Transcription:
Breast and Prostate Cancer Health Disparities

Dr. Daniel Simon: Hello everyone. My name is Dr. Daniel Simon. I am your host of the Science at UH Podcast, sponsored by University Hospital's Research and Education Institute. This podcast features University Hospital's cutting edge research and innovations. Thank you for listening to another episode.

Host: Today, I am happy to be joined by two very special guests, Dr. Cynthia Owusu and Dr. Randy Vince. Dr. Owusu is a renowned oncologist with a research focus on breast cancer prognosis among African-American and socially disadvantaged, often older, breast cancer survivors. She also serves as the Associate Director for Diversity, Equity and Inclusion for the Case Comprehensive Cancer Center. Dr. Vince joined UH last year as an innovative urologic oncologist with a passion for minority men's health and racial justice in medicine. He also serves as the inaugural Minority Men's Health Director for the UH Cutler Center for Men. Welcome, Cynthia and Randy.

Cynthia Owusu, MD: Thank you.

Randy Vince, MD: Thank you.

Host: Before we begin, I think it's always great for us to learn a little bit about you personally. Can you tell us about yourself? Where did you grow up and where did you train, and what inspired you to be a physician scientist, Dr. Owusu?

Cynthia Owusu, MD: Thank you, Dr. Simon, for that wonderful introduction. Yes, I was born and grew up in Ghana. I went to medical school in Ghana, which is in West Africa. After I graduated from medical school, I began to work in a teaching hospital for so many breast cancer patients, and most of these patients came to the hospital with advanced stages. And so, I was very concerned about the plight of African women with breast cancer, very aggressive, and most of them died of this disease.

Guest 1: So as a young physician at that time, I made a decision to specialize in oncology. Well, in those days, there was no opportunities to specialize in cancer in Ghana. And so, I began to look at the United States and the process that I would need to go through to be able to come over to specialize. And so, I followed through with the process. And so back in 1998, I arrived and did my residency in New Jersey at Beth Israel Medical Center and then followed through to Boston University Medical Center to specialize in hematology and oncology as well as in geriatrics. Because by then, I had also realized that it wasn't just racial disparities that we were dealing with, but there was an age disparity as well. So, that is how I arrived in the United States. That is why I decided to specialize in oncology with a focus to look at disparities in breast cancer.

Host: Wow. That's an incredibly interesting path that you've taken. I have to say I didn't recognize that we had common training grounds in Boston where I was for so many years as well. Randy, tell us a little bit about yourself. You've come to UH from Michigan. How did you get there?

Randy Vince, MD: Dan, thank you. It's a pleasure to be here today. I must fully admit that while I'm happy to be here with somewhat of a heavy heart, a few days ago I lost my aunt. Her name was Dora Henry to a battle with pancreatic cancer.

Host: I'm so sorry to hear that.

Guest 2: No problem. I want to just say that I wish my aunt can rest in peace. She was probably one of the most genuine and sweetest people you ever meet. So, I came here from University of Michigan where I did fellowship in urologic oncology. Grew up in Baltimore, Maryland, which I'm sure many people who are listening knows has its own inherent struggles as most inner cities do. Ended up going to school and playing football at Towson University, which is also in the Baltimore area; medical school down in Louisiana; residency in urology at Virginia Commonwealth; and then, ultimately, a fellowship in urologic oncology at the University of Michigan.

When it came to pursuing a fellowship in urologic oncology, it was really around personal experiences in medical school that kind of shaped my desire to want to go into urology, but then also, the field of urologic oncology. And that experience, the major experience, was the experience of my grandmother who passed away from metastatic renal cell carcinoma or kidney cancer. And so, that happened in my second year of medical school and that kind of drove me to want to learn how to do those surgeries for kidney cancer and just be really good at them and ultimately helped people have more time with their family members than what I felt like I lost with my grandmother. So, that kind of led me to the interest of urologic oncology.

In terms of becoming a physician scientist, and I actually didn't go into medical school thinking I wanted to do research at all, I thought, you know, my plan going into medical school is to actually become a nephrologist, believe it or not, because of the fact that we know the disproportionate impact of diabetes, hypertension, chronic kidney disease, end-stage renal disease in black populations like the one that I grew up in. Again, that experience with my grandmother and losing her in medical school, that kind of shifted it. And then also, just hearing lecture after lecture about health disparities at the time really inspired me to want to do something. So, you know, I already looked at so many different things from my childhood and my experiences growing up. And I just said to myself, "Okay, well, the way that we are doing this obviously is wrong." We've had these health disparities for decades, if not centuries. So, how can I use the platform of being a physician to help drive change? And so, that's really what inspired me to become a physician scientist.

