Cancer Care: Gender Bias In Decision-Making
Overview
In the realm of cancer care, the integration and execution of shared decision-making within clinical practice guidelines (CPGs) and consensus statements could potentially exhibit gender-based disparities. This study aimed to meticulously analyze recommendations pertaining to shared decision-making within CPGs and consensus statements, specifically focusing on the most prevalent cancers among males (prostate) and females (endometrial). The study protocol was duly registered with PROSPERO (ID: RD42021241127). A thorough search encompassing MEDLINE, EMBASE, Web of Science, Scopus, and online sources was independently conducted by two reviewers, with no linguistic limitations imposed.
The study encompassed the inclusion of CPGs and consensus statements concerning the diagnosis or treatment of prostate and endometrial cancers, spanning from January 2015 to August 2021. A comprehensive quality assessment was undertaken utilizing a pre-established 31-item assessment tool, and disparities between the two types of cancer were scrutinized. A total of 176 documents met the predefined inclusion criteria, comprising 97 for prostate cancer (consisting of 84 CPGs and 13 consensus statements) and 79 for endometrial cancer (comprising 67 CPGs and 12 consensus statements).
Notably, the recommendation for shared decision-making was noticeably more frequent within prostate cancer guidelines compared to endometrial cancer guidelines (46 out of 97 vs. 13 out of 79, accounting for 47.4% vs. 16.5%; p < .001). In terms of adherence to the 31-item shared decision-making assessment tool, endometrial cancer guidelines exhibited lower compliance (mean 0.48 items, standard deviation 1.29) in contrast to prostate cancer guidelines (mean 2.14 items, standard deviation 3.45) (p < .001). With regards to guidance on the implementation of shared decision-making, only a small fraction of endometrial cancer guidelines (3.8%) and prostate cancer guidelines (16.5%) incorporated such advice (p < .001).
Evidently, a pronounced gender bias was observed, as shared decision-making recommendations were consistently more prevalent within prostate cancer guidelines in comparison to endometrial cancer guidelines. These findings warrant the encouragement of novel CPGs and consensus statements to integrate shared decision-making practices, in an effort to enhance the quality of cancer care, irrespective of the gender-related factors. It is noteworthy that the outcomes of this study may provide valuable insights for forthcoming recommendations by professional associations and governmental bodies, guiding the development and enhancement of high-caliber clinical guidelines that take into account patient preferences and shared decision-making principles in the context of cancer care.
Introduction
The personalized selection of optimal diagnostic and treatment strategies in cancer care is crucial due to the multitude of available approaches. Patient involvement is vital, as gender bias may exist, potentially favoring men’s preferences over women’s in decision-making. Shared decision-making (SDM) is now fundamental in achieving effective cancer care, as diverse options can yield varying outcomes based on patients’ values. SDM enhances patient satisfaction, cost-effectiveness, and reduces legal claims, prompting its legal requirement and endorsement by medical associations. However, implementing SDM in cancer care faces challenges, particularly in guidelines. These issues are relevant for gender-specific cancers, like prostate and endometrial cancers. For instance, prostate cancer decisions involve trade-offs impacting urinary, bowel, or sexual function. SDM is promoted for prostate cancer, backed by evidence from the US Preventive Services Task Force. Similarly, endometrial cancer treatment choices can lead to fertility loss, incontinence, and more. SDM is recommended here too, given the absence of standard screening and risks associated with all methods. Recent research assessed Clinical Practice Guidelines (CPGs) and consensus statements regarding SDM in prostate and endometrial cancers, aiming to explore their unique characteristics.
Method
The systematic review followed a registered protocol (Prospero ID: CRD42021241127) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. It focused on the most prevalent gender-exclusive cancers: prostate cancer (exclusively male) and endometrial cancer (exclusively female), employing a systematic search covering January 2015 to August 2021. MeSH terms, such as ‘shared decision-making’, ‘clinical practice guidelines’, and cancer-specific terms, were combined across databases like TRIP and MEDLINE, alongside other databases like EMBASE, Web of Science, Scopus, Cochrane Database of Systematic Reviews, and ACP Journal Club. Additionally, eight guideline databases and 99 professional society websites were explored. The research encompassed guidelines and consensus statements concerning diagnosis and treatment, excluding outdated, educational, and patient-focused documents. Reviewers independently evaluated the retrieved titles, abstracts, and full texts for eligibility. Quality assessment employed a 31-item tool based on AGREE II and RIGHT tools and relevant SDM literature, with disagreements resolved through consensus. The quality assessment covered 13 domains, and statistical analyses were performed to assess differences between prostate and endometrial cancer guidelines.
