More data needed on sex, gender differences in stroke treatment, outcomes
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Endovascular therapy is now a standard treatment for select patients with severe ischemic stroke to improve the likelihood of functional recovery; yet there remains a paucity of research on outcomes by sex and gender.
The American Heart Association in June published a scientific statement on sex- and gender-related differences in endovascular stroke treatment in Stroke. The statement provides a list of suggestions to assess sex- and gender-related differences in endovascular therapy (EVT) research, along with a guide for clinicians to improve care for people who have undergone EVT by addressing sex- and gender-specific factors.
Healio spoke with Johanna M. Ospel, MD, PhD, a radiology resident at the University Hospital of Basel, Switzerland, and a member of the scientific statement writing group, about the differences between sex and gender, the underrepresentation of women in stroke trials and the importance of talking to stroke patients about their background. The American Academy of Neurology, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons also endorsed the AHA statement.
Healio: Why was a statement like this needed now?
Ospel: EVT became the standard of care for ischemic stroke quite recently. For other forms of stroke, there is a lot of evidence to suggest there are many sex- and gender-related differences regarding treatment effect and also stroke outcomes. Yet, for EVT, not much is known. There are some controversial papers suggesting there are differences; some suggest women have a better poststroke outcome, whereas other suggest there is no difference between sexes. We felt there was a need to summarize the data and also provide some guidance on how to assess sex- and gender-related differences after EVT.
Healio: The statement suggests studies examining biological and hormonal factors related to stroke should consider analysis by sex, whereas research assessing the impact of stroke on quality of life and other social factors may find analysis by gender to be more relevantCan you explain the differences between sex and gender as it relates to stroke research?
Ospel: Sex refers to biological, chromosomal variables. It is binary: male or female. Gender, however, includes gender identity but also refers to the social or cultural roles someone takes on. A person who identifies as male may take on roles or responsibilities more associated with female gender. Gender identity is not binary or static; it exists along a spectrum and may change over a person’s lifetime. Acute stroke is an acute disease, so usually there is no time to discuss social and cultural roles in depth. In cases of an emergency treatment such as EVT, when treatment decisions must be made quickly, usually sex, rather than gender, is reported. Most research papers talk about sex only; however, some use the word “gender,” so there is confusion in the literature. When one talks about females having worse poststroke outcomes, for example, we do not really know what is related to sex vs. gender. Is it due to biological characteristics, such as hormonal differences? Or is it related to social and cultural differences? For example, women are more likely to live alone compared with men and are more likely to be affected by poststroke depression, or perhaps even more dependent on a spouse to drive them to the hospital.
Healio: How should researchers assess sex differences?
Ospel: For researchers, we felt it is important to keep screening logs for studies. Assess which patients were included vs. which were not. Many times, women are excluded from stroke trials because they are older and have worse pre-stroke functional status. Most of the randomized controlled trials consider those as exclusion criteria. It is important to assess whether a study population is misrepresenting women. More healthy, younger, functionally independent women get included, but that is likely not representative of the “real” population of women affected by stroke.
In the end, being male or female can result in different access to health care, employment, financial autonomy and willingness to participate in such research and ultimately differentials in power, all of which may affect post-EVT outcomes.
Healio: How can clinicians improve care for people who have undergone EVT, taking sex differences into account?
Ospel: There are several things. One is to talk to patients about their social environment, particularly with older patients. Might they have trouble getting to a follow-up appointment? Are they still mobile and able to travel to a hospital? Do they live alone? Actively ask about such things in conversation.
Some studies suggest that EVT may be underused in women, even in industrialized countries, although these results should be interpreted with caution. However, being aware of this discrepancy is a first important step for clinicians and should motivate them to thoroughly evaluate female patients with stroke with regard to EVT eligibility.
Healio: What more do we need to learn to improve care and research overall?
Ospel: Learn about the population that is not included in trials and see if that matches the overall population. Learn more about gender. Often, we see the patient and check the “female” or “male” box. In the acute setting, we of course do not have the time to dive into this very deeply. But if a patient is on the ward or the stroke unit, we can go back and ask about their social responsibilities and learn a little more about them. Ask about their environment and social determinants of health, which affects care.
It is so important to ask about access to stroke care, especially for countries outside of North America. In some countries, women do not have the financial means to access care and are dependent on their spouse or families. This is why, in some regions of the world, registries suggest that 80% of stroke patients are men. This cannot be true. We must determine how many people could benefit from EVT lack of access to this highly effective treatment — in our own hospitals, our country and on a global scale.
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For more information:
Johanna M. Ospel, MD, PhD, can be reached at johannaospel@gmail.com; Twitter: @johanna_ospel.
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