Author:

Elisa Manacorda

Introduction

Every year, nearly twenty million women worldwide are diagnosed with cancer. Almost two and a half million die prematurely—yet in two-thirds of cases, these deaths could have been prevented through early detection and timely prevention strategies.

Over the past few decades, oncology has made remarkable strides, yet gender bias remains a largely overlooked factor shaping the experiences of women with cancer. We know that gender disparities in healthcare exist, but when it comes to cancer care, the evidence on systematic bias against women is surprisingly scarce. This lack of focused research leaves important questions unanswered—questions about how bias may be influencing women’s access to care, the treatments they receive, and ultimately, their chances of survival.

Gender bias in oncology can take many forms. In some cases, women may be offered less aggressive treatment than men for the same type of cancer. In others, they may experience worse outcomes, even when they receive similar treatments. A further challenge lies in research itself: women are often underrepresented in clinical studies, meaning there is less sex-specific evidence available to guide treatment decisions. Together, these factors create a gap between the care that is possible and the care that women actually receive.

The Lancet Commission on Women, Power, and Cancer (Ginsburg, 2023) has recently drawn attention to the urgent need to address gender inequalities in cancer care, framing them within broader structures of social inequity and power imbalance.

In this article, we take a historical view of Europe’s oncology landscape, tracing the obstacles women with cancer have faced—and continue to face—in securing equal access to care and the most effective treatments available.

Clinical Perspective

Although the word cancer (from the Greek karkinos, meaning “crab”) was already used by Hippocrates and Galen, tumors were described within the broader context of surgery or general medicine, and certainly not as an autonomous discipline (Hajdu, 2010). It was in the 19th century, with the introduction of microscopy and advances in pathological anatomy, that the cellular nature of cancer began to be understood. In Europe, the first hospitals and wards dedicated exclusively to cancer treatment emerged, such as the Institut Gustave Roussy in France and the Royal Marsden Hospital in England, established between the late 19th and early 20th centuries. Around the same time, the term oncology came into use to define the branch of medicine devoted to tumors.

Nevertheless, during the 19th century, medical understanding of cancer was still in its infancy. For example, there was no clear distinction between tumor types, and benign and malignant tumors were often poorly differentiated (ACS, 2014). Additionally, cancer was commonly perceived as a systemic or constitutional disease, meaning it was believed to affect the entire body rather than being localized. This perspective suggested that cancer stemmed from an internal imbalance within the body's systems (Moscucci, 2005), potentially triggered by trauma, physical injuries, or dietary habits that disrupted the body's humoral balance.

Women were considered particularly vulnerable due to their so-called "cold and moist" bodies, which were believed to accumulate harmful humors more easily. Because of these beliefs, along with limited early detection methods, female cancers—such as cervical and uterine cancer—were often diagnosed at advanced stages (Löwi, 2011).

Compared to male patients, women with cancer faced additional challenges. Beyond the lack of effective diagnostic and therapeutic tools, they also encountered social stigma, particularly regarding breast and gynecological cancers, which were associated with intimate areas of the female body, such as the reproductive system. Even today, several studies show that this stigma causes many women to delay seeking medical treatment, driven by a fear of social shame (Pakseresht, 2021).

On the other hand, in the field of treatments and surgery the 19th century was a period of significant innovation. Radical mastectomy was introduced by William Halsted in the 1890s, marking the beginning of aggressive surgical approaches to breast cancer (Plesca, 2016). However, before the advent of anesthesia in 1846, such surgical procedures—including hysterectomies—were performed without pain relief, making them traumatic and highly risky. Surgeons were forced to operate quickly due to the patient's conscious suffering, which significantly limited the complexity and duration of procedures (Andrew, 2022). Hysterectomy became a more common treatment for uterine cancer, but despite its increased use, it remained a high-risk procedure with significant mortality rates (Munro, 2006).

The postwar period in Europe saw major medical advances, changing social attitudes, and increased cancer awareness among women. However, access to health care varied greatly between Eastern and Western Europe due to political and economic differences. A significant advance in the detection and treatment of breast and gynecological cancers, for example, was the use of mammography during the late 1950s and early 1960s, enabling the identification of non-palpable tumors and facilitating earlier intervention.

