I'M ALAN SCHECHTER, AND I
WELCOME YOU TO THIS LECTURE IN
THE BIOMEDICAL LECTURE SERIES
SPONSORED BY THE OFFICE OF NIH
HISTORY.
WE ARE VERY PLEASED TO HAVE AS
OUR SPEAKER TODAY DR. OTIS
BRAWLEY, WHO IS THE BLOOMBERG
DISTINGUISHED PROFESSOR OF
ONCOLOGY AND EPIDEMIOLOGY AT
JOHNS HOPKINS, WHO WILL TALK TO
US TODAY ON THE EVOLUTION OF
MINORITY HEALTH RESEARCH.
BEFORE I GO FURTHER ABOUT
TODAY'S TALK, AND DR. BRAWLEY,
I'D JUST LIKE TO MENTION THAT WE
ARE VERY PLEASED THAT AN
INDIVIDUAL WAS RECENTLY
DESIGNATED AS THE OFFICIAL NIH
HISTORIAN, STARTING I THINK NEXT
WEEK, DR. KIM PELLIS, WHO HAS
BEEN A SENIOR STAFF MEMBER IN
THE OFFICE OF THE NIH DIRECTOR
FOR MANY YEARS, WHO WILL BECOME
THE DIRECTOR OF THE OFFICE OF
NIH HISTORY AND THE STETTEN
MUSEUM VERY SHORTLY.
BUT NOW LET ME RETURN TO TODAY'S
TALK AND OUR SPEAKER.
DR. BRAWLEY WAS TRAINED IN
MEDICINE AT THE UNIVERSITY OF
CHICAGO, AND THEN DID FURTHER
INTERNAL MEDICINE TRAINING AT
THE UNIVERSITY OF MICHIGAN
BEFORE COMING TO THE NIH, THE
NATIONAL CANCER INSTITUTE, IN
1988, TO DO AN ONCOLOGY
FELLOWSHIP, WHERE HE REMAINED
FOR 13 YEARS, JOINING THE STAFF
OF THE NCI.
BUT IN 2001, HE WAS RECRUITED TO
ATLANTA, TO EMORY UNIVERSITY
SCHOOL OF MEDICINE, AS MEDICAL
DIRECTOR OF THE GEORGIA CANCER
CENTER, AND ALSO AS A SENIOR
PROFESSOR IN THE ONCOLOGY
PROGRAM AT EMORY.
FROM 2007 TO 2018, HE WAS ALSO
THE MEDICAL AND SCIENTIFIC
DIRECTOR OF THE AMERICAN CANCER
SOCIETY IN ATLANTA, AND HAD A
VERY DISTINGUISHED TRACK THERE,
BEING INVOLVED IN MANY DIFFERENT
STUDIES, INCLUDING HEALTH
DISPARITIES AND THE ROLE OF
SCREENING IN DIAGNOSING AND EVEN
OVERDIAGNOSING CANCER IN THE
COUNTRY AND IN THE WORLD, IN
FACT.
IN 2018, DR. BRAWLEY LEFT
ATLANTA AND CAME TO HOPKINS,
WHERE HE IS A PROFESSOR OF
ONCOLOGY AND EPIDEMIOLOGY AS I
MENTIONED.
HE ALSO HAS ROLES IN THE KIMMEL
CANCER CENTER THERE, AND THE
SCHOOL OF PUBLIC HEALTH.
EARLIER THIS WEEK HE PRESENTED A
TALK TO THE NIMH INNOVATIVE
SEMINAR SERIES ON BEHAVIORAL
EFFECTS ON CANCER INCIDENCE AND
OUTCOMES, BUT TODAY'S TALK IS
COMPLEMENTARY TO THAT TALK IN
WHICH HE WILL TALK ABOUT HIS OWN
THOUGHTS AND PERSPECTIVE ON THE
EVOLUTION OF MINORITY HEALTH
RESEARCH.
IT'S GOING FROM VARIOUS TITLES,
INCLUDING SPECIAL POPULATIONS
AND HEALTH DISPARITIES TO ITS
CURRENT FORM, WHICH HE WILL
PRESCRIBE HISTORICALLY AND HIS
PERSPECTIVES FOR THE FUTURE.
IN THE MEANWHILE, I'D LIKE TO
TURN THE SCREEN OVER TO
PROFESSOR BRAWLEY FOR HIS TALK
ON MINORITY HEALTH RESEARCH.
DR. BRAWLEY.
>> THANK YOU.
