ORIGINAL RESEARCH Gender influence on work satisfaction and leadership for medical oncologists: a survey of the Spanish Society of Medical Oncology (SEOM) E. Elez1, F. Ayala2, E. Felip3, R. García Campelo4, R. García Carbonero5, J. García Donás6, A. González del Alba7, E. González Flores8, J. Hidalgo9, D. Isla10, M. Majem11, Á. Rodríguez Lescure12, M. J. Safont13, A. Santaballa14, G. Villacampa1, R. Vera15 & P. Garrido16* 1 Vall d’Hebron Institute of Oncology (VHIO), Medical Oncology Department, Barcelona; 2Hospital Universitario Morales Meseguer, Murcia; 3Hospital Universitario Vall D’Hebron, Barcelona; 4Complexo Hospitalario Universitario, A Coruña; 5Hospital Universitario 12 de Octubre, Madrid; 6Centro Integral Oncológico Clara Campal (CIOCC), Madrid; 7Hospital Universitario Puerta de Hierro Majadahonda, Madrid; 8Hospital Universitario Virgen de las Nieves, Granada; 9Hospital Lluis Alcanyís de Xativa, Valencia; 10Hospital Clínico Universitario Lozano Blesa, Zaragoza; 11Hospital de la Santa Creu I Sant Pau, Barcelona; 12Hospital General Universitario de Elche, Alicante; 13Consorcio Hospital General Universitario, Valencia; 14Hospital Universitari I Politècnic la Fe, Valencia; 15Complejo Hospitalario de Navarra, Pamplona; 16 Hospital Universitario Ramón y Cajal, Madrid, Spain Available online 6 February 2021 Background: Women represent an increasing proportion of the oncology workforce; however, globally this does not translate into leadership roles, reflecting disparities in career opportunities between men and women. The Spanish Society of Medical Oncology (SEOM) undertook a survey to investigate gender disparity in the Spanish oncology context. Design: An online survey was made available to SEOM medical oncologists between February and May 2019. It included demographics, professional context and achievements, parenthood and family conciliation issues, workplace gender bias, and approaches to address disparities. Results: Of the 316 eligible respondents, 71.5% were women, 59.5% were aged 45 or younger, and 66.1% had children. Among women, 12.4% were division or unit heads, compared with 45.5% of men, with most women (74.3%) being attending medical oncologists, compared with 45.5% of men. More males were professors (34.4% versus 14.2% of females), had a PhD (46.7% versus 28.8%), and/or had led clinical research groups (41.1% versus 9.7%). Spending time overseas after completing a residency was also more common for men than women (34.4% versus 20.4%). Professional satisfaction was similar between genders, driven primarily by patient care and intellectual stimulation. More women (40.7%) considered parenthood to have a strong negative impact on their career, compared with men (9.0%). Main perceived barriers to gender equality included a lack of workelife balance (72.6% women, 44.4% men), bias of peers and superiors (50.0% women, 18.9% men), and different career goals (41.2% women, 24.4% men). Preferred solutions included educational programs and scholarships (52.9%), communication and leadership training (35.8%), childcare at conferences (33.2%), and postmaternity return-to-work incentives (32.0%). Conclusion: There is a clear paucity of equal opportunities for female oncologists in Spain. This can be addressed by encouraging professional development and merit recognition particularly for younger female oncologists, and empowering women to be involved in management and leadership of institutions and professional societies. Key words: gender, Spain, survey, oncology, women INTRODUCTION challenges confronting females in the health and science The subject of the gender gap in the professional context is workplace in terms of equal opportunities in a variety of increasingly the focus of attention worldwide. While there cultural contexts. Women account for approximately two- has been notable progress in reducing this gap over the past thirds of all workers in the health care area,1 and this few decades, many recent studies have highlighted ongoing trend is continuing. In Spain, 2019 membership data of the Spanish Society of Medical Oncology (SEOM) showed a higher proportion of female oncologists (59%). This pre- *Correspondence to: Prof. Pilar Garrido, Hospital Universitario Ramón y Cajal, Carretera Colmenar Viejo km 9100, 28034 Madrid, Spain. Tel: þ34 913368000 dominance is increasingly pronounced in younger age E-mail: pilargarridol@gmail.com (P. Garrido). brackets. In a survey of female and male oncologists per- 2059-7029/© 2021 The Authors. Published by Elsevier Ltd on behalf of Eu- formed by the European Society for Medical Oncology ropean Society for Medical Oncology. This is an open access article under the CC (ESMO) Women for Oncology (W4O) Committee in 2016, BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Volume 6 - Issue 2 - 2021 https://doi.org/10.1016/j.esmoop.2021.100048 1 ESMO Open E. Elez et al. 67% of responding females were aged under 45.2 A similar The survey was available online from February to May trend is apparent in the SEOM, with female members ac- 2019. SEOM members were informed via the weekly elec- counting for nearly three-quarters of medical oncologists tronic newsletter