Host: Wow. Well, you're both certainly inspiring me. Let's get right into the heart of the discussion, which is obviously troubling to me. So, we live in a city considered a biomedical mecca, two great health systems, a phenomenal medical school. Ohio is ranked 47th in the country in health disparities and inequities. The city of Cleveland is the poorest urban center after Detroit, and health outcomes, follow that. Both of you are studying disparities and inequities from a different angle. Obviously, Cynthia, you with breast cancer; Randy, you focusing on prostate cancer. But let's start with you, Cynthia. So, we know that breast cancer survival rates are significantly lower for African-American women compared to non-Hispanic Caucasian counterparts and, in particular, for older African-American women compared to older white women. Why is that the case? Is this a genetic issue? Is it a disease-specific issue or is it, as we say, an issue of social determinants of health?

Guest 1: That's an excellent question. There are multiple factors which have come together to give us those disparities. There are the issues with social determinants of health, such as lack of access to care, so that's a major issue. But there are also differences in biology. Unfortunately, African-American women are more likely to be diagnosed with the most aggressive form of breast cancer, which is triple-negative breast cancer, which does not respond well to treatment. When you couple that with presentation at late diagnosis, so you have a lot of African-American women due to lack of insurance, lack of access to care, inability to navigate these big health system present at advanced stage, like stage III, stage IV. So, that obviously impacts treatment and outcomes.

And then, there are differences in treatment. Unfortunately, even when these women present in on time for a variety of reasons, data or research has shown that the time to diagnosis is longer for African-American women compared with their white counterparts. The time to treatment initiation is longer compared to their white counterparts. Even the actual treatment itself, when they should be getting chemotherapy, the chemotherapy regimen sometimes is less aggressive or lower than the standard of care. So, these treatment differences, presentation differences, biology of the tumor, lack of access to care, and then last but not the least, the poor health, unfortunately, of our African-American population. They come in with comorbidities, diabetes, hypertension, renal complications, all of that makes it challenging to give them the standard of care treatment. And so, that's why we have all these disparities. So, some of these reasons can be intervened on, can be addressed, and we should be focusing all our energies on addressing those issues that we can, particularly more research needs to be conducted into looking at triple-negative breast cancer and developing novel treatments that can kill that disease.

Host: Wow. That's a terrific answer. Now, Cynthia, you've recently been named a co-investigator on a new NIH-funded study called the Thrive Intervention, testing regular resistance exercise sessions delivered via telehealth during the time when patients are undergoing chemotherapy can help improve outcomes. And this new NIH study is among the first to test the beneficial effects of exercise for patients with breast cancer. Can you talk a little bit about this? How did you come to understand the possibility that exercise could influence cancer outcomes?

Guest 1: Excellent question. One of the important things we examine or evaluate to determine whether any patient is fit or can tolerate chemotherapy is your physical fitness, your physical function, simply put, whether you can walk through the door, that's what we see. If you can walk through the door without any help, then you are fit for chemotherapy. So, that's where exercise comes in, that is where older women come in. And this study is particularly dedicated to women 65 years and older, newly diagnosed, who are about to receive chemotherapy. A lot of times, we examine these women and we decide they are not fit for chemotherapy, they cannot tolerate chemotherapy. So, the disparities begin right there and then.

Now, this study is going to evaluate whether if we offer older women with breast cancer exercise during chemotherapy, whether they are going to be able to tolerate chemotherapy better. There is this technology called relative dose intensity. How much of your chemotherapy did you receive? If you are able to receive 85% of the intended dose, it's been determined that you are less likely to have recurrence. Only about 50% of older women with breast cancer actually receive the intended dose of chemotherapy. So, that's the primary outcome of the study. Will exercise allow older women to achieve an 85% relative dose intensity? And to be able to do that, this is a randomized control trial, so half of the women will be in the exercise intervention and the other half will not be. And so, we are very excited about it because it's a first such study to be conducted in older women with breast cancer.

