Dec 4, 2023
Inthis episode, guest host, Dr. Christopher Cross, Director of GlobalHealth Equity Strategies at ASCO moderates a discussion with theDr. Ophira Ginsburg Co-Author of theLancetCommission on women, power, and cancer and Dr. Julie Gralow, anadvisor to the Commission. Dr. Ginsburg and Dr. Gralow sharetheir insight into social determinants of health in cancer andprevention among women and global efforts underway to advancehealth equity.
TRANSCRIPT The guest on thispodcast episode has no disclosures todeclare.
Dr. Christopher Cross: Welcome to ASCO's Social Determinants of Health in Cancer CarePodcast. I'm Dr. Christopher Cross, Director of Global HealthEquity Strategies at ASCO.
I'mjoined by Dr. Ophira Ginsburg, Senior Advisor for Clinical ResearchCenter for Global Health at the National Cancer Institute, and Dr.Julie Gralow, Chief Medical Officer, and Executive Vice Presidentof ASCO.
Inthis episode, we will discuss social determinants of health,focusing on women, cancer, and prevention. Thank you both for beinga 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 ourguests, how do you define social determinants of health and cancercare?
Dr. Ophira Ginsburg: Well, social determinants of health, according to the WorldHealth Organization, I'm sure as you know, is really looking at aperson's background that leads them to health inequities or healthinequality. So, it has to do with the conditions under which peopleare born, how they develop, grow, live, work, age, and all the sortof forces and systems that shape their daily livingconditions.
Withrespect to the interaction of women and cancer with respect to thesocial determinants of health, as we put forward in our commissionreport, really, gender has an influence on all of these factors.And not just gender, but the other intersectional aspects of aperson's identity that can serve to compound and influence in anegative way their opportunities to understand what their risks ofcancer are, to avoid those risks, to seek and obtain respectful,prompt, timely quality cancer health services.
Andthis also influences the way in which women interact with thehealth systems for cancer as care providers, whether it'sclinicians, et cetera, or also, is the unpaid caregivers, as wesometimes call them, informal workforce. There's nothing informalabout it.
Dr. Julie Gralow: And I would agree with the Ophira's definition. I think of itas the environment in which people are born, live, learn, and work,and how it impacts health.
Andso, that can include economic stability, education access andquality, healthcare access and quality, the neighborhood and theenvironment in which the person lives. And then the socialcommunity context, the family, the relationships, all of those cancombine to impact health.
Dr. Christopher Cross: Thank you for those responses. What does social determinantsof health for women mean at a global level, Dr.Ginsburg?
Dr. Ophira Ginsburg: Global is local. So, we see social determinants of health, andby the way, also commercial determinants of health, which would bewrong not to include in this discussion as greatly impacting theaspects of opportunities to seek and prevent cancer, et cetera,everything we just discussed; this happens also on a globallevel.
So,as we show in our commission report where a woman lives doesgreatly influence cancer incidents, mortality, survival, and also,very importantly, who that woman is in her community. Whether she'sliving in a circ*mstance situation or there are identity factorsthat render her structurally marginalized will impact also on herlived experience of cancer.
Andwe have nine stories that highlight and offer some human aspect towhat people are going through, whether they're care providers orwomen living with the experience of cancer on a personal level, thedifferent 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 cancerin so many ways. I mean, the easy way to think about it is womenwith a diagnosis of cancer, but we've also got women working toreduce their risk of cancer and detecting itearly.
We'vealso got women in the workforce, health professionals, researchers,we've got women as policymakers, and in the home environment, wehave women as caregivers. And they are much more frequently thedecision makers for everybody in the family with respect tohealthcare related issues.
So,women interact with cancer in so many different ways, and thosesocial determinants of health mean that women are more commonlysubject to discrimination. It can be discrimination due to theirgender, but also, their age, their race, their ethnicity, theirsocioeconomic status. And as Dr. Ginsburg has pointed outthat this can marginalize them.