and a personalized email sent mid-way aged 35 and younger in 2019.3 during the survey availability period. A link to the survey While globally women occupy a large proportion of po- was also promoted on the SEOM website. The survey was sitions within the oncology field, this does not translate into hosted on the SEOM website, and respondents could an equivalent presence in senior and leadership roles in complete it online at the time and location of their choice. academic or clinical settings, in either the public or the Participants were informed that the survey was voluntary private domain. This disparity is both deep seated and and that data were being collected anonymously. All data multifactorial, and is seen in a variety of settings. Women were automatically collected and downloaded into MS Excel are underrepresented as presenters at major oncology (2010). conferences, a recognized platform for breakthrough clinical A descriptive analysis of study variables was performed. research. An analysis covering nearly a decade of annual Categorical variables were expressed as absolute values and meetings of the American Society of Clinical Oncology percentages. Fisher's exact test was used to compare the (ASCO) and ESMO showed that only 21% of oral pre- percentage of responses across gender. Multivariate anal- sentations were by women, that women represented 28% ysis was not conducted and no correction for multiple of all abstract authors, and that the proportion of female testing was performed due to the exploratory nature of the presenters has not changed significantly over this period.4 study. The data analyses were carried out using R statistical Similarly, fewer women are recipients of prestigious re- software package version 3.6.2 (The R Foundation). wards in the scientific and medical settings.5 Female participation at an educative level in oncology training RESULTS programs and grand rounds seminars is also weaker, and is particularly pronounced at the leadership level.6,7 With the Population demographics proportion of female oncologists continuing to increase, it is Responses were collected from 318 of the 2151 members essential that gender disparities be addressed. contacted, two of whom were ineligible (not medical on- A number of surveys over the last few years have re- cologists). Members from all 17 Spanish autonomous ported on the underrepresentation of women oncologists in communities responded, with the regions of Madrid, Cat- leadership roles worldwide, as well as women's perception alonia, Valencia, and Andalusia being the most highly rep- of the role of gender in their professional environment.2,8-11 resented, together accounting for 58.2% of respondents. Cultural factors can be strong gender drivers in the pro- Other regions each represented between 1.0% and 6.7% of fessional environment, with women experiencing different the analyzed population. challenges and playing different roles in the workplace ac- Demographics are presented in Table 1. Among the 316 cording to the cultural setting. To better understand the role respondents, 226 (71.5%) were women and 90 (28.5%) were of gender in professional satisfaction and career develop- men. Respondents were aged between 27 and 70, with 59.5% ment in the oncology field in the Spanish context, the SEOM aged 45 or younger. All professionally active age groups were Working Group of Women in Oncology developed a ques- well represented. In terms of marital status, the majority of tionnaire for its members, both male and female, focusing respondents (76.9%) were married or living as a couple, and on the perceptions of gender issues in the professional 66.1% of the population had children, with half of the cohort context and what can potentially be done to address any having either one or two children. A higher proportion of imbalances. female respondents had no children compared with male respondents (38.5% versus 24.4%, P ¼ 0.02). MATERIALS AND METHODS Professional environment All SEOM members were invited to complete the ques- The large majority of respondents (95%) worked in a public tionnaire. To be eligible, participants had to be an SEOM hospital with only 5% in private institutions. Most re- member and a medical oncologist, either qualified or in spondents' institutions (n ¼ 230; 72.8%) had between 5 and training. The questionnaire was developed by the SEOM's 20 attending medical oncologists, with 5.7% (18 re- New Working Group of Women in Oncology, and was spondents) working in large institutions (>30 attending adapted from the ESMO survey.2 Responses were anony- medical oncologists). More than half of the 316 re- mous. It consisted of 39 questions in Spanish, addressing spondents (n ¼ 187; 59.2%) had a permanent contract. demographics, professional context, professional achieve- Two-thirds (66.1%) of respondents were attending med- ments, parenthood, and gender impact in the workplace, ical oncologists (Table 1). The remainder mostly held senior and possible approaches to address these (see positions including 12.7% who were heads of division and Supplementary Information, available at https://doi.org/ 9.2% who were unit heads. The