How to fill the gender gap in oncology

Roberta Villa

The lack of women in apical positions is a weakness of oncology, and a loss for patients. Mentorship programs launched in recent years by scientific societies like ESMO and ASCO, together with practical support for career development, are starting to address the many factors that make the climb to success steeper for women

The 2018 Gender Gap Report of the World Economic Forum’s perspective is quite pessimist: at the current pace, the overall global gender gap in pay and job opportunities, education, health and politics, will take more than one century to close. In Europe, and in the field of medical workforce, this goal will be hopefully reached before, but, all over the world, progress is not as fast as one would think. Recent news stories seem to confirm this dreary view.

Conscious and unconscious bias

In 2018 a scandal broke out at Tokyo Medical University in Japan, where an internal investigation unveiled that senior officials systematically and deliberately falsified female applicants’ grades in order to limit at 30 per cent the rate of women studying medicine. Their excuse? Women would take maternity leave and take more care of children, causing a shortage of doctors in the country. The following investigation in more than 80 medical schools by the education ministry found out that this was all but an exception.

“Japan is a very male-dominated society so even after women become doctors there is always gender bias — such as discrimination against women — and it probably gets harder as they get older” declared urologist Yoshiko Maeda, chief of the Japan Medical Women’s Association. In fact, Japan is at the bottom of the OECD ranking for the share of female doctors, at around 20%. European countries do better, but data from France and Canada show that the share of female doctors tends to be greater in less specialized and paid activities, such as primary care more than surgery.

Even within the same speciality, such as oncology, where women rate is rapidly increasing in Europe as well as in the United States, their presence at leadership roles is still far from parity. A lot of effort is being made to remove barriers that prevent women to reach the highest positions, but much remains to be done. Laws mandating equal pay are not always and everywhere respected. There are still conscious or unconscious bias against women, who are considered less competent than men are, even when they have the same experience and qualifications. For men, being ambitious in the workplace is a quality, while the same aspiration is not equally appreciated in women. At conferences, all male panels are the norm, while all female ones are exceptions, so that a Twitter hashtag, #allmalepanel has been launched to raise awareness on this. Male speakers are always introduced with their professional title like “doctor” or “professor”, while for women, when they are addressed by a man, this is not the rule (J Womens Health (Larchmt) 2017, 26(5):413-419).

Many female oncologists, few leaders

In 2013, in order to explore the challenges facing female oncologists and to promote equal access to career development opportunities, the European Society for Medical Oncology (ESMO) established the Women for Oncology Committee (W4O). A first exploratory study carried out with about 480 female medical oncologists responding confirmed great disparities: women were the majority in 57.6% of clinical teams, but in less than 40% of them they were manager and only 14.4% of the respondents covered a high profile leadership role (e.g. CEO, Board, Department Head).

The map was not so different in the United States. At about the same time, according to the Association of American Medical Colleges (AAMC), women were occupying only 15% of department chairs and 16% of deanships, even though they were already nearly the half of medical students.

A new survey (ESMO Open 2018, 3:e000423 doi:10.1136/esmoopen-2018-000423) has been carried out in 2016 and recently published by the ESMO W4O Committee, which includes new questions and addresses both male and female professionals. Data show that about 1 out of 4 board members of the international societies reviewed were female oncologists, only 5 of the 53 international and national societies analysed had female presidents, and women represented less than one-third of invited speakers at major oncology congresses held during 2015-2016.

The main barrier to achieving gender parity in leadership roles is still a lack of work-family balance, according to 64,2% of male and female respondents to another survey made by the ESMO W4O Committee (ESMO Open 2018, 3:e000422. doi:10.1136/esmoopen-2018-000422). Other relevant reasons cited by respondents are that men are perceived as natural leaders, while a cultural prejudice persists about priority in family and domestic responsibilities by women.

“At ESMO, we are committed to developing initiatives that can help all oncologists to achieve their full potential without risk of burnout, especially during the early stages of their career,” said Josep Tabernero, ESMO President (2018-2019), Director of the Vall d’Hebron Institute of Oncology in Barcelona, Spain. “Having a family should not be seen as a burden for women or for men and we are looking into supportive policies to enable career advancement to co-exist more easily with family and/or private life”.

Men, in fact, also could take advantage for themselves from a better life-work balance and from an equal sharing of family burden, without delegating their parental role.

Childcare services at congresses

“We cannot stand by and watch colleagues – women or men – leave our profession prematurely because they cannot achieve the work-life balance they seek. They are the future of oncology and we must value and support them” Tabernero adds. “For instance, many young oncologists cannot attend congresses because they don’t have anyone to look after their children. One step in the right direction was the introduction in 2016 of a childcare service at the ESMO annual congress.”

Attending conference when having children is not a trivial issue, according to the informal survey made by Miriam A. Knoll of Hackensack University Medical Center among 2016 American Society of Clinical Oncology (ASCO) Annual Meeting attendees. She found that 60% of the 52 female colleagues polled “reported that the number one decision-making factor in whether or not they attended the Annual Meeting was childcare,” she wrote. “Surprisingly, whether or not one was presenting research at the Meeting was the determining factor for only 5.8% of the physicians I polled… If going to a conference is too stressful to consider, we’re not even sitting at the table.” Furthering this and other claims, the ASCO Meetings Department put in place a plan to better track the gender of Annual Meeting attendees, and to explore resources that will make it easier for women to attend.