In the field of surgical approaches, after the radical mastectomy developed in the late 19th century, conservative surgery came to the fore. In the 1960s, surgeons such as Italy's Umberto Veronesi introduced quadrantectomy, breast-conserving surgery involving the removal of only the tumor and a margin of surrounding tissue. Clinical trials showed that this method, combined with radiation therapy, was as effective as radical mastectomy in terms of survival and recurrence rates (Corso, 2017). At the same time, European clinical trials were exploring the efficacy of lumpectomy (removal of tumor with minimal surrounding tissue) combined with radiation therapy as an alternative to mastectomy. These studies contributed to a paradigm shift toward breast-conserving treatments (Ben-Dror, 2022).

As for prevention, this is the era when the Pap test is made available in Europe. Introduced by Dr. George Papanicolaou in the 1940s, this screening method significantly reduced cervical cancer mortality by allowing detection of precancerous and cancerous lesions at an early stage (Safaeian, 2007). A little later, organized cervical cancer screening programs were implemented in several Western European countries, leading to a sharp decline in incidence and mortality rates. In the early 1980s, however, it was German virologists Harald zur Hausen and Lutz Gissmann who established a causal relationship between HPV infection and cervical cancer by identifying specific types of human papillomavirus (HPV), particularly HPV16 and HPV18, in cervical cancer tissue and leading to the development of preventive HPV vaccines. Zur Hausen was awarded the Nobel Prize in Physiology or Medicine in 2008 (Lowy, 2024).

Bias in clinical practice

Today, cancer is among the top three causes of premature death for women in nearly every country around the globe. Each year, 2.3 million women die from the disease before the age of 70. Strikingly, around 1.5 million of these deaths could be prevented through measures such as primary prevention and early detection. An additional 800,000 lives could be saved if all women, regardless of where they live, had access to the best available cancer care. The burden is particularly heavy in countries with a low ranking on the Human Development Index (HDI), where as many as 72% of cancer deaths among women occur prematurely—compared with 36% in countries at the highest HDI level (Ginsburg, 2023).

Data from the European Cancer Information System (ECIS, 2022) show that the most common cancers among women are breast, colorectal, and lung cancer—followed by endometrial, melanoma, pancreatic, and thyroid cancers. Among these, breast, lung, and colorectal cancers remain the leading causes of cancer-related death for women (L’Hôte, 2024).

Whether the disease is female-specific or not, women often face greater hurdles than men in navigating illness. Although the evidence is limited, and many studies lack the methodological rigor needed to definitively distinguish bias from other explanatory factors, some research has highlighted discrimination against women in treatment, with consequences for both outcomes and survival.

The study Gender disparities in metastatic Renal Cell Carcinoma therapies and outcomes found clear evidence of bias against women. In an analysis of 77,124 patients, researchers observed that women had a shorter median overall survival compared to men (7.2 months vs. 8.94 months). Even after adjusting for other variables, women were less likely to receive immunotherapy. Crucially, female gender remained associated with worse survival rates even when immunotherapy use was taken into account (Gordon, 2023).

Similarly, research on advanced gastroesophageal cancer revealed gender differences in treatment allocation. Women received systemic treatment less frequently than men in cases of esophageal adenocarcinoma (42.7% vs. 47.4%) and gastric adenocarcinoma (33.8% vs. 38.8%). In gastric adenocarcinoma specifically, multivariable analyses showed that women had a lower likelihood of receiving systemic treatment (Dijksterhuis 2021).

A problem of underrepresentation

Although many cancers disproportionately affect women, females remain consistently underrepresented in medical research. Across cooperative group cancer trials, enrollment rates for women—as well as for ethnic minorities and older adults—lag behind those for white individuals, men, and younger patients. This imbalance is more than a statistical concern: because drug dosage plays a key role in sex-based differences in adverse reactions, underrepresentation leaves crucial safety data for women incomplete.