distribution of roles differed 10.1016/j.esmoop.2021.100048). Questions had pre- between males and females, with the majority of women specified multiple-choice answers, and for some questions (74.3%) holding positions as attending medical oncologists more than one answer and/or open text was possible. versus 45.5% of males in the same position. By contrast, 2 https://doi.org/10.1016/j.esmoop.2021.100048 Volume 6 - Issue 2 - 2021 E. Elez et al. ESMO Open institution, reporting that within their institutions, 60.6% Table 1. Demographics, professional, and academic characteristics of survey participants (2031/3349) of attending physicians and 63.7% (1167/1831) of fellows were women, whereas men accounted for 62.1% Total Females Males n (%) n (%) n (%) of the unit heads (231/372) and 78.8% of the division heads (N [ 316) (N [ 226) (N [ 90) (249/316). Female 226 (71.5) d d Age (years) 30 35 (11.7) 29 (12.8) 6 (6.7) Professional satisfaction and achievements 31-40 110 (34.8) 90 (39.8) 20 (22.2) 41-50 88 (27.8) 66 (29.2) 22 (24.4) Three-quarters (n ¼ 241; 76.3%) of the respondents re- 51-65 76 (24.1) 38 (16.8) 38 (42.2) ported being satisfied with their professional career, with a >65 7 (2.2) 3 (1.3) 4 (4.4) slightly but not statistically significant higher proportion of Marital status males (n ¼ 73; 81.1%) compared with females (n ¼ 168; Married/partner 244 (77.2) 166 (73.4) 78 (86.7) Single 57 (18.0) 51 (22.6) 6 (6.7) 74.3%). When questioned over the aspects they most Separated/divorced/widowed 15 (4.7) 9 (4.0) 6 (6.7) enjoyed about their jobs from a prespecified list, their Number of children relationship with patients was reported by almost all par- 0 109 (34.5) 87 (38.5) 22 (24.4) 1 47 (14.9) 36 (15.9) 11 (12.2) ticipants (n ¼ 299; 94.6%), as was intellectual stimulus (n ¼ 2 113 (35.7) 74 (32.7) 39 (43.3) 265; 83.9%; Figure 1). For most respondents (n ¼ 206; 3-5 47 (14.9) 29 (12.8) 18 (20.0) 65.2%), patient care accounted for at least three-quarters of Institution position Attending medical oncologist 209 (66.1) 168 (74.3) 41 (45.5) their time. Managing financial aspects was the least Department head 40 (12.7) 16 (7.1) 24 (26.7) appreciated part of their job (<1% of respondents). The Resident/postgraduate 36 (11.4) 28 (12.4) 8 (8.9) profiles of sources of potential satisfaction were similar Unit head 29 (9.2) 12 (5.3) 17 (18.9) between males and females (P ¼ 0.34). Fellow 2 (0.6) 2 (0.9) 0 Management roles In terms of professional projects (Table 1), approximately PI of a competitively 156 (49.4) 97 (42.92) 59 (65.5) half of the respondents (49.4%) had led competitively funded research project funded research projects, with a lower proportion of fe- Leader of a research group 59 (18.7) 22 (9.7) 37 (41.1) Leader of a cooperative group 29 (9.2) 12 (5.3) 17 (18.9) males receiving funding (42.9%) than males (65.6%; P < Academic qualifications 0.001). Among the 160 remaining respondents, 128 (80.0%) Professorship 63 (19.9) 31 (13.7) 31 (34.4) had never applied for a competitive grant, although 112 Medical degree 107 (33.9) 65 (28.8) 42 (46.7) Doctoral thesisa 90 (28.5) 70 (31.0) 20 (22.2) (70.0%) stated that they would like to lead projects, with PI, principal investigator. equivalent proportions of men and women. A total of 59 a Completed/ongoing. respondents (18.7% of the population) had led a clinical research group during the last 5 years, corresponding to 41.1% (n ¼ 37) of males compared with 9.7% (n ¼ 22) of 12.4% of female respondents were division or unit heads, females. Of note, for 42 (71.2%) of them, this role had not compared with 45.6% of males (P < 0.001). These gender been officially recognized. Most respondents (68.5%, 176/ differences were mirrored when respondents were 257) who had not led a research group had not actively questioned in terms of the overall numbers in their applied for this position, with reasons cited including their Total (n = 316) 100% 96% 94.6% Women (n = 226) 91.1% 85.6% Men (n = 90) 83.9% 83.2% 80% Proportion (%) 62.2% 60% 53.5% 50% 50.4% 48.1% 42.2% 40% 20% 8.9% 7.3% 6.6% 2.2% 0.9% 0.4% 0% Patient Intellectual Medical Working with Professional Financial relationship stimulation challenge specialists prestige aspects Figure 1. Activities contributing to professional satisfaction (choice of 3 from a prespecified list). Volume 6 - Issue 2 - 2021 https://doi.org/10.1016/j.esmoop.2021.100048 3 ESMO Open E. Elez et al. patient care burden, lack of interest or of appropriate sexual orientation was also more frequently experienced by qualifications, or hospital infrastructure. Only 9.2% (n ¼ 29) women (28.8%, 65/226) than by men (13.3%, 12/90). had led a cooperative group, and the majority of those who Participants were asked to select from a prespecified list had not (269/287; 93.7%) had not actively applied to. approaches they consider would support professional Overall, 33.9% (n ¼ 107) of respondents had a medical development for female oncologists (Figure 3). Flexible degree, with a higher proportion of the male respondents educational programs and scholarships ranked most highly (46.7%, 42/90) than female respondents (28.8%, 65/226; (52.9%, 167/316), along with skills training