I WANT TO THANK DR. SCHECHTER,
MY OLD FRIEND DR. GOTTESMAN, DR. WANJEK FOR ARRANGING THIS.
IT IS REALLY A PRIVILEGE TO BE
HERE AND A PRIVILEGE TO TALK A
LITTLE BIT ABOUT HISTORY AND THE
NIH.
I REALLY GREW UP AT THE NIH, AND
REALLY BECAME A DOCTOR THERE SO
I'M VERY FOND OF IT.
I AM A PROFESSOR AT THE SCHOOL
OF PUBLIC HEALTH AT JOHNS
HOPKINS AND THE SCHOOL OF
MEDICINE AT HOPKINS.
IN ADDITION, I DO SOME
CONSULTING BOTH FOR THE NIH,
CDC, THE DEPARTMENT OF DEFENSE
AND SEVERAL COMPANIES.
NONE OF THIS TALK HAS TO DO
ABOUT ANY OF THOSE EXCEPT A LOT
HAS TO DO ABOUT THE NIH.
I'M GOING TO TELL YOU RIGHT NOW,
I WAS TAUGHT FROM AN EARLY AGE
THAT YOU SHOULD LABEL THINGS
WHAT YOU KNOW, WHAT YOU DON'T
KNOW AND WHAT YOU BELIEVE, BUT
QUESTION WHAT YOU KNOW MORE SO
THAN ANYTHING ELSE, BUT QUESTION
ALL THINGS.
AND THESE ARE GOOD RULES FOR
HEALTHCARE.
AND I'M GOING TO APPLY THAT TO A
FEW THINGS AS I MAKE A FEW
COMMENTS DURING THIS TALK.
WE'RE GOING TO TALK ABOUT THE
EVOLUTION OF AN ACADEMIC
DISCIPLINE.
IT WAS FIRST CALLED MINORITY
HEALTH BACK IN THE 1970s AND
80s, AND THEN SPECIAL
POPULATIONS HEALTH, IT EVOLVED
INTO HEALTH DISPARITIES OR THE
STUDY OF DISPARITIES IN HEALTH
UNDER THE LEADERSHIP OF DAVID
SANCHER.
OTHERS HAVE STARTED CALLING IT
HEALTH EQUITY AND IT'S NOW
STARTING TO BLOOM INTO THE
PHRASE "HEALTH JUSTICE."
MORE ON THAT IN A BIT.
WHEN WE TALK ABOUT HEALTH
EQUITY, I WANT YOU TO THINK
ABOUT THE FOLLOWING.
EQUALITY IS EVERYBODY GETS THE
SAME THING.
EQUITY REALIZES THAT SOME
PEOPLE, SOME GROUPS, SOME
POPULATIONS WHEN WE'RE DOING
HEALTH, MAY NEED A LITTLE BIT
MORE THAN OTHER POPULATIONS TO
GET TO WHERE WE ALL WANT TO BE.
SOME PEOPLE MAY NEED A LITTLE
BIT MORE.
NOW, HOW CAN WE PROVIDE ADEQUATE
HIGH QUALITY CARE TO INCLUDE
PREVENTIVE SERVICES AND
PREVENTIVE SERVICES ARE
FREQUENTLY FORGOTTEN, IS ONE OF
THE MOST IMPORTANT QUESTIONS
THAT WE CAN ASK.
HOW CAN WE PROVIDE ADEQUATE HIGH
QUALITY CARE TO POPULATIONS THAT
SO OFTEN DON'T RECEIVE IT?
I WANT TO START OUT WITH A
LITTLE HISTORY.
REVEREND RICHARD ALEB ALLEN AND
REVEREND ABSALOM JONES WERE TWO
BLACK MINISTERS TOWARDS THE END
OF THE 17 HUNDREDS LIVING IN
PHILADELPHIA.
THIS WERE ONLY ABOUT 50,000
PEOPLE IN PHILADELPHIA AT THE
TIME, ALTHOUGH IT WAS THE
LARGEST CITY IN THE THEN EARLY
UNITED STATES.
IN 1793, THERE WAS A YELLOW
FEVER EPIDEMIC.
IT WAS BELIEVED WIDELY THAT
BLACK PEOPLE, NEGRO PEOPLE, DID
NOT GET YELLOW FEVER, THIS WAS
ONLY SOMETHING THAT WHITE PEOPLE
GOT.
AS A RESULT, THERE WERE ALL
KINDS OF REQUESTS THAT NEGROES
COME AND NURSE THE SICK, BURY
THE DEAD, AND SO FORTH.