And these factors canrestrict a woman's rights and her opportunities to reduce her riskof getting cancer. And it can be a barrier to early diagnosis toachieving quality cancer care. And we've gotthis whole (which is really predominantly portrayed in there)unpaid caregiver workforce that is almost all female around theworld. And this can hinder a woman's professional development aswell.
Dr. Christopher Cross: When you were talking, Dr. Gralow, it made me think of hearingabout the story of the former First Lady Rosalynn Carter. Herfather passed away when she was around 13 or 14 from cancer, andshe said she had to become the caregiver as like the oldestsibling.
Andtalking about that in wake of her passing, in her advocacy formental health and caregiving, I think is right along thisconversation that people may not be experts as you two are, butthey have lived experiences where they've had to step into theseroles. And so, thank you for bringing to light the globalcontext.
Likeyou were saying, Dr. Ginsburg, local is global, and I think this issomething that everybody can relate to.
Now,let's get into the work that you both are doing. Can you tell ouraudience about Women, power, and cancer: A Lancet Commission andyour role and any of the key findings you may want tohighlight?
Dr. Ophira Ginsburg: Yeah, I'm happy to take that one on. To start with, I was veryfortunate to have a conversation with the editor-in-chief of theLancet, Dr. Richard Horton, several years ago now, three years agoactually.
Andwe at that time, were making kind of note of where we were at somethree years after the publication of a three-part series calledHealth, Equity, and Women's Cancer that was published in the Lancetthat was specifically oriented around breast and cervical cancer,and the difficulties and challenges women have in obtainingequitable access to care.
Andto some extent, we commented on what we don't know about, forexample, the children that are left behind when a woman dies of oneof these cancers. And we emphasized the importance of more researchin that area.
Thisled to my pitching proposal for a commission, and this wasapproved, and we published an initial commentary (Richard andmyself) in July of 2020 that led to the commission that we now haveas a major report in the Lancet that was published on September27th, and excited to speak about that.
Imight just emphasize a couple of key data points in the report thatI think the listeners would be interested to know. Well, for thefirst time, we were able to show the number of women's lives thatcould 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 isthis important for women? Well, it's important for men as well, andI know people often ask, “Why did you focus on women?” We can getto that if people are interested.
Butto emphasize the importance of the preventability and lack thereof,we know what is contributing to a large proportion of cancer inwomen, but what many people don't know is what the numbers actuallyshow with respect to premature mortality and how that relates tomaternal orphans, that I just mentioned that hadn't been reallyaddressed before.
So,when you look at the number of men and women with cancer, it'sroughly equal. It's almost 50/50. Now, men are more likely to dieof cancer than women. About 44% of all cancer deaths occur inwomen, so it's not that much less.
Butwhen you look at the number of women experiencing cancer under theage of 50, in 2020 alone, of the 3 million adults diagnosed withcancer, two in three were women. That was a data point hiding inplain sight, we produced that. That was published in advance ofthis report in the Lancet Oncology with a few of us on thecommission.
Andthen in the commission report, we really dug into thepreventability of premature deaths, and we found that 1.5 million women could be spared, a death under theage of 70 due to cancer if everyone had access to primaryprevention and early detection strategies that we know work and weknow exist. And another 800,000 women's lives could be savedpremature deaths below the age of 70 if every woman everywherediagnosed with cancer had access to optimalcare.
In2020 alone, 1 million children lost their mothers due to cancer,just that year. And when we looked at the prevalence, so the numberof kids who were without their mothers who were still children in2020, it's seven and a half million.
Thiswas work done by our colleagues at IARC, Dr. Valerie McCormackgroup, and many of us were on that report as well. So, these arebig numbers and I think that's what's gotten people talking aboutthis.
Dr. Julie Gralow: Iwas fortunate to be invited by Dr. Ginsburg early in the formationof this commission to serve as an advisor on the commission. I didnot serve as a commissioner itself, but at a high level, tried tosee what I could do to support the gathering of information and thediscussions that led to the recommendations that came out ofit.