such as P < 0.01). Among respondents, 28.5% were working on or communication and leadership (35.8%; 113/316), childcare had completed a doctoral thesis, corresponding to 22.2% of at conferences (33.2%, 101/316), and a financial incentive males and 31.0% of females. In most cases (61.8%), re- to return to work after maternity leave (32.0%, 101/316). spondents cited a lack of time as the main reason for not The profile was similar for men and women, although completing their thesis. significantly more women than men saw value in education In terms of academic qualifications, 19.9% (63/316) of programs (flexible education and scholarships 57.5% versus participants were university professors, most of whom 41.1% of men; skills training 42.5% versus 18.9% of men, all (88.9%, 56/63) held associate professorships; among male P values < 0.01). respondents, 34.4% (31/90) were professors compared with 14.2% of female respondents (32/226). Less than half the participants (n ¼ 138, 43.7%) were aware of the Spanish DISCUSSION National Agency for Quality Assessment and Accreditation This SEOM survey offers insight into gender disparity in the (ANECA), and among them, most (n ¼ 113, 81.9%) had not Spanish oncology setting. In our nationally representative requested accreditation required for any academic position population, younger females dominated (2.5:1 female:male at university. Seventy-seven respondents (24.4%) had spent ratio and 52.6% of female respondents were aged 40 or time overseas after completing a residency, most (n ¼ 61, younger, compared with 28.9% of male respondents), and 79.2%) of whom stayed for up to 12 months. This was more almost all respondents worked in public institutions with common among male respondents (31/90, 34.4%) than moderate to large oncology services. In addition, although female respondents (46/226, 20.4%; P ¼ 0.01). we received 318 answers, this only represents nearly 15% of the total population and is thus a potential limitation of the study. The survey highlighted gender-based disparities in a Impact of parenthood and gender in the professional number of domains, with leadership and decision-making context positions dominated by men. Despite the fact that Of the 201 parents who responded to the question whether women represent the majority of the oncology workforce, parenthood had negatively impacted their career, 40.7% significantly more male respondents held senior positions (55/135) of women considered that parenthood had a compared with females (45.6% versus 12.4%, respectively), strong negative impact on their professional career, and respondents confirmed this reflected the profiles of compared with 9.0% (6/66) of men (Figure 2A). Conversely their institutions. Similar gender disparities were apparent 11.1% (15/135) of women considered there was no nega- in terms of professional achievements with four times as tive impact compared with 54.5% (36/66) of men. many men as women having led a research group over the In terms of gender impact on their careers, 68.9% (62/90) last 5 years. In addition, obtaining competitive research of men considered it had no impact, compared with 15.9% funding, leading cooperative groups, or achieving a pro- (36/226) of women. Most women (71.2%, 161/226) re- fessorship were also notably more common among male ported a minor to moderate impact, compared with 22.2% respondents, although these leadership roles were infre- (20/90) of men (Figure 2B). From a prespecified list of the quent in the overall population. main barriers to gender equality, lack of workelife balance These trends in poor representation of women in lead- was the most common reason selected (64.6%, 204/316), ership positions and academic achievements in this Spanish notably by women (72.6%, 164/226 versus 44.4%, 40/90; cohort echo reports from other oncology settings and the P < 0.001) than men (Figure 2C). Bias of peers and supe- broader health care system. Recognition of this vertical riors (conscious or unconscious) was reported by 41.1% segregation is increasing, with calls to break this so-called (130/316) of respondents, chosen by 50.0% (113/226) of glass ceiling.12 Implicating women in leadership positions women versus 18.9% (17/90) of men. Different career goals provides a diverse perspective in a male-dominated medical were considered a barrier for 36.4% (115/316) of re- setting. Gender-diverse institutions are more likely to spondents, selected by 41.2% (93/226) of women and outperform those that are not,13 whereas lower mortality 24.4% (22/90) of men. Men were more likely to consider and hospital readmission rates have been reported with there were no barriers (38.9%, 35/90) compared with female physicians.14 women (4.9%, 11/226, P < 0.001). Lack of training was not Men were more likely than women to consider that their considered as a contributing reason by any of the re- gender has not had any impact professionally (68.9% versus spondents. Among women, 41.6% (94/226) reported having 15.9% respectively), whereas women primarily cited a mild suffered sexist or pejorative comments compared with 4.4% to moderate impact. The high proportion of younger female (4/90) of