THIS WAS WRITTEN BY ALLEN ABOUT
THE FACT THAT BLACKS ACTUALLY
DID GET YELLOW FEVER.
THIS WAS THE BEGINNING, AT LEAST
THE FIRST THAT I CAN FIND
DOCUMENTED WHERE THERE WAS THIS
DIFFERENCE BETWEEN BLACK AND
WHITE OR NEGRO AND CAUCASIAN
BIOLOGY.
AND THAT'S GOING TO BE A THEME
FOR THE REST OF THIS TALK THAT
WE HAVE BEEN STUCK ON THIS THING
ABOUT RACE FOR SO LONG.
NOW THIS HAS BEEN WRITTEN ABOUT
A FEW TIMES.
HARRIET WASHINGTON WROTE THE
MOST AUTHORITATIVE BOOK THAT I
KNOW OF CALLED "MEDICAL
APARTHEID," AND IT TALKS ABOUT
MEDICAL RESEARCH AND DIFFERENCES
IN RACIAL TREATMENT OVER A
PERIOD OF ABOUT 200 YEARS.
ANOTHER WONDERFUL BOOK, "BAD
BLOOD" BY JAMES JONES.
THIS IS BAD BLOOD ABOUT THE
TUSKEGEE SYPHILIS EXPERIMENT,
NOT BAD BLOOD ABOUT THE COMPANY
THERANOS.
AND I WANT TO TELL YOU A LITTLE
ABOUT THE TUSKEGEE SYPHILIS
EXPERIMENT WHICH IS NOT REALLY
APPRECIATED BY A LOT OF PEOPLE.
FIRST, THE OFFICIAL NAME OF THE
STUDY WAS THE STUDY OF UNTREATED
SYPHILIS IN THE NEGRO MALE.
AND BACK IN THE LATE 1920s,
THERE WAS SIGNIFICANT SYPHILIS,
ESPECIALLY IN THE SOUTHERN
UNITED STATES.
SYPHILIS CONTROL EFFORTS, WHICH
WERE LARGELY SEX EDUCATION,
IDENTIFICATION AND ISOLATION OF
THE INFECTED, AND TREATMENT WITH
MERCURIALS, OF ALL THINGS, WERE
STYMIED BY THE DEPRESSION.
MANY FELT THAT MONEY FOR
SYPHILIS CONTROL, WHICH WAS
SHORT, SHOULD BE SPENT ON THE
WHITE POPULATION BECAUSE BLACKS
DON'T DIE OF SYPHILIS.
AGAIN, THIS THEORY THAT BLACKS
ARE BIOLOGICALLY DIFFERENT FROM
WHITES SUCH THAT AN INFECTIOUS
DISEASE DOESN'T AFFECT BLACKS
VERSUS WHITES.
NOW, SOME OF WHAT I WILL CALL
THE GOOD WHITE PEOPLE BACK IN
THE LATE 1920s, ACTUALLY GOT
INTO A LITTLE BIT OF TROUBLE
WITH THEIR EXAGGERATION.
THEY WOULD GO TO A 2 BY 2 BLOCK
TENEMENT HOUSING PROJECT IN
BIRMINGHAM, ALABAMA, TEST ALL
THE MEN LIVING THERE FOR
SYPHILIS, FIND THAT 25% OF THOSE
MEN HAD SYPHILIS, AND THEN THEY
WOULD SAY, SEE, WE DESPERATELY
NEED TO SPEND MONEY ON SYPHILIS
CONTROL IN THE BLACK POPULATION.
25% OF ALL BLACK MEN IN THE
SOUTHERN UNITED STATES HAVE
SYPHILIS.
AND THEN, OF COURSE, THE MORE
RACIST WHITES WOULD SAY, YOU'RE
MAKING OUR POINT.
THEY'RE NOT DYING.
SHOW US THE BODIES IF 25% HAVE
SYPHILIS.
SO WHAT ENDED UP HAPPENING WAS
THE U.S. PUBLIC HEALTH SERVICE,
CDC DIDN'T EXIST AT THE TIME.
THE U.S. PUBLIC HEALTH SERVICE
ORGANIZED THE STUDY OF UNTREATED
SYPHILIS IN THE MEE GROW MALE.
WE IN THE NEGRO MALE.
WE WOULD CALL THIS A CASE
CONTROL STUDY TODAY.
IT COMPARED 399 MEN WITH
SYPHILIS WITH AN AGE MATCHED 201
MEN WHO DID NOT HAVE THE
DISEASE.