Andin my advisor role, I am working hard to promote this commission,to get the word out. It's really been interesting to see theengagement across the board with media, with policymakers, cancercenter directors, the NCI director who now, is our NIH director,actually wrote an editorial as part of this MonicaBertagnolli.
Ihave been thrilled to see the uptake of it. And part of my job asan advisor is to continue to get that message out and frankly tohelp us respond to the recommendations that came out of thisreport.
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, thiskind of work takes a village.
Wehave 21 commissioners, 10 mentees from across the world. More thanhalf of our commissioners are living in a lower middle-incomecountry. Most of those in high-income countries actually wereraised and trained in a low and middle-income country.
Wehave four men among us, but we have our advisory board, and also, aseven-person patient advocacy committee that I don't want to forgetto mention, who really held our feet to the fire and ensured thattheir voices were not just heard, but they helped to co-create thecontent, as did very much our advisors like Dr. Gralow.
Dr. Christopher Cross: I also want to add my thanks to your thanks Dr. Ginsburg, forall the work that both you and Dr. Gralow are doing at thecommission.
So, Iwant to set the stage here for the audience. In the first half, Ithink we talked about really laying the landscape globally aroundsocial determinants of health broadly. Then it sounds like wereally focused on the disproportionate burden of caregiving acrossglobally.
Now,Dr. Ginsburg, you've mentioned these four key areas around if weaddress them, it would have a marketed effect of impact. I justwanted to reiterate those. You've mentioned tobacco, alcohol,obesity, and infection.
Youtalk about sort of a mindset or an approach that I thinkunderscores these things that we've already mentioned. Could youtalk a little bit more about how important is feminism inaddressing and achieving equity at a global scale for womenaffected by cancer?
Dr. Ophira Ginsburg: Oh, I'm so glad you asked that. It was something that, to behonest, very early on as we came together as a commission on Zoom,because it was mostly during the worst part of the pandemic, wequestioned amongst ourselves whether we should use the wordfeminism. And it was actually to his credit that Dr. RichardHorton, the editor-in-chief said, “Absolutely, youshould.”
Andwe thought about it from our various countries where we were allliving. Some felt a little nervous about it, said, “Well, maybe wewon't be taken seriously, maybe we'll get backlash. It'll take awayfrom the key messages, et cetera.”
Andthen we decided as we decided everything by consensus, which by theway is a feminist approach — that the fact that we were debating itmeant 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 toreflect on what do we actually mean by feminism here?
Well,one way they define it, and I think it's Mary Wollstonecraft whosaid, “Feminism is not about women having power over men, it'sabout women having power over ourselves. This is where power comesin, the asymmetries of power that prevail.”
Inthe report as people will read, we looked at three domains of this:knowledge, understanding what our risks are, understanding our rolein society, and understanding anything about cancer, ourdecision-making as we show in the very elaborate section on healthsystems where women in many situations, in many countries, not justin the global south, don't really have decision-making power overtheir own health. And then the third being asymmetries of powerwith respect to economics.
Andin fact, it was an intersectional feminist approach that weultimately decided was most useful here. And we have a conceptualframework, sort of one of those diagrams people can look at andthink about, “How does that impact on my own interaction with thecancer health system, whether I'm living with cancer, looking aftersomebody 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 ofwhat you've just said. For the first couple of years of thecommission's workings, it was called the Commission on Women &Cancer. And as you were getting to the finish line and ready tolaunch it, you added that word “power.” So, it's the LancetCommission on Women, Power, and Cancer.
Howdid that come about and what's been the reaction to adding thatword power in?
Dr. Ophira Ginsburg: In fact, there was a commentary written in response to thethree-part series I mentioned earlier: Health, Equity and Women'sCancer by then President of Chile, Dr. Michelle Bachelet, who wenton to become the UN Human Rights Commissioner.