Programs for career advancement

Not only women are penalized by this sort of discrimination, but also oncology itself, which is globally suffering from a lack of workforce, as well as patients, who are deprived of women’s peculiar competencies and attitudes. “This disparity can have a huge impact on clinical practice, because groups having a mix that includes diverse backgrounds, nationalities and genders produce better outcomes. Women often exhibit a cooperative work style that enhances the effectiveness of groups, and, when in leadership, will contribute to a people-oriented and interactive approach to the development and implementation of patient treatment policies,” says Marina Garassino, Head of the Thoracic Oncology Unit of the Milan National Cancer Centre, Italy, member of the ESMO W4O Committee and president of W4O Italy. “Policies developed by gender-balanced groups will encourage more women to practice oncology and will also reflect a female perspective that will benefit both male and female patients. The integration of women into all levels of oncology will ensure that the physician workforce reflects the gender diversity and cultural perception of the population it serves”.

“Other programmes are in place to support members in career advancement with advice provided by a gender-diverse faculty,” adds Solange Peters, Chair of the ESMO Women for Oncology Committee, ESMO President Elect, Head of Medical Oncology, Thoracic Malignancies Chair at the Centre Hospitalier Universitaire Vaudois (CHUV) in Lausanne, Switzerland. “Gender balance has already been achieved in the 2017 edition of the ESMO Leaders Generation Programme, which comprised eight female and seven male oncologists who learnt the skills for successful leadership. In addition to these programmes, ESMO also provides fellowships consisting of financial and professional support”.

Oncologists interviewed in the ESMO survey give other suggestions, in addition to promoting work-life balance, cited by 50.4% of male and female respondents as the main goal. Other efforts in the right direction will be to favour development and leadership training of women (40.6%), to offer and support flexible work, to establish transparent carrier paths and salary structures, to promote role models, to get visible leadership commitment to gender equality, to seek ways to remove unconscious bias, to build awareness of the benefit of gender diversity among managers, and to support women’s integration into the value chain.

The European Union, on its side, requires a gender equality perspective to be integrated into all EU policies as well as into EU funding programmes. Research projects need to consider this.

On the other side of the Atlantic sea

Actions are being taken also in the United States. In 2018 the American College of Physicians issued a Position Paper in which summarizes the unique challenges female physicians face over the course of their careers and provides recommendations to improve gender equity and ensure that the full potential of female physicians is realized (Ann Intern Med 2018, 168(10):721-723).

ASCO opened a Women in Oncology blog on its website, in order to give voice to all the challenges, insights and best practices that can help members to achieve professional and personal development. Another initiative was the establishment at ASCO Annual Meetings of the Women’s Networking Center, a place for women to openly discuss and to provide an opportunity for one-on-one mentorship.

Speaking is important, but funding is even more relevant: ASCO also offers the Women Who Conquer Cancer (WWCC) program, which was created to support the careers of female researchers through the Conquer Cancer Foundation of ASCO’s Young Investigator Award (CCF YIA). In 2016, the WWCC established the Women Who Conquer Cancer Mentorship Award, which focus on leadership, teaching, mentoring and role modelling capacities.

Optimism comes from younger professionals, among which gender parity and diversity is growing, feeding the professional pipeline with new approaches. “If you look at ASCO’s Leadership Development Program, for example,” ASCO Immediate Past President Julie M. Vose explains “or look down the road at people going into oncology, participation is pretty much 50-50 between men and women. As long as we have a good supply chain, so to speak, and the initiatives to mentor those people and provide opportunities, eventually—hopefully— things will even out, but it’s going to take time”.

Many top female oncologists cite mentorship as a key. “Mentorship definitely got me where I am today,” says Vose “and I wouldn’t be the same person without it. You have to have an intrinsic drive to be a leader, but you also have to have mentorship, good networking, and the ability to meet people and get into the right positions. A mentor can help in all of those respects”.

Anyway, according to WHO, one of the most important actions required to close the gender gap is engaging women and girls, alongside men and boys, to transform norms and roles. In other words, at this point, it is more of a cultural issue, to remove unconscious bias and behaviours, than a legal one, at least in most Western countries where parity should be guaranteed by law and few people admit to being against that.

Women are the first who should change their approach. They must learn to negotiate their salary with the same self-confidence a man would, well aware of the local benchmark for such a position. They should not be afraid to speak with calm, but loud, clear, self-confident voice in meetings, sticking to facts and repeating them, if needed.

And when a man talks and is appreciated for an idea a woman had expressed before, being ignored, what should she do? “You can simply say, ‘I’m so glad you agree with me,’ in a friendly way” suggests Reshma Jagsi, of the University of Michigan Health System, who has been researching gender inequity in academic medicine for more than 10 years. Believe her.

#Metoo in oncology

Last year, 2018, will be remembered, among other things, for the birth and spread of the #metoo movement: a wave that from the United States raised the voices of thousands of women all over the world, showing how common and underestimated abuse and sexual harassments are, at any level of the society, even among doctors and researchers.

In the ESMO survey cited in the article, 37.7% of female oncologists reported they had encountered unwanted sexual comments by a superior or colleague: in most cases they were general sexist remarks and behaviours (69%), but almost one out of five respondents (19.8%) had to tackle with inappropriate sexual advances. Some faced subtle bribery to engage in sexual behaviours (8.6%), coercive advances (1.7%) and even threats to engage in sexual behaviours (0.9%).

Sexual harassment goes beyond fairly considering female talent to senior positions at faculty or board levels, or addressing gender balance at national and international meetings: “It is completely unacceptable, and ESMO has a clear responsibility to help trigger an essential change on this issue in the whole scientific community,” Tabernero said, echoing a recent Science editorial (Science 2017, 358(6368): 1223).

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