THEY WERE FOLLOWED OVER A PERIOD
OF TIME TO SEE WHAT THE RESULTS
OF SYPHILIS WAS.
YOU SEE, IRONICALLY, THE
TUSKEGEE SYPHILIS STUDY WAS
DESIGNED TO SHOW THAT BLACK
PEOPLE ARE LIKE WHITE PEOPLE.
PARTICIPANTS UNFORTUNATELY WERE
LIED TO.
MOST WERE TOLD THEY HAD BAD
BLOOD AND THEY THOUGHT THEY WERE
ALL GETTING SOME KIND OF
TREATMENT FROM THIS STUDY.
IT WAS USUALLY VITAMINS.
PARTICIPANTS GOT FREE MEDICAL
EXAMS, FREE MEALS, BURIAL
INSURANCE.
THEY ALSO GOT TO DRIVE IN THE
SHINY CARVE A BLACK NURSE WHO
ORGANIZED THE ROUNDUPS.
HERE'S A ROUNDUP WHERE MEMBERS
OF THE STUDY WERE LOOKED AT ONCE
A YEAR.
THEY ACTUALLY HAD ROUNDUPS ONCE
A YEAR FROM 1930 TO 1971.
THEY GOT MEDICAL EXAMS, WHICH
INCLUDED PAINFUL SPINAL TAPS,
UNNECESSARY X-RAYs.
I SHOULD NOTE THAT PENICILLIN
BECAME THE TREATMENT OF CHOICE
FOR SYPHILIS IN THE MID 40s,
BUT THESE MEN WERE NOT TREATED.
THE STUDY WAS ENDED IN 1972,
AFTER THE ASSOCIATED PRESS
PUBLISHED ARTICLES ABOUT IT.
NOW THE STUDY WAS NEVER A
SECRET.
LOCAL DOCTORS WERE TOLD NOT TO
TREAT THESE MEN IN 1936 AND
BEYOND.
RESEARCHERS KEPT THE MEN OUT OF
THE DRAFT BECAUSE IF THEY WERE
DRAFTED INTO THE MILITARY, THEY
MIGHT BE DIAGNOSED AND TREATED.
THE MAYCON COUNTY, ALABAMA
MEDICAL SOCIETY, WHICH WAS A
CHAPTER OF THE BLACK NATIONAL
MEDICAL ASSOCIATION, ENDORSED
THE STUDY IN 1969.
THOSE OF YOU WHO REMEMBER
HISTORY MAY RECALL THAT WE HAD A
BLACK SURGEON GENERAL NOMINEE
WHO LOST HIS NOMINATION BECAUSE
HE WAS INVOLVED IN THIS, OR
THERE WERE RUMORS HE WAS
INVOLVED IN THIS.
SEVERAL ARTICLES WERE PUBLISHED
OVER THE YEARS IN MAJOR JOURNALS
ABOUT THE TUS KEY GOA SYPHILIS
STUDY.
INTERESTINGLY, SEVERAL OF THESE
ARTICLES WERE PUBLISHED IN
PLACES LIKE THE JOURNAL OF THE
AMERICAN MEDICAL ASSOCIATION.
SO THAT GIVES YOU A LITTLE
PICTURE AGAIN OF THIS BELIEF
THAT BLACK BIOLOGY IS DIFFERENT
FROM WHITE BIOLOGY.
THEN OF COURSE WE GO INTO THE
1960s, AND WE HAVE THE CIVIL
RIGHTS MOVEMENT.
THE CIVIL RIGHTS MOVEMENT
BECOMES EVEN MORE OF AN
APPRECIATION OF HEALTHCARE
ISSUES.
MANY PEOPLE DON'T REALIZE THAT
IN THE 1960s, HOSPITALS WERE
SEGREGATED BLACK VERSUS WHITE,
SCHOOLS WERE SEGREGATED BLACK
VERSUS WHITE, SCHOOLS INCLUDING
MEDICAL SCHOOLS.
IN THE 1970s, THE EARLY
1970s, RICHARD NIXON SIGNED
THE NATIONAL CANCER ACT.
NOW THIS PUT A LOT OF MONEY IN
THE CANCER RESEARCH AND
REVITALIZED THE NATIONAL NATIONAL CANCER
INSTITUTE, BUT IT ALSO CREATED
SOME PROGRAMS THAT GAVE US MORE
AND MORE INFORMATION ABOUT
OUTCOMES, AND IT HELPED TO
STIMULATE THE BEGINNING OF
OUTCOMES RESEARCH, NOT JUST IN
CANCER BUT IN OTHER THINGS.