Andshe wrote a commentary in response to our three-part series calledWomen, Power, and the Cancer Divide. And it really spoke to me. Iremember keeping that in my head all this time, it's several years,that was 2017, actually.
Andwe ultimately realized that power was really at the center of thisimportant aspect of inequality and inequity. And if we couldrecognize where the power differentials are, it would help informthe solutions that we bring forward in our 10recommendations.
So,at the end of the day, we had that placeholder, women and cancerreport, and our editor, our handling editor, Dr. Vania Wisdom said,“Why don't we just call it Women, Power, and Cancer?” And we alllaughed. 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 affectwomen and even other groups.
So,you've mentioned disaggregating deaths of women and looking at ageas a spectrum, and then underscoring that less than 50 at that age,there's so many other disparities that are dominantly affectingthat age group. To me, that underscores the ROI, if you will, thevalue, the power in using a feminist approach to address cancerresearch for women.
Andnow, I got a question for you, Dr. Gralow; you humbly mentionedyour role as an advisor on this commission, but I want you to speakto the roles that women are taking, especially physicianresearchers in these organizations that are pivotal in addressingand achieving global health equity.
Dr. Julie Gralow: Thanks for bringing that up. We haven't really delved into therole of women in the workforce, and there have clearly beeninequities there across the world and in the UnitedStates.
But I think it's a very exciting time in the United States as we nowhave a female head of our National Institutes of Health, and wehave a female nominee to replace her as the Head of the NationalCancer Institute. The CEO of both the American Cancer Society andthe National Comprehensive Cancer Network are nowwomen.
We have female presidents of both ACR and ASCO right now. I'm in myrole 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 inthe workforce in the United States, much less the rest of theworld, but we do have female leaders and we are all committed tohold the door open to those who follow behind us.
Andwe've actually had some joking about, “Just blow up the doorentirely. Why do we have a door that's blocking the women who we'rehelping promote?” So, I think it's a very exciting time in ourworkforce in the U.S., and I see it in many other countriestoo.
Imean, look at some of the commissioners on this Lancet Commission,Dr. Ginsburg, the current president of AORTIC, the AfricanOrganization for Research and Training in Cancer, for example, andmany others.
Dr. Ophira Ginsburg: Absolutely. I love the way you put that. Yeah, leave the doorwide open. We do have tremendous leadership amongst ourcommissioners. And in fact, the fact that we have all these menteescoming up ranks, it's just great.
AORTIC,the African Organization for Research and Training in Cancer isparticularly notable, representing the continent of Africa forhaving a lot of strong women leaders, including as Dr. Gralow justsaid, Dr. Miriam Mutebi. She's a breast surgeon based in Nairobi,Kenya, who just came on as the new president of AORTIC.
Andwe actually held a launch event there. We had the global launch ofthis commission report September 27th in Geneva, Switzerland at theGraduate Institute. And we had a lot of activity around that launchand media activity.
Andjust a week and a half or so ago, we had our African regionallaunch held at the biannual meeting of AORTIC, and that was justphenomenal. I mean, Dr. Gralow was there, I don’t know if you wantto say anything, but the panelists were just — I was so pulled overby the depth and the breadths and the scope of the conversation,and the way it was so personal for so many of our commissioners whoare from the region.
Dr. Julie Gralow: Yeah, I was at the African launch sitting next to our ASCOpresident, Dr. Lynn Schuchter, it was her first AORTIC meeting. Andshe was so impressed with the launch and the talks that went alongwith it, and the content of this commission that she immediatelysaid, “Okay, we need to feature this prominently at our ASCO annualmeeting next June in Chicago.”
So,we are working with Dr. Ginsburg and the commission on what we cando to bring this to North America now in a prominentway.
Dr. Ophira Ginsburg: Yeah, we're very excited about this prospect. I just want toadd, we do intend to have regional launches elsewhere and we'reworking with our colleagues in SLACOM, another one of our valuedpartners — Society of Medical Oncology from Latin America & theCaribbean led by Dr. Eduardo Cazap was also an advisor to see howbest to put together a launch event in that region as well,sometime in the spring.