Over the past three decades, women’s participation in clinical research has improved, yet major gaps remain—particularly in phase I trials, which are designed to assess a drug’s safety and tolerability. In industry-sponsored early-phase trials, fewer than 30% of participants are women (Waltz, 2023). Interviews with U.S. phase I investigators and institutional review board members reveal that, while many acknowledge the value of including women, exclusion is often justified on the grounds of reproductive risk. Four themes emerge repeatedly: the structural nature of the drug-development system, fears of harm to potential fetuses, distrust in women’s ability to avoid pregnancy, and concerns about institutional liability. These attitudes have deep roots. In 1977, following the thalidomide tragedy, the U.S. Food and Drug Administration imposed a blanket ban on including women of childbearing age in early-phase clinical trials (Vargesson, 2015). Intended as a protective measure, the policy had the unintended effect of institutionalizing exclusion. Although the ban was lifted in 1993, its legacy remains deeply embedded in research culture.

The later phases of cancer drug development show little improvement. A systematic review of 426 Phase III lung cancer trials conducted between 1984 and 2019 found that women accounted for just 30.98% of participants (Aslam, 2023). This matters: studies demonstrate clear sex-based differences in cancer treatment, with women often mounting stronger immune responses but also experiencing more severe side effects. Such variations should guide decisions on dosing, toxicity management, and quality-of-life considerations, yet they remain poorly reflected in trial design and analysis (L’Hôte, 2024).

This persistent underrepresentation has not only limited the safety data available for women but has also influenced the very design and testing of new cancer therapies. When women are inadequately included in clinical trials, treatments may be developed, dosed, and approved without a full understanding of their effects across sexes. The consequences are evident in clinical practice: delayed diagnosis—often associated with poorer outcomes—remains common among women. Factors contributing to this delay include limited awareness of early symptoms and, crucially, restricted access to genetic testing, which plays a key role in prevention strategies and in tailoring targeted treatments (Green, 2023).

The economic burden

Women battling cancer often face not only the physical and emotional toll of their illness but also significant financial hardships. The Lancet Commission on Women, Power, and Cancer (Ginsburg, 2023) highlights that “women are more likely than men to experience financial catastrophe due to cancer, with devastating consequences for their families—even in countries where quality cancer care is available.” Once again, this financial strain is particularly severe for elderly women.

According to the OECD (2021), women's wages and pensions remain 25–40% lower than those of men. However, this disparity is even greater for elderly women, as Dr. Godelieve De Lempdes, a geriatrics specialist with expertise in onco-geriatrics and global support for elderly cancer patients, points out. More than younger generations, elderly women may have had interrupted careers due to childbearing, lacked access to higher education, or worked in an era when the gender pay gap was far more pronounced.

The combination of these socioeconomic factors contributes to delayed diagnoses of cancers that predominantly affect women—such as ovarian, cervical, and breast cancer—which are often linked to poorer outcomes. A lack of awareness regarding symptoms can prevent women from seeking medical advice in time, while access to routine genetic testing remains limited and difficult to obtain. A study by the World Ovarian Cancer Coalition (WOCC, 2019) found that over two-thirds of women had little to no prior knowledge of ovarian cancer before their diagnosis. Furthermore, among women with two or more relatives diagnosed with ovarian cancer, 80% had not undergone genetic testing before learning they had the disease.

Finally, women affected by cancer often face discrimination and stigma in the workplace, creating a "double penalty" effect. This discrimination can significantly impact career stability, professional responsibilities, and advancement opportunities, as well as raise concerns about job security (Stergiou-Kita, 2017).

Young women with cancer—often at the early stages of their careers and more vulnerable to job instability, lower wages, and age-related discrimination—may be particularly affected. Many women, especially those living with metastatic cancer, face pressure to take early retirement or prolonged sick leave, even when they wish to and can continue their professional lives and contributing to society (Rosenberg, 2019).

Another important factor is that, as noted in the Policy Action Paper by the European Cancer Organisation (L’Hôte, 2024), women with cancer often carry a heavier load of household responsibilities, including caring for children and elderly relatives. These demands not only add to stress and take a toll on mental health, but can also limit women’s ability to participate in national cancer screening programs, such as breast and cervical screening. The result is that many women miss out on essential information about cancer risk factors.

