Women, power, and cancer: a Lancet Commission

Executive summary

Women interact with cancer in complex ways, as healthy individuals participating in cancer prevention and screening activities, as individuals living with and beyond a cancer diagnosis, as caregivers for family members and friends, as patient advocates, as health workers and health-care professionals, and as cancer researchers and policy makers.

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. In all these domains, women experience gender bias, and are subject to overlapping forms of discrimination, such as due to age, race, ethnicity, socio-economic status, sexual orientation, and gender identity, that render them structurally marginalised. These myriad factors can intersect and restrict a woman’s rights and opportunities to avoid modifiable cancer risks and impede their ability to seek and obtain a prompt diagnosis and quality cancer care. At the same time, they serve to unfairly burden and perpetuate an unpaid cancer caregiver workforce that is predominantly female, and hinder women’s professional advancement as leaders in cancer research, practice, and policy making. However, we believe that much can be achieved if actions are urgently taken.

Key findings and priority actions

Key findings

• 1 Cancer ranks in the top three causes of premature mortality among women in almost all countries of the world.
• 2 Of the 2·3 million women who die prematurely from cancer each year, 1·5 million deaths could be averted through primary prevention or early detection strategies, while a further 800 000 deaths could be averted if all women everywhere could access optimal cancer care.
• 3 Overall, cancer is less amenable to primary prevention in women than in men.
• 4 In countries ranked as low on the Human Development Index (HDI), as much as 72% of cancer deaths among women were premature (younger than age 70), compared with 36% in countries ranked as very high HDI.
• 5 In many countries, regardless of geographic region or economic resources, women are more likely than men to lack the knowledge and the power to make informed cancer-related health-care decisions.
• 6 Women are more likely than men to risk financial catastrophe due to cancer, with dire consequences for their families, even if quality cancer care is available.
• 7 Patriarchy dominates cancer care, research, and policy making. Those in positions of power decide what is prioritised, funded, and studied.
• 8 Within the cancer workforce, women are under-represented as leaders.
• 9 Women in the cancer workforce report frequent and severe experiences of gender-based discrimination, including bullying and sexual harassment.
• 10 Unpaid caregiving for people with cancer is largely undertaken by women. New methods are needed to estimate the true value of women’s work in cancer care.

Priority actions

To advance a more nuanced, inclusive, and gender transformative approach to the cancer field, we propose the following priority actions.

• 1 Ensure data on sex, gender, and other sociodemographic factors are routinely collected in cancer health statistics, publicly reported, and updated.
• 2 Develop, strengthen, and enforce laws and policies that reduce exposures to known cancer risks for girls and women.
• 3 Research, monitor, and act on emerging cancer risks that disproportionately affect girls and women, including occupational and environmental factors.
• 4 Design and implement gender and intersectional transformative strategies to increase equitable access to early detection and diagnosis of cancer.
• 5 Co-create accessible and responsive health systems that provide respectful, quality cancer care for girls and women.
• 6 Ensure equitable access to cancer research resources, leadership, and funding opportunities for women.
• 7 Develop, strengthen, and enforce policies that prevent gender-based harassment and discrimination in the cancer workforce.
• 8 Integrate a gender competency framework into the education and training of the cancer workforce.
• 9 Develop and validate a feminist economics approach to investment cases and other economic evaluations of cancer.
• 10 Establish, implement, and enforce pay standards for all cancer caregivers that are fair, equitable, and inclusive.

This Commission was created to investigate the nexus of women, power, and cancer. By applying an intersectional feminist approach, we investigate, expose, and challenge the prevailing asymmetries of power in relation to cancer in three key domains: decision making, knowledge, and economics. In this Commission report, we present our key findings and recommend a set of ten actions, with the overarching recommendation that sex and gender are included in all cancer-related policies and guidelines, making all policies responsive to the needs and aspirations of women in all their diversities. The following ten key findings are based on our original research and evidence syntheses.

