By Yun Rose Li, MD, PhD, Parul Barry, MD, and Adrianna Masters, MD, PhD
While many women scientists and physicians made critical contributions that paved the path to modern day advances in radiation oncology, few were recognized for their work. Perhaps one of the most well-known pioneers in the field of radiation oncology is a woman: Marie Curie, recipient of two Nobel Prizes for her extensive work on radioactivity and the discovery of radium.
But aside from Marie Curie, most of her contemporaries received little acknowledgment. For example, Lise Meitner, an Austrian-Swedish physicist, helped discover the element protactinium-231 and described the process of nuclear fission (Sime, 1996). Her work demonstrating that uranium atoms split when bombarded with neutrons allowed for the later development of nuclear energy and nuclear bombs. For her contributions, she was nominated for the Nobel Prize in chemistry and physics 48 times, though she never received the award.
Another example is Margaret Cleaves, who in the early 1900s was one of an estimated 20 physicians (the only female) to have access to radium for clinical purposes and ultimately became the first to use radium in gynecology to treat cervical cancer (Aronowitz, Aronowitz, & Robison, 2007). She was heavily criticized and was largely dismissed by other physician colleagues. At that time, not only were educational opportunities and access to postgraduate training for women extremely limited, but society placed strict limitations on the role of women as physicians and leaders in medicine.
It was not until the demands created by WWI and WWII that broader access to medical/graduate education and career opportunities, aside from those that were traditionally seen as “feminine” roles, were made available to women. Often considered to be a founder of nuclear medicine, Edith Quimby studied the medical effects of radiation and dose limiting side effects with the application of radioactive isotopes in the treatment of thyroid disease, brain tumors and other cancers during her time at Memorial Hospital for Cancer and Allied Disease in New York (Linton, 2012). In 1954, she became the first female president of the American Radium Society and was the recipient of the Janeway Medal of the American Radium Society, the Gold Medal of the Radiological Society of North America and the Gold Medal from the American College of Radiology.
Other important women who made contributions to radiation oncology include Chien-Shiung Wu, also known as the First Lady of Physics. Wu, a Chinese American particle and experimental physicist, worked on the Manhattan Project and played an important role in the advancement of nuclear and particle physics. Despite their successes, very few women obtained faculty positions and even fewer chaired departments during the mid-1900s. One example was Ruth Guttman, who became the director of the Department of Radiotherapy at Columbia University from 1955 to 1976. Other notable examples include Florence Chu, who was the chair of Radiotherapy at Memorial hospital 1976-1984, and Anna Hamann, who at the end of a long career, became the director of radiation therapy at Evanston Hospital, although she never attained a full professorship. These women and many other women physicians and scientists overcame tremendous challenges and faced persecution and hostility in order to pursue their dreams to advance the field of radiation oncology and radiation physics.
Though many would like to believe that efforts made to address challenges faced by women in science and medicine have allowed women to break the glass ceiling in radiation oncology, there is still a lot left to do. In fact, the lack of gender diversity among radiation oncologists begins with medical school applicants and continues to widen throughout career development. Currently, women represent at least half of all medical school students but make up only 30% of applicants to radiation oncology training programs. The gender disparity widens as women progress in their careers, with leadership positions and chair positions further widening the gap: academic positions 17.4% and female chairs 11.7% (Gharzai and Jagsi 2020).
Leadership roles on editorial boards of oncology journals are another area of noticeable disparities in representation of underrepresented minorities and women. A recent abstract presented by Patel et al. reviewed 54 oncology journals and 793 board members, and there was not a single editor-in-chief position held by a minority female. At a time when COVID-19 has disproportionately affected the career development of women, who often serve as primary caretakers at home, how do we create an even ground for achieving career success? This is a pivotal time to reevaluate our measures of productivity and the metrics we use to decide on tenure or promotion. Recognizing that women in STEM in general have shown much larger interruptions in submissions to journals during this time than their male counterparts, even those with young children, the charge is with institutions and national organizations within our field to make a change to do better for women in radiation oncology.
