Equity in Care Addresses Gender Bias and Identity

The overarching theme of the 2022 American Society of Clinical Oncology (ASCO) Annual Meeting was the challenge of delivering equitable cancer care with the aim of uncovering fresh solutions that can fundamentally improve the lives of patients and caregivers affected by the disease. Novel ideas to knock down barriers in order to make access to care more equitable, convenient, and efficient for patients worldwide were shared and discussed among attendees with the hope that these efforts would lead to new directions in training and awareness.

Although exciting presentations on clinical developments were met with great enthusiasm, an aspect of equity that was addressed had to do with gender bias and identity. The “Aspirations of Equity in Oncology” symposium addressed the need for training among oncologists on LGBT (lesbian, gay, bisexual, and transgender) cultural sensitivity and awareness, the need for a systematic, multipronged approach to improve gender equity, and the need to achieve gender equity of scientific presentations at ASCO.

Matthew Schabath, PhD, a tenured associate member of the departments of cancer epidemiology and thoracic oncology at Moffitt Cancer Center in Tampa, Florida, shared results from a trial evaluating a curriculum aimed toward oncologists to improve knowledge, attitudes, and affirming practices for LGBT patients with cancer, a medically underserved population that is often marginalized in a predominantly hetero- and cisgender-normative society.¹

The cultural competency training program, called Curriculum for Oncologists on LGBT Populations to Optimize Relevance and Skills (COLORS) training, consisted of four 30-minute online modules that allowed participants to complete the curriculum at their own pace. It addressed LGBT basics, inclusive environments, initiating oncology care with LGBT patients, and issues in cancer care and survivorship.

Each of the modules followed an interactive “choose your own adventure” format with featured vignettes, eg, discussing fertility options with a transgender man. At various decision points in the vignette, which depicts the interaction of an oncologist with an LGBT patient, the oncologist follows a specific pathway.

“There’s no right pathway and no wrong pathway,” Schabath said during the presentation. “The oncologist is allowed to go back to this interaction and see what would have happened if the other pathway was chosen,” Schabath continued.

The investigators conducted a randomized pragmatic trial comparing COLORS to a webbased LGBT general health care training offered by The Fenway Institute, a national training organization that provides teaching and training assistance for health care organizations in order to optimize access to quality health care for LGBTQIA+ (lesbian, gay, bisexual, trans, queer, intersex, and asexual) populations in the US. Oncologists underwent pre- and post-training assessments, immediate post-training follow-up, and follow-up 3 months post training. Oncologists were randomized to COLORS or Fenway.

High-level demographic findings suggest no statistically significant demographic differences between oncologists who completed only pre-assessment vs those who completed both pre-and post-assessment,” Schabath said, “and further, there was no difference between patients who were randomized to COLORS vs Fenway.”

Oncologists’ beliefs and behaviors were assessed using the Gay Affirmative Practice (GAP) scale. Schabath noted that GAP score increased significantly between pre- and posttraining and from pre- to 3-month follow-up, indicating an increase in LGBTaffirming practice behaviors.

When the oncologists were assessed for their knowledge score, Schabath said baseline knowledge was elevated and both the COLORS and Fenway training sessions yielded significant improvements in knowledge that was maintained at the 3-month follow-up.

Schabath concluded that COLORS demonstrated effectiveness in improving knowledge, attitudes, and affirming practices for LGBT patients with cancer. Its benefit over Fenway is that it is specifically oncology focused, is interactive and contemporary, and has no technology barriers. The next steps are to develop a pilot program and develop modules for other health care providers, according to Schabath.

Further Training Is Needed

To further the discussion about the need for training, Ash B. Alpert, MD, MFA, a fellow in hematology and medical oncology at the Wilmot Cancer Institute of the University of Rochester Medical Center in New York, addressed how the topic of stigma in the oncology setting may be damaging to sexualand gender-minority people.

Alpert noted the potential for sexual- and gender-minority people to experience stigma from their oncologist and the stigma of experiencing a cancer diagnosis as a traumatic event. If a person experiences the denial of self or that one’s selfhood or identity is not recognized, it could be experienced as a traumatic experience.