Imight just add, it's not just meant to have another disseminationevent and we can have a webinar and have a discussion, which isimportant, but we can also tailor the data to reflect the uniqueepidemiology and health systems issues and other aspects that arerelevant to achieving the outcomes we want to see in a givenregion.
So,for example, in Senegal, Dr. Isabelle Soerjomataram, one of theco-chairs, the other being Dr. Verna Vanderpuye, also one of theleaders of AORTIC. Dr. Soerjomataram is at IARC, WHO's canceragency, and she put together specific data points breaking downwhat was relevant for the African continent and presented thatalongside this panel discussion we were just talkingabout.
Dr. Christopher Cross: For me, a natural question just follows up … listening to youboth talk about all of these advancements and these powerhousesthat are moving the needle. What is the hope for in the next maybe5 to 10 years that we will hope to see, given this change inleadership and this new direction we're going in?
Dr. Ophira Ginsburg: I'll say that with what we just heard from Dr. Gralowregarding the leadership currently between the NIH, I mean we'rejust thrilled that Dr. Monica Bertagnolli wrote a commentary forour commission report and then becomes the NIH director and theincoming NCI director also being female, etcetera.
Butin fact, when we looked at other aspects of research outputs, thisis one thing I'd like to bring up because I mean the peoplelistening would be ASCO members primarily, people who arescientists and working in the research ecosystem in cancerepidemiology 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 youthink had an editor-in-chief that was female? Putting you on thespot, any guesses? Dr. ChristopherCross: I would say less than20%.
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 reportwas looking at the membership of UICC, the Union for InternationalCancer Control, also valued partner.
UICCmembership organizations that were listed as research institutes,cancer centers, et cetera, had also that same number. Only 16% wereled by women. So, we do really have a long way to go, but therehave been a lot of improvements over time.
Butif we maintain the status quo, it's going to be like a hundredyears to get to parity. So, I encourage people to look at thereport. We have specific recommendations, and we also invite peopleinterested in collaborating with us to action thoserecommendations.
Lookinginto emerging cancer risks, we need scientists who are interestedin that area. We only understand about a third of the risk ofbreast cancer right now, and that third includes mostly factorsthat are not really amenable to primary prevention. So, what's upwith that?
Dr. Christopher Cross: Absolutely. Dr. Gralow, I'm curious, what do you think thehope is given our new leadership landscape to address health equityand cancer care for women?
Dr. Julie Gralow: In the next five years, as you started the question, I wouldhope to see that we've now created awareness, and so we begindismantling some of the structural things that have been put inplace, that have created the barriers.
Hearingthe numbers of all cancer deaths globally, only 44% are women. Youwould really potentially come at this, thinking, “Oh, it's not sucha problem.” But then diving into the data and the report of cancerdeaths under the age of 50, a significant proportion of them arewomen, many leaving behind children.
A lotof that is cervical cancer, which with the HPV vaccine, we couldprevent, or with early detection of pre-cancer, we can eliminatecervical cancer, that's our goal. We're working with WHO and breastcancer, early detection. So, those are the two main cancers thatare impacting women in this young age group.
So, Ithink recognition of that, acknowledgement of that, looking at theprevention piece, those four main risk factors: tobacco, alcohol,obesity, and infection — working on breast and cervical cancer inpartnership with the WHO's initiatives there, I think we can make adent.
Withrespect 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 ASCOboard, our ASCO presidents. We work very hard to achieve balanceacross gender and race and ethnicity, et cetera.
So,those are some of the things I hope we can make a dent in, in thenext five years. We have a long way to go, but we can't wait ahundred years as Ophira says, to make these strides.
Dr. Ophira Ginsburg: If you think about what are the so-called lower hanging fruitin this that could be really actioned within the immediate andmedium term. So, five years, absolutely. By five years, we shouldhave — for example, we have a specific recommendation on a gendercompetency framework for the education and training of the cancerhealthcare workforce.