We would argue that we need to promote diversity of not just representation and service on committees, but chairing committees, successfully applying for FASTRO status and even the Gold medalists. We reviewed the listed ASTRO Gold medalists on the website and found that since 1977 only 12% of honorees were female. The majority of the current ASTRO executive committee is female. In reviewing the chair and vice-chair positions of the councils, two of five council vice-chairs are women. Because portions of the application process for FASTRO focus on recommendations of existing recipients, leadership roles and other metrics of academic success, is this placing an undue burden on persons from underrepresented groups? We are curious to know what the success rates are for applications and if there is a way to blind applications to reduce bias.
It is important to recognize that, even though much remains to be done to level the playing ground for women in radiation oncology, our field has seen enormous contributions made by women, and more and more women are being recognized for their work. The 2021 ASTRO Gold medalists were notably both women (Colleen Lawton, MD, FASTRO, and Lori Pierce, MD, FASTRO). Moreover, Sue Yom, MD, PhD, FASTRO, who has made tremendous contributions to major societies in our field including ASTRO and American Radium Society where she is the immediate past chair, is the incoming editor-in-chief of the Red Journal.
What are some of our thoughts on increasing representation of diverse groups of people in leadership?
- Recognize the accomplishments of others and go out of your way to highlight those who may not be in a position to do it for themselves.
- Do not assume that someone doesn’t want to serve in a leadership role, is too busy or wouldn’t want to take time away from a specific activity (raising young children, for example). Why not simply ask?
- Offer support in a positive way that sponsors the success of others and specifically think about multiple candidates for a task or role in leadership.
- Be thoughtful with your word choices and their impact on those around you.
- Acknowledge the additional burden of unpaid domestic work, specifically during global pandemics, and think about ways to provide resources: Adapt to a changing environment to allow diversity of experience to enrich our culture as radiation oncologists!
- Be aware of biases, speak up when you recognize them and acknowledge when you recognize your own. Positive change cannot happen unless we do.
Join us on the ROhub to share your thoughts and discuss: What other ways can we support diversity of leadership and diversity of thought?
And be sure to acknowledge Marie Curie on Sunday, November 7 with #WeWhoCurie day!
Aronowitz JN, Aronowitz SV, Robison RF. Classics in brachytherapy; 2007.
Gharzai LA, Jagsi R. Ongoing Gender Inequity in Leadership Positions of Academic Oncology Programs: The Broken Pipeline. JAMA Network Open 3 (3): e200691–e200691. 2020. doi:10.1001/jamanetworkopen.2020.0691
Linton O. Edith H. Quimby. Journal of the American College of Radiology, 9(6), 449. 2012. https://doi.org/10.1016/j.jacr.2011.11.020
Sime RL. Lise Meitner: A Life in Physics. University of California Press. 1996.
By Crystal Seldon, MD; Awad Ahmed, MD; Anna M. Laucis, MD, MPhil; and Cristiane Takita, MD, MBA
Gender inequality is an ongoing problem among United States (U.S.) medical professionals.1-2 While there have been gains in diversifying the field of medicine, such as the number of women surpassing the number of men matriculating into U.S. medical schools,3 women continue to remain in the minority among faculty of academic institutions.4 Academic oncology is no exception.5 Women make up the minority of all faculty in the fields of medical oncology, radiation oncology (RO) and surgical oncology at U.S. academic institutions.6 This extends to leadership positions, specifically program director and department chair positions. In RO alone, women constitute 30.7% of the academic workforce and only 17.4% of the leadership roles.6 Women also make up the minority of positions on governing boards, such as the Board of Directors, as well as leadership positions for the national professional societies of the American Society of Clinical Oncology (ASCO) and the American Society for Radiation Oncology.7 There is some progress in this arena, as the current ASCO President is Lori J. Pierce, MD, FASCO, FASTRO, a female radiation oncologist and vice provost at the University of Michigan. And ASTRO currently has three women in Board leadership roles: ASTRO President Laura Dawson, MD, FASTRO, President-elect Geraldine Jacobson, MD, MPH, MBA, FASTRO, and Secretary/Treasurer Neha Vapiwala, MD.