men. Inappropriate behavior in terms of gender or participants may conceal the true extent of this impact, 4 https://doi.org/10.1016/j.esmoop.2021.100048 Volume 6 - Issue 2 - 2021 E. Elez et al. ESMO Open A 100% B 100% 2.7% Strong 4.4% Significant 14.2% Moderate Slight 15.9% None Minor 80% 80% None Fisher's test Other 55.2% P < 0.001 Fisher's test Proportion (%) 43.3% P < 0.001 Proportion (%) 36.7% 60% 60% 68.9% 40% 40% 34.5% 35.8% 20% 42.5% 20% 13.4% 8.9% 9% 10.2% 4.4% 0% 0% Women Men Women Men C Lack of work–life balance [64.6%] *** Colleague bias (conscious or not) [41.1%] *** Different career goals [36.4%] ** Lack of personal support [20.6%] Social pressure [20.3%] ** Lack ofconfidence in women's ability [19.6%] *** No barriers [14.6%] *** Lack of self-confidence (women) [12%] ** Less defined career path [9.8%] *** Lack of role models [9.2%] Don't know [4.7%] * Women (n = 226) Lower leadership capacity in women [2.8%] Men (n = 90) None listed [2.2%] ** Other [3.2%] 50% 25% 0% 25% 50%75% Proportion by gender Symbol * represents P-values < 0.05, ** P-values < 0.01 and *** P-values < 0.001 Figure 2. Impact of parenthood and gender. (A) Negative impact of parenthood on respondents' career (N [ 66 men; N [ 135 women); (B) Impact of gender on respondents' career (N [ 90 men; N [ 226 women); (C) Three main barriers to gender equality, overall and by gender (N [ 90 men; N [ 226 women). with it being too early in younger participants' careers for a barriers women face has been reported in the scientific true impact to have become apparent. Identifying perceived research setting.15 barriers to gender inequality from both a male and female Perceived barriers reported in this Spanish female pop- perspective was revealing. While women were significantly ulation, notably the challenges of balancing work and home more likely to cite several factors than men, notably a lack and unconscious biases (such as men being perceived as of workelife balance, peer bias, and different career goals, natural leaders), echo those reported in other publications men were primarily of the opinion that there were no addressing gender inequality in a range of populations, barriers to achieving gender equality. This is worth high- including the ESMO survey, primarily reflecting a European lighting given the higher proportion of men in our cohort perspective (accounting for 72% of respondents),2 as well as who were themselves occupying leadership positions. This in the Middle East, North Africa, and India.10,16 Lack of lack of recognition of gender inequality by men and of the mentorship, local gender bias, and lack of assertiveness and Volume 6 - Issue 2 - 2021 https://doi.org/10.1016/j.esmoop.2021.100048 5 ESMO Open E. Elez et al. ● 52.8% 57.5% Flexible education/scholarships ● ● 41.1% ** Skills training programs ● 35.8% ● 42.5% (communication/leadership) ● 18.9% *** ● 33.2% Creches at conferences ● 34.5% ● 30% Postmaternity return-to-work ● 32% ● 30.1% subsidy ● 36.7% ● 31%32.3% Women oncologist networks ● ● 27.8% Quotas to increase ● 19.3% numbers of women ● 20.8% ● 15.6% Total (n = 316) ● 19.3% Women (n = 226) Tutoring programs ● 19.9% ● 17.8% Men (n = 90) ● 9.8% Other ● 6.2% ● 18.9% ** 0% 20% 40% 60% Proportion of acceptance Symbol ** represents P-values < 0.01 and *** P-values < 0.001 Figure 3. Proposed approaches to addressing barriers to gender equality (men N [ 90; women N [ 226). confidence were also cited as reasons, albeit less frequently, consequences, not only for women, but also for the quality across different geographic regions. A recent global study of research, suggesting that bias against female medical reporting on barriers found they did not differ by age oncologists might have consequences on research in group.17 Other factors such as difficulties in attending in- oncology. In addition, some research findings apply only to ternational conferences or training programs, and lower men, establishing ‘biased knowledge’. Research into gender salaries were more prominently cited in surveys of female bias is less likely to be funded and is published in journals oncologists in the Middle East, North Africa, and India.10,16 with a lower impact factors than research into equivalent Among the two-thirds of participants who were parents, social discrimination such as race.21 women were four times as likely as men to report that The existing merit-based system is biased against gender parenthood had a strong negative impact on their career equality with the responsibilities of women outside of work (40.7% versus 9.0%, respectively). Addressing workelife not taken into consideration such as when accessing funding. balance in a social environment where women are The male-dominated professional and social systems commonly expected to put family first highlights a need for perpetuate this situation, penalizing women in the pursuit of support in terms of shared responsibility for care of children leadership positions, and contributing to maintaining the vi- and aging parents. In a study investigating women leaving cious circle. Changes at the level of systems, organizations, surgical oncology, in addition to absence of interactions