The bias within the bias: older women

Nearly half of all cancer cases in women occur in those aged 65 and older—about 4.3 million diagnoses in 2020—despite this group representing less than 12% of the world’s female population. This strong link between cancer and ageing means that, as life expectancy rises globally, the number of cases among older women is projected to increase sharply, by around 73% by 2040.

Yet older women with cancer often face significant barriers to receiving age-appropriate care. Economic insecurity, a higher likelihood of living alone, greater disability rates, and limited access to resources all contribute to their vulnerability. Survival rates are generally lower than in younger women, particularly in those over 80, a disparity partly driven by undertreatment. This undertreatment is linked to the chronic under-representation of older adults in cancer clinical trials, which limits knowledge about how ageing affects treatment tolerance and outcomes.

Ageism—prejudice or discrimination based on age—plays a major role, often compounding existing sexism. Older women may face delayed diagnosis, restricted treatment options, and poorer communication with healthcare providers. These disadvantages are reinforced by lifelong gender inequalities, such as the gender pay gap and lower pensions, which reduce financial security in older age.

While organisations like the American Society of Clinical Oncology (ASCO) and the International Society of Geriatric Oncology (SIOG) have issued recommendations to better integrate geriatric principles into cancer care, sex and gender differences are still often overlooked. Ignoring these dimensions risks missing crucial opportunities to improve outcomes for older women living with cancer.

Elderly women are particularly at risk in this regard. Dr. De Lempdes explains that women over 70 face specific barriers in accessing care and navigating healthcare pathways.

“The discontinuation of screening programs beyond the age of 69—without any encouragement for individualized screening based on a woman’s life expectancy, which depends not just on chronological age but on physiological age, considering frailty and comorbidities—leads to delayed diagnoses and, consequently, more advanced stages of cancer at the time of detection. Other factors also contribute to this delay, including family biases and even prejudices among some healthcare professionals regarding elderly women’s ability to undergo oncological treatments. Additionally, logistical challenges can further limit access to diagnostic and treatment centers,” says Dr. De Lempdes.

Elderly women bear the highest burden in underrepresentation as well. "They are still too often excluded from clinical trials," says Dr. De Lempdes, which limits the data available to develop tailored and evidence-based treatments and management strategies. In the absence of standardized treatment protocols for this population, existing protocols designed for younger patients must be adapted to account for the diversity in aging and health conditions among elderly women, ensuring each patient receives appropriate care.

The field of geriatric oncology, which merges expertise from both oncology and geriatrics, aims to provide individualized and comprehensive care. On one hand, it contributes to the development of recommendations and guidelines for treating elderly women, particularly those issued by scientific societies such as the SIOG, which has published treatment recommendations for breast cancer in elderly patients (Biganzoli, 2012). On the other hand, geriatric oncology seeks to promote the inclusion of elderly women in clinical research and has developed protocols specifically designed for this demographic.

Ensuring equal cancer treatment for all women

According to the Lancet Commission (Ginsburg, 2023), to foster a more inclusive, gender-sensitive, and transformative approach to oncology, several priority actions are needed. First, cancer health statistics should routinely collect, publish, and update data on sex, gender, and other sociodemographic factors. Stronger laws and policies must be implemented to reduce women’s exposure to known and emerging cancer risks, including occupational and environmental hazards. Strategies grounded in gender and intersectional perspectives should be developed to improve equitable access to early detection and diagnosis, while health systems must be co-designed to ensure respectful, high-quality care for women and girls.

To address these topics, in February 2021 Stella Kyriakides, European Commissioner for Health and Food Safety, introduced the EU’s Cancer Plan. This initiative outlines a new EU-wide strategy for cancer prevention, treatment, and care. A total of €4 billion has been allocated to reducing inequalities, improving cancer screening and HPV vaccination rates, and updating the 2003 Council Recommendation on cancer screening. The plan aims to ensure that by 2025, 90% of the EU population eligible for breast, cervical, and colorectal cancer screenings will have access to these services.

Additionally, the plan includes enhanced support for cancer survivors and seeks to address existing inequalities not only based on gender but also in relation to ethnicity, income level, education, and geographic disparities between urban and rural areas.

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