“Those types of traumas can be multiplicative and can cause increased harm for patients,” Alpert said.

Another type of stigma can be related to cancers associated with anatomy that can be confl ated with gender, eg, prostate cancer, ovarian cancer, testicular cancer, and breast cancer, said Alpert. “Often the way we talk about these types of cancers is very gender [oriented],” Alpert said. Transgender people who are affected with these types of cancers may experience misgendering, or the use of the wrong name, pronoun, or gender marker, by clinicians, Alpert added.

“We know that hormone therapy and surgeries are lifesaving interventions for transgender people who want them and also that the data about how hormone therapy improves or worsens outcomes in the setting of cancer are sparse and almost nonexistent,” Alpert said. “In that context, transgender people and their oncologist face great uncertainty in terms of continuing or discontinuing hormone therapy in the setting of hormone-sensitive cancers.”

COLORS training is the fi rst randomized pragmatic trial of a cultural humility training in oncology that was developed in partnership with LGBT people with cancer. Alpert noted its benefi ts and its performance compared with Fenway training.

Alpert asked if the COLORS trial represented a paradigm shift for oncology. Would the National Cancer Institute (NCI) require COLORS training for all NCI-designated cancer centers? Would there be an assessment for COLORS training requirements by the Healthcare Equality Index?

To address the limitations of training in the context of COLORS training, Alpert noted that the tool focuses only on gay and lesbian people and may not adequately assess negative attitudes about transgender people, nonbinary people, bisexual people, and queer people. Further, should the training address how clinicians are treating other sexual and gender minority people and whether these practices translate to oncology? “There may be a difference between how we talk about our attitudes in a survey and how we interact with our patients and our patients’ experiences in clinic,” Alpert said.

Alpert called for the development of community-informed and validated measures of experiences and outcomes of sexual- and gender-minority patients and the development of alternatives to training, including holding oncologists and administrators in larger health systems accountable. Ultimately, COLORS may provide a paradigm shift, but future work needs to develop measures, assess trainings based on more proximal measures, and change systems.

ASCO Meetings Examined

Turning to speakership gender disparity at the current ASCO meeting, Jessica Caro, MD, chief fellow in hematology/oncology at NYU Langone Health in New York, New York, noted that the ASCO planning committees achieved more equal gender balance among the invited speakers as well as the educational roles of presentation chairs, discussants, and speakers. However, she said that while progress has been made, there is still a need for a systematic, multipronged approach to improve gender equity in opportunities to present original research.²

The representation of women in medicine has increased signifi cantly over the past several decades with an increase in women in medical school, as medical school graduates, and as hematology/oncology fellows.³ However, Caro noted a signifi cant gap in scholarly productivity among women, with 21.9% of women academic oncologists reporting that they were likely to pursue a career outside academia in the next 5 years.⁴

This gender gap is also apparent when evaluating invited speakership at medical conferences, Caro said. “Medical conferences provide unique opportunities for networking, mentorship, increased international visibility, potential funding, and collaboration,” Caro said. “Unfortunately, women physicians are currently under-represented as invited speakers at medical conferences.”

Arora et al⁵ examined over 23,000 speakers in multiple specialties at 98 conferences. The investigators found that only 30% of invited speakers were women, and more than onethird of the panels consisted only of men.

Caro et al examined presentation patterns from recently featured ASCO meeting speakers from 2018 to 2021 and characterized them by presentation type and gender.2 Presentations were reviewed from poster discussions, oral abstracts, plenary sessions, case-based panels, clinical science symposiums, and education. Caro and collaborators collected participant data on gender, academic degree, academic rank (if applicable), and institutional geographic region.

Results demonstrated that for original research submissions, 62.7% of first authors were male and 37.3% were female. Among senior authors, 72.0% were male and 28.0% were female. For ASCO-appointed chairs, discussants, or speakers, 53.1% were male and 46.9% were female.