Result
Out of the 4702 citations identified in the search, 176 met the inclusion criteria, with 97 related to prostate cancer (84 Clinical Practice Guidelines (CPGs) and 13 consensus statements) and 79 concerning endometrial cancer (67 CPGs and 12 consensus statements). The publications were distributed between journal articles (47.7%) and other sources (52.3%). Geographically, documents originated from Europe (38.1%), North America (36.9%), Asia (10.2%), South America (6.3%), Oceania (3.4%), Africa (2.8%), and international organizations spanning continents (4.0%). Diagnostic guidelines (51.1%) and therapeutic guidelines (79.5%) were prevalent, with 33.5% including shared decision-making (SDM) information. The post-2018 period showed increased SDM reporting compared to earlier years (p = .010). No correlation was found between SDM presence and country, journal publication, or guideline nature. Prostate cancer diagnostic guidelines had higher SDM frequency than therapeutic ones (p = .057). European endometrial cancer guidelines discussed SDM more than non-European guidelines (p = .003). SDM was addressed in 47.4% of prostate cancer guidelines and 16.5% of endometrial cancer guidelines (p < .001).
Assessing compliance using the 31-item tool, significant differences emerged based on cancer type. Prostate cancer guidelines showed a mean score of 2.14 (SD 3.45) and endometrial cancer guidelines scored 0.48 (SD 1.29) (p = .043) regarding SDM. Key disparities were observed in individual items. SDM was rarely featured in executive summaries, tables of content, or glossaries for endometrial cancer guidelines, while appearing in 7.2% (p = .017), 9.3% (p = .005), and 2.1% (p = .502) of prostate cancer documents. Several aspects, such as SDM basis, primary affected population, and patient subgroups, were poorly addressed in endometrial cancer guidelines compared to prostate cancer guidelines.
Recommending SDM was common in both prostate (24.7%) and endometrial (7.6%) cancer guidelines (p = .003), though specific recommendations for subgroups and strength indications were lacking in endometrial cancer guidelines (0.0% and 5.1%) compared to prostate cancer guidelines (10.3%, p = .003, and 14.3%, p = .041, respectively). Facilitators, barriers, practical application advice, and additional SDM support material were better covered in prostate cancer documents (9.3%, 2.1%, 16.5%, and 6.2%, respectively) than in endometrial cancer documents (2.5%, 0.0%, 3.8%, and 0.0%, respectively). Resource implications, monitoring or evaluation criteria, limitations, and conflict of interest information related to SDM were largely absent from both types of guidelines. Declaration of the value of SDM use was mentioned in 25.8% of prostate cancer and 10.1% (p = .008) of endometrial cancer documents.
Discussion
Our comprehensive systematic review examined clinical practice guidelines and consensus statements related to prostate and endometrial cancer diagnosis and treatment, revealing noteworthy differences in recommendations for shared decision-making (SDM). Notably, these recommendations were notably stronger for prostate cancer compared to endometrial cancer, indicating a gender bias in SDM within cancer care. We observed an increasing trend of SDM coverage in recent guidelines, although key aspects of SDM reporting, especially advice on implementation, were notably lacking across timeframes. We selected prostate and endometrial cancers, both highly recommended for SDM due to uncertain treatment outcomes. For instance, the European Association of Urology’s recent prostate cancer guideline emphasizes individualized decisions considering disease stage, patient frailty, and consensus. Endometrial cancer treatment options, like ovarian preservation or minimally invasive surgery, should be tailored to patients’ clinical situation and desires. While prostate cancer guidelines included SDM in around half the cases, endometrial cancer guidelines included it in only a sixth. Importantly, this gender disparity could extend beyond this study’s scope, revealing an underlying bias influencing SDM presence in clinical guidelines. Notably, our study focused on potential gender bias regarding SDM for cancers affecting distinct biological sexes as a proxy for broader social, cultural, or psychological differences. To validate these findings, further research should investigate if these disparities indeed reflect gender bias in cancer care. Our study’s strength lies in its global perspective, encompassing a substantial number of clinical practice guidelines and consensus statements. Language and data source restrictions were avoided. However, it’s essential to acknowledge that gender bias varies across regions and might influence the results. Subjectivity in data extraction concerning SDM reporting was minimized through duplicated extraction and arbitration. While the quality assessment tool’s uniform weighting might be a limitation, future research should establish a quality threshold. These findings might not be universally applicable to all exclusively male and female cancers, but rather represent prostate and endometrial cancers. We focused on these specific cancers due to their high prevalence, complexity, and SDM recommendation. Gender differences in SDM might extend to other cancers like testicular, cervical, or ovarian cancer, warranting further investigation. While our study doesn’t delve into the specifics of clinical evidence for men and women, this should be explored in subsequent research. Overall, our results underscore the need for enhanced SDM implementation, addressing gender bias and promoting equitable cancer care improvements. Integrating SDM into endometrial and gynecological cancer guidelines is imperative, fostering better patient outcomes and patient-centered care. In conclusion, while SDM was present in approximately half of prostate cancer guidelines and a fifth of endometrial cancer guidelines, several vital aspects of SDM were lacking in both types of guidelines. Prostate cancer guidelines exhibited more comprehensive recommendations, advice on practical application, and recognition of SDM’s value compared to endometrial cancer guidelines. These disparities indicate a gender bias that requires further investigation and rectification to establish equity in enhancing cancer care.
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