with and policies have been advocated to address limitations women, another important factor cited was unavailability of imposed by these networks on opportunities for women to or not having a valid reason for leave.18 Sexism and/or gender advance in their career path.17,22,23 Increasing transparency discrimination in the workplace were reported by up to 40% of the system is an essential part of addressing this. Steps of our female respondents. Research has linked a harmful need to be taken at the highest levels, with active encour- workplace environment and gender-based discrimination agement and integration of diversity and inclusion into the with adverse effects on women's occupational well-being and missions of institutions and oncology academic societies, as health,19 and the unfavorable impact of these behaviors ap- highlighted by different organizations including SEOM and pears greater in male-dominated work contexts.20 ESMO.24 Academic societies should be role models demon- In terms of scientific research, the gender gap is a strating leadership in advocating for gender equality. This can documented phenomenon that has had detrimental include statements highlighting the absence of evidence for 6 https://doi.org/10.1016/j.esmoop.2021.100048 Volume 6 - Issue 2 - 2021 E. Elez et al. ESMO Open gender-based differences in science ability, ensuring inclusive development of additional professional skills, such as conferences in terms of speakers, expert panels, organizing leadership and management, or obtaining a PhD. Avail- committees, and attendees, and implementing codes of ability of educational programs and scholarships and skills conduct to ensure equal financial support.22 Encouragingly, training for communication and leadership were supported one study noted that faculties with at least one woman in a by a significantly higher proportion of women in our cohort leadership position had a higher proportion of women faculty as means of improving their career opportunities, while members, supporting a positive knock-on effect from both men and women recommended childcare at confer- implementing change to reverse the current trends.7 The ences and financial postmaternity return-to-work in- reported presence of women in senior leadership positions or centives. These are all widely reclaimed means of as invited speakers in national and international oncology addressing gender equality across geographical re- societies and conferences is dismally low (ranging from gions.2,10,16 In a study by Riaz et al., while women in the approximately 10% to 25% depending on the position), with United States are clearly underrepresented in senior aca- similar outcomes in Europe and South America, and slightly demic hematology and oncology positions (22% of full lower rates in Asia.25 professors, 36% of associate professors, and 45% of assis- At an institutional level, accountability and committed tant professors), after adjusting for clinical experience, ac- resources (financial and infrastructure) are needed, such as ademic productivity, and workplace ranking, the odds of officially integrating dedicated time for gender-related obtaining professorship were not significantly different for training and activities into staff workload, hiring adminis- female and male physicians.30 This supports the theory that trative support staff, and formal recognition of contribu- for women to reach equal leadership representation, dif- tions.22 In addition to appointing more women to senior ferences in length of clinical experience need to be roles, other actions include seeking junior women for addressed, and publication profiles and workplace visibility mentorship and sponsorship, encouraging them to proac- must be increased. tively communicate their need for leadership, incentivizing Associations dedicated to promoting the role of women mentorship, and implementing targeted recruitment to in cancer care are an important foundation for the path to improve diversity.17 The current funding system undermines changing current attitudes and habits, as well as an excel- the role of women. It has been reported that in the attri- lent conduit for increasing awareness of career opportu- bution of health research funding, female principal in- nities for women. Several global groups have been formed, vestigators were evaluated less favorably than male such as the ESMO W4O Committee, the Women in investigators, and this was not due to differences in the Oncology Work Group in ASCO, and Women in Cancer quality of their proposals.26 The dominating position of men Research (WICR) from AACR. National initiatives are being in obtaining research funding is reproduced in authorship of launched, such as the Women's Working Group for peer-reviewed publications, with a direct link established Oncology recently introduced by the SEOM,31 and the between the proportion of female-first authorship and of ASEICA (Asociación Española de Investigación Sobre el female faculty positions.27 Although the presence of Cáncer/The Spanish Association for Cancer Research) women in key author positions in oncology publications has Mujer/Women, developed by the