When stratified by conference year, the percentage of women first authors ranged from 32.7% to 40.7%. The percentage of women senior authors ranged from 25.3% to 30.6% (FIGURE 1² ). “This was statistically significant when compared to the gender balance of ASCO-appointed presenters in the poster discussion, oral abstract, clinical science, symposium, and plenary sessions,” Caro said.

The investigators also stratified the results by session type with women as the first author in the clinical science symposium and poster discussion at 39% each, followed by the oral abstract (35%), and plenary (22%) (FIGURE 2⁶ ).

“This is notable because the plenary sessions are the most prestigious type of original research session featuring the most prominent cutting edge-research, which can elevate careers and lead to leadership appointments,” Caro said. Turning to ASCO-appointed roles, 46% of women were in the plenary session and clinical science symposium each, 47% were in the oral abstract, and 50% were in the poster discussion.

Caro noted the limitations of the research, including that it was a retrospective study, the investigators were unable to use presenteridentified gender, and it was limited to binary gender designations (ie, male vs female).

Caro concluded that gender disparities persist and that fewer women than men presented original research in a first or senior author role. Findings were significant when accounting for conference year, session type, academic rank, and geographic region.

Academic Oncology

Turning to gender disparities in panel discussions, Sophia Kamran, MD, assistant professor of radiation oncology, Harvard Medical School, and a radiation oncologist at Massachusetts General Hospital Cancer Center, both in Boston, Massachusetts, investigated the prevalence of all-male panels, or “manels,” and evaluated trends of invited panelists at the ASCO annual meetings from 2018 to 2021.⁶

Kamran and colleagues noted a decrease in the proportion of manels at ASCO Annual Meetings in 2021. However, evaluated by topic/session, women were underrepresented in topics of genitourinary cancers (38.6%; n = 54) and translational/preclinical topics (36.7%; n = 117), and overrepresented in supportive oncology (70.3%; n= 83).

Data were collected from ASCO online programs to obtain 2018-2021 session faculty information. Data collected included perceived or self-reported gender, medical specialty, panel role (chair/moderator vs non-chair/-moderator), type of session, and topic. The primary outcomes included percentage of manels/proportion of female panelists over time and statistical analysis included Cochran-Armitage and Fisher’s exact test.

The investigators wrote in their poster that although “the number of invited women panelists increased during the study period with a subsequent decrease in proportion of manels, there are topics/specialties where female representation remains stagnant.”

_REFERENCES:

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_{2. Caro J, Boatwright C, Li X, et al. Examination of speakership gender disparity at an international oncology conference. Presented at: 2022 American Society of Clinical Oncology Annual Meeting. J Clin Oncol.2022;40(- suppl 16):11002. doi:10.1200/JCO.2022.40.16_suppl.11002}

_{3. Riaz IB, Siddiqi R, Zahid U, et al. Gender differences in faculty rank and leadership positions among hematologists and oncologists in the United States. JCO Oncol Pract. 2020;16(6):e507-e516. doi:10.1200/OP.19.00255}

_{4. Merfeld EC, Blitzer GC, Kuczmarska-Haas A, et al. Women oncologists’ perceptions and factors associated with decisions to pursue academic vs nonacademic careers in oncology. JAMA Netw Open. 2021;4(12):e2141344. doi:10.1001/jamanetworkopen.2021.41344}

_{5. Arora A, Kaur Y, Dossa F, Nisenbaum R, Little D, Baxter NN. Proportion of female speakers at academic medical conferences across multiple specialties and regions. JAMA Netw Open. 2020;3(9):e2018127. doi:10.1001/jamanetworkopen.2020.18127}

_{6. Kamran SC, Yeap BY, Ghosh A, Aldrighetti CM, Willers H, Vapiwala N. Recent trends of “manels” and gender representation among panelists at the ASCO annual meeting. Presented at: 2022 American Society of Clinical Oncology Annual Meeting. J Clin Oncol. 2022;40(suppl 16):11053. doi:10.1200/JCO.2022.40.16_suppl.11053}