Cancer ranks in the top three causes of premature mortality among women in almost all countries of the world. Globally, women’s health continues to be focused on reproductive and maternal health, a patriarchal construct that is aligned with narrow anti-feminist definitions of women’s value and roles in society. Notably, women have approximately the same burden of cancer as men, representing 48% of new cases and 44% of deaths worldwide. Shedding light on these data will help drive action to benefit all.

Of the 2·3 million women who die prematurely from cancer each year, 1·5 million premature deaths could be averted through primary prevention or early detection strategies, while a further 800 000 deaths could be averted if all women everywhere could access optimal cancer care. In countries ranked as low on the Human Development Index (HDI), as much as 72% of cancer deaths among women were premature (younger than 70 years), compared with 36% in countries ranked as very high on the HDI.

There are important under-examined social implications and economic repercussions for families and societies when individuals experience cancer, in any country, at any age. This is particularly stark for women raising children, whose premature deaths from cancer resulted in an estimated 1 million maternally orphaned children in 2020 alone.

Overall, cancer in women is less amenable to primary prevention than is cancer in men. Even the causes of breast cancer, the most common cancer among women globally, are poorly understood, and of the risks identified, most (such as genetics and reproductive factors) are not amenable to change. More research is urgently needed to better understand the causes of cancer in women, including occupational and environmental factors, some of which have only been raised as potential hazards over the past 5 –10 years.

In many countries, regardless of geographic region or economic resources, women are more likely than men to lack the knowledge and the power to make informed health-care decisions. Language matters. Gender transformative actions can shift us from blaming women for “late presentation”, “neglected cancer”, or “treatment abandonment”, to valuing women, in all their diversities, as equals of men, with agency and knowledge, empowered to make evidence-based informed decisions about their own care. An intersectional gender-transformative competency framework can be incorporated into the education and training of the global cancer workforce to ensure high quality and respectful care for all.

Women are more likely to experience financial catastrophe due to cancer, with dire consequences for their families, even if quality cancer care is available. In our gender analysis of a study in eight countries in Asia, almost three quarters of women who were newly diagnosed with cancer reported catastrophic expenditures in the year after diagnosis, having spent 30% or more of their annual household income on cancer-related expenses. The study did not even include indirect costs. A gendered investment case for cancer would better inform policy making for cancer prevention, care, and control.

Patriarchy dominates cancer care, research, and policy making. Those in positions of power decide which aspects of these areas are prioritised, funded, and studied. Globally, men are over-represented in the leadership positions of hospitals, treatment centres, and research institutes. The same is true for editors-in-chief of cancer research journals, and lead authors of cancer research papers. Gender bias, racism, and other forms of discrimination in cancer research and knowledge production can be addressed by creating awareness, ensuring equitable access to research opportunities and resources, and by implementing policies mandating that sex and gender dimensions are considered in research and research policy making.

Women in the cancer workforce report frequent and severe experiences of gender-based discrimination, including bullying and sexual harassment. Gender-based discrimination in the cancer workforce occurs in all settings and world regions, during undergraduate and residency training and at the workplace. Discriminatory actions range from unfair promotion and pay practices to outright sexual harassment. Perpetrators are usually male superiors and colleagues, and sometimes male patients and their relatives. Anti-discrimination policies that include pay equity, paid parental leave, and zero-tolerance for sexual harassment should be developed, implemented, and monitored.

Unpaid caregiving for people with cancer is largely undertaken by women. New methods are needed to estimate the true value of women’s work in cancer care. Caregiving represents substantial value to the economy and highlights the need to establish fair and inclusive pay standards for cancer caregivers. Cancer caregiving should not only be recognised but also measured, using a feminist economics approach that considers not only its monetary value but the effects of caregiving on women’s autonomy and economic potential.

In this report, we also feature unique stories that reflect the lived experiences of women from different communities and contexts, whose interactions with the cancer health system illustrate overlapping forms of discrimination that impact their personal and professional lives.

By exposing these realities and the asymmetries of power they reveal, we can envision a path forward that transforms the ways that women interact with the cancer health system, whether as patients, as care providers, or both.