There is unconscious bias against women in the healthcare system, find Rhonda Peebles, Eunice Kim, Melissa Liew, Aurelia Caparros, Jin Gu, Marianthi Psaha
Novartis has run a series of programmes over six years designed to improve gender opportunities and balance in senior positions. As part of its participation in the 2016-17 Executive Female Leaders’ Program (EFLP), one group took on the business challenge of getting to the bottom of why women in general tend to have significantly worse clinical outcomes than men. The topic is of great interest to the organization, as the corporate Diversity and Inclusion Strategy includes not only increasing diversity of internal talent and leadership, but a desire to understand different patients’ needs – and use these insights to develop medicines that result in truly better healthcare outcomes for patients. The team also looked at which business processes could be put in place to improve the company’s ability to routinely gain and use this type of knowledge about their customers.
Identifying the problem
The first step was a systematic literature review of 12 therapeutic areas (six each in Pharma and Oncology) to identify any evidence of gender disparity. Once this review of 105 studies was completed, the team found that heart failure showed the biggest gender disparity among the six Pharma disease areas. In Oncology, the team found more ethnic group disparities than gender, especially in breast cancer. In the next deep-dive research, the team reviewed 2,500 publications to understand details of the disparities in diagnosis and treatment of female heart disease and breast cancer patients. Insights from both the Pharma and Oncology business unit leaders at Novartis further enhanced the results.
Key findings: heart failure
The group found important gender differences in the identification and management of patients with heart failure. Historically, women have been underrepresented in structured clinical studies to assess the efficacy and safety of new treatments related to heart failure. Outcomes from such studies provide clinicians with the evidence they need to treat and manage patients, and to prescribe accurate doses of drugs. However, patients in these clinical trials tend to be younger and more often male. This means that targeted solutions and treatments are less available to women, because fewer are studied at the outset.
Women tend to present with very different symptoms and underlying causes than men – so if they are treated in the same way as male patients, their symptoms will be less well addressed. Women tend to be treated less aggressively compared to men. Women are also more likely to be diagnosed at an older age with more co-morbidities (e.g. diabetes, hypertension). With limited gender analysis in these studies, there is likely a lack of gender-specific management when it comes to medication options.
Key findings: breast cancer
While breast cancer is a predominantly female disease, there are significant ethnic disparities in types of breast cancer: all women are not the same. For example, studies have shown that white women are slightly more likely to develop breast cancer than African American, Hispanic and Asian women. But African American women are more likely to develop triple-negative breast cancer (more aggressive, more advanced-stage breast cancer that is diagnosed at a young age). Japanese, West African and German migrant groups have a higher prevalence of certain types of breast cancer (triple negative) compared with Western populations. New treatments for triple-negative breast cancer are being studied in clinical trials. However, these ethnic differences are under-represented in clinical trials and, as a result, some women may have less access to some of the most promising therapies.
Some of the differences in outcomes may be due to less access to mammography and lower-quality medical care, as well as various lifestyle patterns (eating habits and weight issues for example) that are more common in some ethnic groups than in others.
Studies have identified that both BMI and smoking are possible risk factors that differ across ethnic groups. Among premenopausal women, obesity is associated with a lower risk of breast cancer. In post-menopausal women, obesity is associated with a higher risk of breast cancer. Understanding these factors means that they can be addressed and improved.
The ‘so what?’ question
The EFLP team has highlighted a gap in the healthcare of women, suggesting that available treatments for female patients are often less precise and less effective. Their research using data from patients in real-life practice, known as real-world evidence, confirms the gap. Market research studies are currently underway to assess the role of unconscious bias when it comes to healthcare for women. For example, what are the barriers to including more women in clinical studies? Are there insufficient female physicians? And what role might this play in narrowing female patients’ access to treatment? Closing the gap on these gender disparities will help to ensure that women are not diagnosed later, under-diagnosed, under-treated and, as a consequence, have less access to healthcare and suffer more.
Even with diseases that largely affect only women, a one-size-fits-all approach does not work. For some disease areas, such as breast cancer, there are factors such as ethnicity, education, income and others that effectively apportion women to treatment sub-groups. We need new approaches to ensure that all women are adequately represented when assessing data and health outcomes.
What is next? The team is engaging with Novartis stakeholders and key decision makers to explore how to apply the findings to current and future product launches. They will start with the Oncology and Heart Failure businesses, with plans to expand to other business units. The greatest opportunity lies in systematically digging deeper to understand women’s insights so that these can inform clinical trial design and, in return, the data captured reflects what can be expected in terms of relevant outcomes for female patients. The team recommends that this approach be widely expanded throughout the industry as female disparity likely affects broader areas of healthcare than just those assessed here.
The evidence regarding gender disparity is clear. As the next wave of leaders at Novartis, we proudly take on the mission to ensure that we are improving outcomes for the female patients that we serve.
Left to right: Healthcare company Novartis’ Rhonda Peebles, Eunice Kim, Melissa Liew, Aurelia Caparros, Jin Gu, Marianthi Psaha