH, I mean we're just thrilled that Dr. Monica Bertagnolli wrote a commentary for our commission report and then becomes the NIH director and the incoming NCI director also being female, et cetera.

But in fact, when we looked at other aspects of research outputs, this is one thing I'd like to bring up because I mean the people listening would be ASCO members primarily, people who are scientists and working in the research ecosystem in cancer epidemiology care control.

We found that of the top 100 ranked journals in cancer research, that's by impact factor. I will ask you, Chris, what percent do you think had an editor-in-chief that was female? Putting you on the spot, any guesses? Dr. Christopher Cross: I would say less than 20%.

Dr. Ophira Ginsburg: Ooh, you're good. I thought it would be probably 30%. 16 — 16%, that's it. And another piece of research we did for the report was looking at the membership of UICC, the Union for International Cancer Control, also valued partner.

UICC membership organizations that were listed as research institutes, cancer centers, et cetera, had also that same number. Only 16% were led by women. So, we do really have a long way to go, but there have been a lot of improvements over time.

But if we maintain the status quo, it's going to be like a hundred years to get to parity. So, I encourage people to look at the report. We have specific recommendations, and we also invite people interested in collaborating with us to action those recommendations.

Looking into emerging cancer risks, we need scientists who are interested in that area. We only understand about a third of the risk of breast cancer right now, and that third includes mostly factors that are not really amenable to primary prevention. So, what's up with that?

Dr. Christopher Cross: Absolutely. Dr. Gralow, I'm curious, what do you think the hope is given our new leadership landscape to address health equity and cancer care for women?

Dr. Julie Gralow: In the next five years, as you started the question, I would hope to see that we've now created awareness, and so we begin dismantling some of the structural things that have been put in place, that have created the barriers.

Hearing the numbers of all cancer deaths globally, only 44% are women. You would really potentially come at this, thinking, “Oh, it's not such a problem.” But then diving into the data and the report of cancer deaths under the age of 50, a significant proportion of them are women, many leaving behind children.

A lot of that is cervical cancer, which with the HPV vaccine, we could prevent, or with early detection of pre-cancer, we can eliminate cervical cancer, that's our goal. We're working with WHO and breast cancer, early detection. So, those are the two main cancers that are impacting women in this young age group.

So, I think recognition of that, acknowledgement of that, looking at the prevention piece, those four main risk factors: tobacco, alcohol, obesity, and infection — working on breast and cervical cancer in partnership with the WHO's initiatives there, I think we can make a dent.

With respect to the workforce, we're paying a lot of attention to this, and I do think we've seen strides in our ASCO committees, our ASCO board, our ASCO presidents. We work very hard to achieve balance across gender and race and ethnicity, et cetera.

So, those are some of the things I hope we can make a dent in, in the next five years. We have a long way to go, but we can't wait a hundred years as Ophira says, to make these strides.

Dr. Ophira Ginsburg: If you think about what are the so-called lower hanging fruit in this that could be really actioned within the immediate and medium term. So, five years, absolutely. By five years, we should have — for example, we have a specific recommendation on a gender competency framework for the education and training of the cancer healthcare workforce.

One of our key findings was that sexual harassment, bullying, et cetera, is a huge problem, just like it is in every other domain, unfortunately. And it's long overdue that the oncology community has its MeToo moment and recognition of this that impedes women's progress as healthcare workers, as researchers, as leaders, in as much as it also hinders a woman's opportunity to seek respectful care and feel that they will be dealt with in a respectful manner.

I didn't mention this until now, but when we say women in this report, we're talking about women in all their diversities in terms of race, age, ethnicity, et cetera. And also, women who would identify as belonging to a diverse sexual orientation, gender identity, and expression.

And we do have quite a bit of content in the report on the work of the Cancer and LGBTQ Network, for example, and some of their recommendations. They were one of our partners. We have a story featured on that topic more broadly.

But this gender competency framework is something we can all start looking to now, that was led by one of our commissioners, Dr. Nazik Hammad, who's a medical oncologist from Sudan living in Canada, who has a whole world of experience as an educator as well.

Dr. Christopher Cross: Thank you for sharing that. As you know, ASCO has been doing a number of work with this. We've had our own Sexual Gender Minorities Task Force, which has now gone on to be the Sexual Gender Minority Advisory Group, which will report under our new Equity Diversity Inclusion Committee. So, we're also very excited to make sure we continue to be partners with you and the work you're doing.

So, we're kind of wrapping up, but I wanted to make sure I left time for any final thoughts you would like to share to the listeners.

Dr. Julie Gralow: Well, I'd like to actually thank our listeners because that means you are at least trying to learn. I'd encourage anyone who's made it through this podcast, and this resonates with them, and they want to learn more to look at the report. There are multiple pieces to it, multiple sub articles. You can just read the summary if that's all you have time for, but read it, mull it over. I think we'd all like feedback on it.

And then let's partner together to try to meet some of the goals and the recommendations in the short-term. And then build a strong community where we don't have to be writing commissions related to women in cancer any longer in the coming years.

That's what I would like to share with our listeners. It's a great report. It's packed, full of information. I learned a lot from reading the report, even though I was part of many of the meetings. So, every time I take a look at it, I find another pearl or something else that I can put into a talk.

So, congratulations, Dr. Ginsburg, on leading this really important piece of work, and let's work together to try to overcome some of these really crucial inequities that we've found and make cancer better for everyone. Dr. Christopher Cross: Thank you, Dr. Gralow. Do you have any final thoughts, Dr. Ginsburg?

Dr. Ophira Ginsburg: Well, thanks so much for the opportunity and also to the listeners, I greatly appreciate the way you put that, Dr. Gralow.

And I would say that please don't be daunted. We present a lot of new findings that can be a bit depressing quite honestly, but that's not our aim.

We have a lot of the content oriented around resilience and what's working. For example, two country examples where they actually are paying people looking after their loved ones with cancer at home. The unpaid caregivers are actually paid or covered in some way in some countries. So, there's a lot of good stuff in there as well.

The bottom line is, it really will take all of us to make an impact. And this is not just about making things better for women at risk of or living with cancer or working with cancer patients. If we take these recommendations forward, it will benefit people of all genders.

So, I would suggest, take a look within yourself, think about how you might be part of the problem, you might be part of the solution, and you might work within your organization or even wherever you might volunteer or serve some other aspect of the cancer ecosystem to take these actions forward and look carefully at the recommendations and join us.

This is just the beginning; I'll end with that. We are just at the beginning of this program of work on women, power, and chancellor, and we welcome all input. Thanks so much for the opportunity to speak with you today.

Dr. Christopher Cross: Well, I just have to thank you both. This has been a fantastic discussion, and just thank you again, Dr. Gralow and Dr. Ginsburg for joining us on this episode of the ASCO’s Social Determinants of Health in Cancer Care Podcast. And thank you to our listeners for being a part of the conversation.

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