Spanish Association for increased over time, efforts are required to significantly Cancer Research, which focuses on highlighting and improve current representation.28 fostering the work of female cancer researchers in Spain.32 Education about gender inequalities is a critical part of There are a number of possible biases inherent to this the path forward, including integrating gender stereotypes study. Given the voluntary nature of the survey, it is likely awareness and the value of diversity in improving outcomes that SEOM members who feel more strongly that gender in science and medicine into curriculums at the under- disparity exists participated, potentially skewing the graduate and graduate levels.22 Girod et al. reported a study outcome, as suggested by the participating population be- implementing an educational program about gender bias ing more heavily weighted toward younger females. Ques- and strategies for reducing it within a medical faculty, tions establishing numbers within an institution may have resulting in institutional change and promotion of women been affected if there was more than one respondent from to higher ranks.29 For young oncologists, the turning point the same institution. The study was not planned to analyze in their career is the end of residency. The significantly statistical associations between factors and responses, and higher proportion of males in our cohort who spent time robust analyses in a larger sample size may be of interest. overseas after completing their residency (34.4% versus The greater participation of younger female respondents 20.4% of women) suggests that men can invest more time likely contributed to the lower proportion of females in at an early stage of their training, increasing their access to senior positions and with career achievements, whereas the senior professional opportunities, whereas for women older male respondents could be expected to be at a more motherhood is a likely obstacle for traveling. advanced stage in their career. Nonetheless it is important In our cohort, the high level of professional satisfaction that such voices are heard, and the survey remains valid, (over 75% of both men and women) was principally driven posing both objective and subjective questions. by patient relationships and intellectual stimulation. How- Gender equality is not only just and fair, but implicit to the ever, participants primarily dedicated their time to patient value of a new leadership paradigm increasing diversity of care, and therefore only limited time is available for the thought and of experience. It brings benefit not only to Volume 6 - Issue 2 - 2021 https://doi.org/10.1016/j.esmoop.2021.100048 7 ESMO Open E. Elez et al. marginalized groups that need to gain representation at the 9. Dieci MV, Massari F, Giusti R, et al. Gender influence on professional table, but ultimately to the broader population who can also satisfaction and gender issue perception among young oncologists. A survey of the Young Oncologists Working Group of the Italian As- benefit from new approaches toward long-standing, intrac- sociation of Medical Oncology (AIOM). ESMO Open. 2018;3(6): table problems. Overall, in Spain, as elsewhere, there is a call e000389. to shift the mechanics of addressing gender disparity from 10. Salem R, Haibe Y, Dagher C, et al. Female oncologists in the Middle East individual behavior to comprehensive interventions including and North Africa: progress towards gender equality. ESMO Open. education, affirmative action, and accountability, and to take 2019;4(3):e000487. 11. Temkin SM, Rubinsak L, Benoit MF, et al. Take me to your leader: into account cultural specificities. The findings of this survey reporting structures and equity in academic gynecologic oncology. will be used to support the career development of women in Gynecol Oncol. 2020;157:759-764. Spain working in the oncology field, and to advocate for so- 12. Jagsi R, Tarbell NJ. Women in radiation oncology: time to break through cietal and cultural changes via public policies facilitating the the glass ceiling. J Am Coll Radiol. 2006;3(12):901-903. sharing of care responsibilities, as previously recom- 13. Hunt V, Layton D, Prince S. Why Diversity Matters. 2015. Available at: https://www.mckinsey.com/business-functions/organization/our-insights/ mended.33 Changing the status quo for female oncologists why-diversity-matters. Accessed January 13, 2021. requires their increased visibility and recognition, and an 14. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality active focus on appointing women to senior institutional and and readmission rates for medicare patients treated by male vs female committee positions, and as conference speakers, along with physicians. JAMA Intern Med. 2017;177(2):206-213. increased access to funding and travel opportunities. Di- 15. García-González J, Forcén P, Jimenez-Sanchez M. Men and women differ in their perception of gender bias in research institutions. PLoS versity and inclusion should be integrated into the missions of One. 2019;14(12):e0225763. professional oncology societies and the undergraduate edu- 16. Bajpai J, Mailankody S, Nair R, et al. Gender climate in Indian oncology: cation courses. Changes to the social paradigm are an national survey report. ESMO Open. 2020;5:e000671. important part of the foundations of addressing gender 17. Moyer CA, Abedini NC, Youngblood J, et al. Advancing women leaders inequality, and will support changes made to the professional in global health: getting to solutions. Ann Glob Health. 