Host: You know, Cynthia, it's really a remarkable hypothesis that you have and it hits home with me because my mother has had breast cancer twice. Her second course of breast cancer was in her 80s. And even today at 90, almost 91, she still walks two miles every day outside. And so, I have to tell her she thought the exercise was for heart disease and brain health, but now I can tell her that it's potentially beneficial for cancer as well. That's really terrific.

Randy, you have a particular interest in mitigating the impact of structural racism on healthcare outcomes with a particular focus on prostate cancer. I guess, you know, one of the issues here is the age old notion of nature versus nurture. Is it our environment? Is it our genes? And we've come to learn actually that your research is at the interface of the environment and genes and something called epigenetics. Can you explain to our listeners what is this? How is it that the environment can influence our genes? And how does that impact your research into disparities in prostate cancer?

Guest 2: Yeah. Thank you, Dan. That's a great question. So, I think the first thing is we kind of have to lay a little bit of a groundwork here or a background because we often talk about structural racism, we talk about social determinants of health, we talk about disparities, et cetera. And I feel like sometimes all of those things can get muffled. The way I like to think about it is it kind of, for my simplicity mind's sake, it's a continuum, And the reason I say that is because we know that structural racism has led to many of the issues that we talked about when we talk about social determinants of health, right? So whether it's education, healthcare, poverty, you name it, the community you live in, environmental exposures, toxin exposures, whatever it may be, all of those things are related to social determinants of health, which we can link back to structural racism. And then, we also know that social determinants of health have a very substantial impact on healthcare outcomes and lead to a lot of the disparities that we know exist across multiple disease states.

As a urologic oncologist, the most prevalent cancer that we see is prostate cancer. And so, my research tends to shift that way, but I also tell people all the time, I'm pro-research for anything that will provide equity. But you know, the main question is how do the lived experiences of our patients impact their disease severity at the time of diagnosis? And specifically when we talk about prostate cancer, how does it impact their tumor biology? We know it's been studied in multiple health conditions that the environmental exposures like toxin exposure, pollution, things like that, lived experiences like trauma, racism, discrimination, mixed with all of those other societal issues that we just talked about when we talked about social determinants of health, all hasten the development of chronic disease states, so whether it's diabetes, hypertension, whatever it may be. But when we talk about black men for prostate cancer, we all often talk about prostate cancer as a chronic disease state because it is a cancer. And so for some reason we've just kind of turned a blind eye to how your lived experiences impact your tumor biology and your gene expression.

So, it's not an innate biological thing based off of the color of your skin, but as you go throughout life, these different stresses can ultimately influence inflammatory states, which we know can ultimately impact he biology and make tumors more aggressive. We are just trying to catch up with where research has been within other medical conditions within prostate cancer because so long it has just been, "Nope, you have black skin or you're a black person and you are just preordained from birth to have really bad prostate cancer. And the way we define race in this country historically, those two things don't fit when we talk about from a biological perspective. And so, that's really the gist of how we are trying to develop this research program here.

Host: Randy, let me ask you a question about that, you brought up a very interesting thing that I study in heart disease, which is inflammation. And we know now that the rage in cancer is obviously immunotherapy, harnessing your body's own tumor surveillance system to check cancer and maybe convert it to, as we would say, a chronic disease or a disease of permanent remission, shall we say. So, tell me, armed with that knowledge that there's more inflammation potentially in African-American men with prostate cancer, immunotherapy, is it more effective in those groups as well? Are there opportunities to leverage the immune system, to combat these cancers?

Guest 2: Yeah. So, I'm going to be completely honest, this is not my area of expertise, but I do know that the use of immunotherapies within prostate cancer has been increasing. However, the clinical trials that are looking at or evaluating the utility of immunotherapies don't really have many black men enrolled which kind of goes back to the issue when it comes to clinical trials that we've known has been existing for years. So, I think the data itself, it's still out there. So, I can't say that for sure that it'll benefit black men more. But it has shown some benefit within prostate cancer patients, but I also think it's important to realize that prostate cancer tends to behave a little bit differently than other forms of cancer. So, you know, with that being said, this is the reason why we can do things like active surveillance for prostate cancer because, if it's caught early, for some men, it's very non-aggressive and will not be threatening to their health. So, to answer the question though, I think the data is still out there.

