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Good morning. It's an honor
to be involved in this program.
I'm going to be speaking on a relatively touchy subject,
which is race and prostate cancer.
I'm going to share my screen.
I prepared a brief presentation.
There's no way that
in 10 minutes I can cover this topic in any detail,
but I'll do the best I can.
Why are we talking about this topic?
First of all, there are
substantial differences in
prostate cancer mortality rate.
Whether just for affluent counties versus poor counties,
African Americans still have
a substantially higher mortality rate.
The question comes, of what is race?
I believe race is the system for categorizing people,
not a biologic to biologic construct.
Here's some review article by
Paul Hoffman published in 1994.
He said on average there is 0.2 percent difference in
the genetic material between
any two randomly chosen people on Earth.
That's only six percent,
represents the differences between races.
That six percent of 0.2 percent race accounts
for a miniscule 0.012 percent difference.
Now, SEER data has been
published for years showing a gap that's persisted,
but the interesting thing is
that the gap has been moving.
This implies that the genetics
are not changing over time,
but social circumstances are changing over time.
You have some publications that would argue that,
if we have a healthcare system that
is the same for
everybody and you see differences in outcome,
it must be race,
here's one publication published in JNCI showing
the Kaiser patients that were white did
substantially better than
Kaiser patients that were black.
The implication that
these investigators concluded was that
these findings are most consistent with
the hypothesis of increased tumor virulence in blacks.
The problem is that,
and I wrote a letter to the journal, and I said,
"If a difference in outcome equals a biologic difference,
does the absence of a difference
imply no biologic difference?"
Here, I pointed out that if you looked at
Kaiser whites and Kaiser blacks,
Kaiser blacks did the same as non Kaiser whites.
Does this mean that somehow being
non Kaiser or Kaiser has
something to do with your biology?
There are numerous examples of disparities in healthcare.
For example, there was an article in JAMA
looking at coronary revascularization among
Medicare A enrollees and
the whites were more likely to
have such procedures performed.
Another study from JAMA,
the blacks were 33-54 percent
less likely to undergo cardiac catheterization,
coronary angioplasty and receive
a CABG than whites even in the VA system.
Now, people have argued that these are
genetic differences that are
important and there are genetic differences.
Clearly, if you look at people,
you see some people with blue eyes and blond hair,
dark skin and so forth.
But these things represent polymorphisms
that don't necessarily affect systems.
Here's an example where people showed that CAG repeats,
CAG repeats are part of the genetic information,
were significantly different in terms of
short CAG repeats and
long CAG repeats between blacks and whites.
But they did not correlate with Gleason score or the PSA,
the Stage, and they did not correlate with the outcome.
In fact, if you look internationally,
blacks from the US have a better survival rate
than whites and Asians in many other countries,
suggesting that social circumstances
are far more likely to
have an impact on outcome than anything else.
If you look at SEER data
and you look at outcomes, in this case,
I picked the year 1988 to look at,
and you can see the whites in 1988,
about 35 percent had
no treatment compared to more than 50 percent of blacks.
If you'd looked at aggressive treatment,
there were clear differences in
outcome and these are not accounted for
in some of the SEER statistics that you
see for when they talk about survival rates.
Now, what's my hypothesis?
I believe that chronic stress affects
the environment and this is some work
done by others showing that it affects the immune system,
blood vasculature for tumor
potentially could explain some of
the differences in the incidence and the outcome.
Now, how do you measure chronic stress?
This is an example of work done with mice put in cages.
You can see that if you take mice and put them in
cages and then you restrict
their movement as shown in the bottom right,
this induces a more stressful experience for
the mice measured by various markers like a [inaudible].
Here you see tumor weight in these mice,
those who had chronic stress had bigger tumors and
a larger number of
tumor nodules than those with less stress.
The other example is looking at
the proliferation of viruses and proliferation
of other markers associated with
immune suppression related to stress.
Then they've done the work in patients with,
for example, ovarian cancer.
They matched 10 patients,
five with high social support
and low depression and high with
low social support and high depression and
they perform various tests on these patients.
If you looked at markers
for stimulating the immune system,
there was a clear difference showing more promotion of
precancerous changes with those
who were depressed with less social support.
Now, the most accurate way of trying
to figure out whether race is important is
to look at patients that are treated on
Phase 3 prospective randomized trials,
where you can adjust for all the features of
the patients coming in and then you adjust for treatment,
and then you do systematic follow-up.
This is from a slide I made a couple years ago that
summarized the results of 12 randomized trials,
all of which reported outcomes by race.
Only one of them was studied by
Thompson et al show that blacks had a worst survival.
Eight of them showed no difference in
outcome and the ones I show in yellow,
actually showed that African Americans did
better on the randomized trials.
The preponderance of the evidence from Phase 3
randomized trials when you adjust for quality of care,
suggests that there's no difference in outcome.
Now, I would argue that
this experience with racism has been around for
many years since slavery times in
the post slavery Jim Crow era and has continued
with the development of
the criminal justice system that we currently have here.
In the US it makes up
about five percent of the world population,
but only about 25 percent of the world's prisoners.
The lifetime risk would be
an incarcerated one in 17 for whites,
one in three in blacks.
Blacks make up 40 percent of those incarcerated,
but only 6.5 percent of the general population.
This was caused by
the so-called "War on Crime" "Three-strikes,
you're out" "Mandatory Sentencing" "Minimum sentencing."
But in addition to this whole issue,
there are differences in hypertension,
diabetes, COVID-19, strokes, and unemployment.
There are differences in severity of prostate cancer
related to the neighborhood of deprivation.
There's a philosophical term
that we used to called Occam's razor,
which basically says the simplest explanation should
be considered in the plausibility of a hypothesis.
That is, if you could come up with
a unifying hypothesis to
explain all of this pathology, you should do that.
I would argue that this uniform pathology is racism.
When people say blacks inherently
have more aggressive prostate cancer,
I also remember when people said blacks were
too dumb to play basketball,
too dumb to play quarterback,
too dumb to play golf,
too dumb to be president,
and too dump to play baseball.
We certainly know that none of those things are true.
From a famous alumnus of mine,
"Of all the forums of inequity,
injustice in healthcare is
the most shocking and inhumane."
I think that the issue of race and racism in
prostate cancer has not been appropriately dealt with.
Thank you for your attention.
Mack, thank you for that nice talk.
I guess one question I have for you is what can be done?
You've demonstrated some of
the disparities in the context
of prostate cancer. What next?
Well, there's hope in the next generation.
I encourage people if you haven't watched
it on Netflix while we're all in pandemic,
still a little bit of lock down,
13th is about the 13th Amendment and
marches through the history
of what's happened in this country.
You also might want to look at the 14th,
but the 13th and makes
sure that our children watch these things.
One of the problems is that when people
drive through the Tenderloin in San Francisco,
they see a disproportionate number
of people lying on the streets who are
African American and they don't know
the history behind the stuff they go.
There's got to be something wrong with these people.
How did they end up like this?
They don't understand the victim
versus the circumstances.
Education for young people
to understand how we got where we are and then
moving forward to be part of
the solution by being
involved in politics and other things.
Thanks Mack. That's inspiring.
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