2018;84(4):743- 752. infrastructure. 18. Liang R, Dornan T, Nestel D. Why do women leave surgical training? A qualitative and feminist study. Lancet. 2019;393(10171):541-549. ACKNOWLEDGEMENTS 19. Sojo VE, Wood RE, Genat AE. Harmful workplace experiences and We thank Sarah MacKenzie, PhD, for writing assistance. women's occupational well-being: a meta-analysis. Psychol Women Q. 2016;40(1):10-40. 20. O'Connell CE, Korabik K. Sexual harassment: the relationship of per- FUNDING sonal vulnerability, work context, perpetrator status, and type of This study was funded by the Spanish Society of Medical harassment to outcomes. J Vocat Behav. 2000;56(3):299-329. Oncology (SEOM) (no grant number). 21. Cislak A, Formanowicz M, Saguy T. Bias against research on gender bias. Scientometrics. 2018;115(1):189-200. 22. Coe IR, Wiley R, Bekker L-G. Organisational best practices towards DISCLOSURE gender equality in science and medicine. Lancet. 2019;393(10171):587- The authors declare no potential conflicts of interest. 593. 23. Knoll MA, Glucksman E, Tarbell N, Jagsi R. Putting women on the escalator: how to address the ongoing leadership disparity in radiation REFERENCES oncology. Int J Radiat Oncol Biol Phys. 2019;103(1):5-7. 1. Boniol M, McIsaac M, Xu L, et al. Gender Equity in the Health Work- 24. Tabernero J. All change: closing the gender gap in oncology. ESMO force: Analysis of 104 Countries. Working Paper 1 (WHO/HIS/HWF/ Open. 2018;3(7):e000448. Gender/WP1/2019.1). Geneva, Switzerland: World Health Organiza- 25. Hofstädter-Thalmann E, Dafni U, Allen T, et al. Report on the status of tion; 2019. Available at: https://apps.who.int/iris/bitstream/handle/ women occupying leadership roles in oncology. ESMO Open. 2018;3(6): 10665/311314/WHO-HIS-HWF-Gender-WP1-2019.1-eng.pdf?sequence¼1 e000423. &isAllowed¼y. Accessed January 13, 2021. 26. Witteman HO, Hendricks M, Straus S, Tannenbaum C. Are gender 2. Banerjee S, Dafni U, Allen T, et al. Gender-related challenges facing gaps due to evaluations of the applicant or the science? A natural oncologists: the results of the ESMO Women for Oncology Committee experiment at a national funding agency. Lancet. 2019;393(10171): survey. ESMO Open. 2018;3(6):e000422. 531-540. 3. Rivera F, Andres R, Felip E, et al. Medical oncology future plan of the 27. O'Connor EE, Chen P, Weston B, et al. Gender trends in academic Spanish Society of Medical Oncology: challenges and future needs of radiology publication in the United States revisited. Acad Radiol. the Spanish oncologists. Clin Transl Oncol. 2017;19(4):508-518. 2018;25(8):1062-1069. 4. Dijksterhuis WPM, Stroes CI, Tan W-L, et al. From presentation to 28. Salinaro JR, Puechl AM, Havrilesky LJ, Davidson BA. Gender trends in paper: gender disparities in oncological research. Int J Cancer. gynecologic oncology authorship: implications for the critical evalua- 2010;146:3011-3021. tion of gender distribution in academic rank and leadership positions. 5. Melnikoff DE, Valian VV. Gender disparities in awards to neuroscience Gynecol Oncol. 2018;151(3):542-546. researchers. Arch Sci Psychol. 2019;7(1):4-11. 29. Girod S, Fassiotto M, Grewal D, et al. Reducing implicit gender lead- 6. Sharpe EE, Moeschler SM, O'Brien EK, et al. Representation of women ership bias in academic medicine with an educational intervention. among invited speakers for grand rounds. J Womens Health (Larchmt). Acad Med. 2016;91(8):1143-1150. 2020;29:1268-1272. 30. Riaz IB, Siddiqi R, Zahid U, et al. Gender differences in faculty rank and 7. Chowdhary M, Chowdhary A, Royce TJ, et al. Women's representation in leadership positions among hematologists and oncologists in the leadership positions in academic medical oncology, radiation oncology, United States. JCO Oncol Pract. 2020;16(6):e507-e516. and surgical oncology programs. JAMA Netw Open. 2020;3(3):e200708. 31. SEOM. Nuevo Grupo de Trabajo de Mujeres por la Oncología [New 8. Barry PN, Miller KH, Ziegler C, et al. Factors affecting gender-based Working Group of Women in Oncology]. Available at: https://seom.org/ experiences for residents in radiation oncology. Int J Radiat Oncol es/noticias/106799-nuevo-grupo-de-trabajo-de-mujeres-por-la-oncologia. Biol Phys. 2016;95(3):1009-1016. Accessed January 13, 2021. 8 https://doi.org/10.1016/j.esmoop.2021.100048 Volume 6 - Issue 2 - 2021 E. Elez et al. ESMO Open 32. ASEICA [Asociación Española de Investigación Sobre el Cáncer]. The 33. Artazcoz L, Borrell C, Benach J. Gender inequalities in health among Spanish Association for Cancer Research. Available at: https://www. workers: the relation with family demands. J Epidemiol Community aseica.es/aseica-mujer?lang¼en. Accessed January 13, 2021. Health. 2001;55(9):639-647. Volume 6 - Issue 2 - 2021 https://doi.org/10.1016/j.esmoop.2021.100048 9