Over the years, we have seen more women enter the field of medicine in the U.S., now representing a narrow majority of matriculating medical students, 50.5% as of 2019.8 However, as more women join the field of medicine, the number of female RO residents appears to have plateaued at 30.2% as of 2019.9 This plateau is also seen in leadership roles in RO residency programs. In 2012, the percentage of female program directors and department chairs was 24% and 9% respectively10 as compared to 23.8% and 11.7% in 2020.6 Studies have shown that female trainees are more likely to practice in programs with women in leadership positions.11-13 The lack of gender equity in leadership positions also likely contributes to the low number of female trainees who matriculate into the field each year, creating a self-perpetuating cycle with a limited supply in the workforce to become leaders.
To address the lack of gender equity in radiation oncology, barriers to equality must be addressed. These barriers include but are not limited to gender specific expectations, barriers to mentorship, disparities in research funding and biases in tenure and academic tracks.14 The lack of predefined finite time limits to leadership positions in academic radiation oncology may contribute to the lack of inclusion in the U.S. academic RO community. Policies introducing term limits for leadership positions in academic medicine have been proposed as a potential solution.15 Work by Odie et al. has showed that gender disparities among chairs exist and are widespread, even in fields where women make up the majority of the workforce, such as obstetrics and gynecology.16 This suggests that the pipeline may not be the heart of the matter. The current disparities seen in leadership, both gender and racial, represent a relic of the past and are unlikely to change without motivational policy; social and institutional guidelines will likely be needed to create gender parity in these leadership roles.
Within recent years, movements geared toward promoting gender equity, such as the #MeTooSTEM, #WomeninMedicine and #HeforShe online platforms, have identified the need for addressing this issue, especially in academia. With more women entering into the field of medicine, it is important to close the gap between men and women faculty members, especially those in leadership positions. Observing other women in leadership roles can inspire and motivate a bright message to students and the public that the field of RO is not only diverse but inclusive as well. An honest assessment of these barriers will be integral as the specialty seeks to attract future radiation oncologists and create a diverse workforce, such that the ideas and opinions representing those from diverse gender, racial and socioeconomic backgrounds can be better represented to ultimately help guide and inform the very best oncologic care for our patients.
Join us in the Gender Equity Community on the ROhub to continue the discussion. What are your suggestions to improve gender equity in radiation oncology?
Crystal Seldon, MD, is a PGY-3 radiation oncology resident at the University of Miami/Sylvester Comprehensive Cancer Center.
Awad Ahmed, MD, is a radiation oncologist practicing at Multicare Tacoma Washington and ASTRO CHEDI member.
Anna M. Laucis, MD, MPhil, is a chief resident physician in radiation oncology at the University of Michigan and an ASTRO CHEDI member.
Cristiane Takita, MD, MBA, is a professor and residency program director at the University of Miami/Sylvester Comprehensive Cancer Center and ASTRO CHEDI member.
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9. Boyle P. More women than men are enrolled in medical school. AAMC. Published online December 9, 2019. Accessed January 22, 2021. https://www.aamc.org/news-insights/more-women-men-are-enrolled-medical-school
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By Malika Siker, MD, Ross Zeitlin, MD, and Danielle Bitterman, MD
In June 2017, the ASTRO Board of Directors named diversity and inclusion a core value in its Strategic Plan. As diversity, equity and inclusion advocates, we are thrilled to see reaffirmation of these values and eager to participate in expanded initiatives. To highlight ASTRO work in this area, ASTRONews featured stories on diversity and inclusion in its 2018 issues. Margaret Barnes, MD, penned a thoughtful Letter to the Editor that expressed disappointment in the lack of inclusion of the lesbian, gay, bisexual, transgender and queer or questioning (LGBTQ+) community in these efforts and discussed a need for ASTRO to be intentional about considering LGBTQ+ voices as we advocate for diversity and inclusion. To Dr. Barnes and anyone else who has felt excluded by this omission, we emphatically agree with this suggestion and believe that addressing this issue will strengthen our field.
In 2017, the American Society of Clinical Oncology (ASCO) issued recommendations for reducing cancer disparities among sexual and gender minority (SGM) populations. This article defined known SGM cancer disparities and suggested ways to address these challenges. In addition to focusing on our SGM patients, we see a need to ensure that our SGM colleagues feel safe and included in our field. ASTRO’s Committee for Health Equity, Diversity and Inclusion (CHEDI) has been working behind the scenes on initiatives to advocate for SGM health equity from both a patient and provider perspective.