Host: Well, now you just tossed me a followup question that I have to ask Cynthia. So Cynthia, in your role as the Associate Director for Diversity, Equity Inclusion in the, Case Comprehensive Cancer Center, for which I serve on the executive governing council, I have to ask you what are you going to do? What is the Case comprehensive Cancer Center doing to increase enrollment of black patients in clinical trials?

Guest 1: What we are doing in that space right now is really to look at where we are. And when I say where we are in terms of the workforce. So, that's the major focus of this initiative or that department. We know that African-American patients tend to feel more comfortable if there is racial convergence with whoever is their provider. And so, the focus of that space or that department is to increase the diversity, enhance the diversity in the leadership of the case comprehensive cancer center, as well as in the physician scientist workforce as well as the provider workforce. And so, what we are doing as our initial initiative is actually to determine the diversity of our leadership and workforce and also assess where our engagement and inclusion is. Once we have that baseline, we are then going to use that baseline as metrics to measure our progress as we develop other initiatives to improve diversity and inclusion within the cancer center.

Host: You've issued a very important challenge to leaders like me, and I think one of the things that we're trying to do is to do exactly what you said, which is to attain more convergence. So, I know seeing you now caring for breast cancer; Randy for prostate cancer; Woody McClelland, who was just recruited for neuro tumors as a radiation oncologist, tumors of the brain and spine; and Dr. Obeng for lung cancer. So, we have a ways to go. But I think that you're absolutely right, recruitment of African-American faculty to lead and enroll in these clinical trials is going to be critical, and we will continue to try to improve in that regard. So Randy, I want to ask you, a near final question, and that is that you also have an interesting title as the inaugural director of the Cutler Center for Men's Minority Health Group. Tell me a little bit about what are you trying to do with that program? What's your main goal?

Guest 2: So, I think I can't say that there's one main goal. I think there are a few goals that I have that are set out for myself personally as well as with the program that we're trying to build. And being here, you know, I started a little over six months ago. It was I wanted to hit the ground running in terms of building relationships with community members as well as community leaders. And this kind of hints on or hits on the previous question about clinical trial enrollment. Because one of the things that we know whether it's Cleveland, Detroit, Baltimore, DC, Philadelphia, you name the city, when you go to a black community, there's this distrust within the medical system because of the history of exploitation, right? And so, one of the things for me that was really important was to get out into the community and start to build these relationships with people, because I want people to get to know me as a man first, understand my passions and then we can start to build that trust, right?

In terms of overarching with the programs that we're trying to do, it really aligns with the mission of the Cutler Center and that is we want to increase health literacy, which ultimately we know change healthcare behaviors or healthy behaviors for patients. We want to be able to connect more men with primary care physician, so they can undergo preventative medicine services because we know screening does work. And then, again, build those connections. So if we can now build those relationships where people trust us and they can come to us and say, "Hey, I don't have insurance. Can you help me?" Right? We can help those people who are uninsured or underinsured, get the services that they need. So, it's really those are the big three things, kind of the big three pillars of our goals that we want to achieve with the program. But, you know, to take that a step further, I'm here for the long run. The one goal that we want to do is after we get those things set up, we want to actually start doing other wraparound services for patients in the community. So, you know, it's a process. It takes a long time to start to reverse a lot of things that have been decades, if not centuries, in the making. But we're up for the task.

Host: Well, I want to thank both of you for joining me today on this podcast. You know, I had the good fortune yesterday of interviewing Dr. Ted Teknos, our president and scientific director of the Seidman Cancer Center, and he shared with me something which I think leads me to believe that the glass is half full. And that is that if you look at the 2023 American Cancer Society Statistics, we are seeing a major reduction in mortality from cancer in the United States over the past several years. And one of the things that's very heartening about those statistics is that the reduction in mortality is greatest in black men. And what's happening is, although black men continue to have the highest cancer mortality, the differences between black men and white men and white women and black women is narrowing over time. So, cancer mortality is going down, survival is improving, and everybody is benefiting. Our challenge now is to eliminate those inequities, and the mortality differences that still exist. And so, I want our listeners to know that we could not be in better hands than having people like you, Dr. Randy Vince and you, Dr. Cynthia Owusu.

Guest 1: Thank you.

Guest 2: Thank you, Dan.

Host: I want to thank you all for taking the time to listen today to Dr. Owusu and Dr. Vince. For our listeners interested in learning more about research at University Hospitals, please visit uhhospitals.org. Thank you.