Oneof our key findings was that sexual harassment, bullying, etcetera, is a huge problem, just like it is in every other domain,unfortunately. And it's long overdue that the oncology communityhas its MeToo moment and recognition of this that impedes women'sprogress as healthcare workers, as researchers, as leaders, in asmuch as it also hinders a woman's opportunity to seek respectfulcare and feel that they will be dealt with in a respectfulmanner.
Ididn't mention this until now, but when we say women in thisreport, we're talking about women in all their diversities in termsof race, age, ethnicity, et cetera. And also, women who wouldidentify as belonging to a diverse sexual orientation, genderidentity, and expression.
Andwe do have quite a bit of content in the report on the work of theCancer and LGBTQ Network, for example, and some of theirrecommendations. They were one of our partners. We have a storyfeatured on that topic more broadly.
Butthis gender competency framework is something we can all startlooking to now, that was led by one of our commissioners, Dr. NazikHammad, who's a medical oncologist from Sudan living in Canada, whohas 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 anumber of work with this. We've had our own Sexual GenderMinorities Task Force, which has now gone on to be the SexualGender Minority Advisory Group, which will report under our newEquity Diversity Inclusion Committee. So, we're also very excitedto make sure we continue to be partners with you and the workyou're doing.
So,we're kind of wrapping up, but I wanted to make sure I left timefor any final thoughts you would like to share to thelisteners.
Dr. Julie Gralow: Well, I'd like to actually thank our listeners because thatmeans you are at least trying to learn. I'd encourage anyone who'smade it through this podcast, and this resonates with them, andthey want to learn more to look at the report. There are multiplepieces to it, multiple sub articles. You can just read the summaryif that's all you have time for, but read it, mull it over. I thinkwe'd all like feedback on it.
Andthen let's partner together to try to meet some of the goals andthe recommendations in the short-term. And then build a strongcommunity where we don't have to be writing commissions related towomen in cancer any longer in the coming years.
That'swhat 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 thereport, even though I was part of many of the meetings. So, everytime I take a look at it, I find another pearl or something elsethat I can put into a talk.
So, congratulations, Dr. Ginsburg, on leading this really importantpiece of work, and let's work together to try to overcome some ofthese really crucial inequities that we've found and make cancerbetter for everyone. Dr. ChristopherCross: Thank you, Dr. Gralow. Doyou have any final thoughts, Dr. Ginsburg?
Dr. Ophira Ginsburg: Well, thanks so much for the opportunity and also to thelisteners, I greatly appreciate the way you put that, Dr.Gralow.
And Iwould say that please don't be daunted. We present a lot of newfindings that can be a bit depressing quite honestly, but that'snot our aim.
Wehave a lot of the content oriented around resilience and what'sworking. For example, two country examples where they actually arepaying people looking after their loved ones with cancer at home.The unpaid caregivers are actually paid or covered in some way insome countries. So, there's a lot of good stuff in there aswell.
Thebottom 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 riskof or living with cancer or working with cancer patients. If wetake these recommendations forward, it will benefit people of allgenders.
So, Iwould suggest, take a look within yourself, think about how youmight be part of the problem, you might be part of the solution,and you might work within your organization or even wherever youmight volunteer or serve some other aspect of the cancer ecosystemto take these actions forward and look carefully at therecommendations and join us.
Thisis just the beginning; I'll end with that. We are just at thebeginning of this program of work on women, power, and chancellor,and we welcome all input. Thanks so much for the opportunity tospeak with you today.
Dr. Christopher Cross: Well, I just have to thank you both. This has been a fantasticdiscussion, and just thank you again, Dr. Gralow and Dr. Ginsburgfor joining us on this episode of the ASCO’s Social Determinants ofHealth in Cancer Care Podcast. And thank you to our listeners forbeing a part of the conversation.
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