The 2019 ASTRO Annual Meeting showcased the results of collaborative efforts focused on elevating SGM equity in the field of radiation oncology during three educational sessions. All of these sessions were held on Tuesday, September 17, and were well attended with engaged audiences eager to learn more.
- The NCI/ASTRO Diversity Breakfast, held from 6:45 a.m. to 8:00 a.m., highlighted a panel on recruitment and retention of women and minorities in the radiation oncology workforce. Dr. Raymond Mailhot of the University of Florida was featured on this panel and discussed the additional obstacles he faced as a gay Latino man navigating medical education, the residency application trail and beyond. His story illustrated the courage and resiliency our SGM colleagues need to develop as they navigate their careers in an environment that has traditionally not been inclusive of SGM population issues. Our field and the care we provide to patients will be enriched by addressing barriers faced by LGBTQ+ individuals throughout their career to ensure they are supported in achieving their personal and professional aims.
- CHEDI sponsored a panel on the treatment of vulnerable communities in radiation oncology from 2:45 p.m. to 4:00 p.m. Dr. Ross Zeitlin of the Medical College of Wisconsin was included on this panel and examined cancer disparities in the SGM community with a specific focus on the impact these have in radiation oncology. His presentation included an evidence-based review of the current data, clinical challenges and future directions. Raising awareness and educating health care providers about SGM community cancer disparities is essential so we can improve health equity in this vulnerable community.
- From 4:45 p.m. to 6:00 p.m., a multi-institutional and multidisciplinary panel entitled “Is there a Standard of Practice in Oncologic Care for Transgender Patients?” featured Dr. Daphne Haas-Kogan, Dr. Anthony Zietman, Dr. Stephanie Terezakis, Paula Neira, MSN, RN, JD, Dr. Danielle Bitterman and Dr. Zackory Burns. During this session, they discussed fundamentals of transgender care, the need for workforce education, cultural sensitivity and legal issues in an engaging format. As radiation oncologists, we need to understand the best practices in caring for transgender patients to ensure we are meeting the needs of this population.
As a reminder, these sessions are available on the ASTRO Annual Meeting Virtual Meeting platform. If you attended the Annual Meeting, you have access to the Virtual Meeting; if not, the Virtual Meeting is available for purchase through the catalogue.
We are pleased to see that ASTRO and its members are interested in advocating for SGM health equity and inclusion through the events featured at the 2019 Annual Meeting and see a need to continue to build on these efforts. Recently, a new initiative for radiation oncology residents identifying as or allied with LGBTQ+ individuals was announced within the ARRO network. This initiative is in the building stages, and we are eager to extend an invitation to the radiation oncology community at large as we build this idea from the ground up. For further details, please email Dr. Ross Zeitlin.
With diversity and inclusion listed as a core value in ASTRO’s Strategic Plan, we know that these values remain part of the DNA of our organization, even starting with the first interaction one may have with ASTRO: the membership application. ASTRO recently updated the gender options on the membership application form to now include non-binary.
We must remain vigilant, transparent and responsive to the needs of our diverse members to ensure that all our colleagues feel included. Through CHEDI, ARRO and other collaborating groups, we must continue to work together to make sure we embody these values as an organization. Having a diverse and inclusive workforce ready to care for our diverse society will translate to improved health equity. We value our SGM patients and colleagues and will continue to advocate to ensure all voices are heard.
Malika Siker, MD, is an associate professor of radiation oncology and associate dean for Student Inclusion and Diversity at Medical College of Wisconsin in Milwaukee, Wisconsin. Her professional areas of interest include health equity, diversity and inclusion as well as hematologic and CNS malignancies.
Ross Zeitlin, MD, is a radiation oncology resident at the Medical College of Wisconsin. His academic interests include gynecologic malignancies and oncologic health disparities in the sexual and gender minorities.
Danielle Bitterman, MD, is a PGY-4 resident at the Harvard Radiation Oncology Program.