ONE ASPECT OF THE NATIONAL
CANCER ACT WAS THE CREATION OF
THE NATIONAL CANCER INSTITUTE'S
SURVEILLANCE EPIDEMIOLOGY END
RESULTS PROGRAM.
IT, ALONG WITH SOME OTHER STATE
REGISTRIES, THEN ALLOWED US TO
ACTUALLY GET INCIDENCE AND
MORTALITY DATA AND FIGURE OUT
WHAT SURVIVAL RATE WERE, FIGURE
OUT WHO WAS GETTING CANCER.
ALSO EVEN DO SOME WORK ON WHY
THEY WERE GETTING CANCER.
THE SEER PROGRAM EXISTS TO THIS
DAY AND HAS DONE SOME MARVELOUS
WORK.
ONE EXAMPLE OF WHAT THEY DID WAS
PLOT MORTALITY BY RACE.
AND HERE, YOU CAN SEE INTO THE
1980s, THEY ONLY DID BLACK,
WHITE, FROM 1975 ONWARD, AND YOU
CAN SEE IN THE 1970s,
INTERESTINGLY, THERE WAS NO
DIFFERENCE IN BLACK OR WHITE
MORTALITY FOR BREAST CANCER.
FOR EVERY 100,000 BLACK WOMEN,
IT WAS ABOUT 32 DEATHS A YEAR,
FOR EVERY 100,000 WHITE WOMEN,
IT WAS ABOUT 32 DEATH PER YEAR.
THE SEER PROGRAM WHICH ACTUALLY
GIVES US DATA USUALLY ABOUT
THREE YEARS BEHIND.
THE 2019 DATA IS COMING OUT
RIGHT NOW.
THE SEER PROGRAM DOCUMENTED
INCREASING BREAST CANCER
DISPARITY, BLACK VERSUS WHITE,
FROM A TIME WHEN THERE WASN'T
ONE.
BY THE WAY, BY EXECUTIVE ORDER
IN THE 1980s, RONALD REAGAN
ORDERED THAT WE START COLLECTING
AND PUBLISHING DATA FOR
HISPANICS, NATIVE AMERICANS AND
ALASKA NATIVES AND ASIANS, AND
THAT'S WHY THE LINES FOR THOSE
GROUPS START IN 1990.
HERE YOU CAN SEE ALL THE WAY TO
2015.
BUT IN THE LATE 1970s, EARLY
1980s, STARTING TO GET A SENSE
OF SOME OF THESE DISPARITIES.
NOW PATRICIA ROBERTS HARRIS WAS
SECRETARY OF HEALTH EDUCATION
AND WELFARE IN THE LATE CARTER
ADMINISTRATION.
SHE WAS ACTUALLY THE HUD
SECRETARY BEFORE SHE WENT TO
HEW.
IT WAS CALLED HEW AT THAT TIME,
FOR THOSE OF YOU WHO DON'T HAVE
GREY HAIR.
AND SHE STIMULATED SOME GREATER
INTEREST IN STUDYING SOME OF
THESE DIFFERENCES AMONG
POPULATIONS.
AT THAT TIME, IT WAS STILL
CALLED MINORITY HEALTH.
MARGARET MARY HECKLER WAS A
REPUBLICAN CONGRESSWOMAN WHO
PRESIDENT REAGAN APPOINTED TO BE
SECRETARY OF HEALTH AND HUMAN
SERVICES, EDUCATION HAD DROPPED
OUT TO BE ITS OWN DEPARTMENT BY
THIS TIME.
AND MARGARET MARY HECKLER, OUR
SECRETARY HECKLER WAS VERY
INTERESTED IN THIS ISSUE, AND
WITH THE ENCOURAGEMENT OF
SEVERAL VERY PROMINENT BLACK
PHYSICIAN, ONE OF WHOM YOU'LL
SEE A PICTURE OF LATER, A MAN
NAMED SULLIVAN, SHE COMMISSIONED
THE HECKLER REPORT.
AND HERE'S THE REPORT OF THE
SECRETARY'S TASKS FORCE ON MY
MORTGAGE HEALTH.
THIS IS A GROUP OF PEOPLE WHO
MET VERY MUCH LIKE THE SURGEON
GENERAL'S TASK FORCE ON TOBACCO.
THEY MET REGULARLY AND THEY
PUBLISHED THIS VERY LARGE REPORT
ABOUT BLACK AND MINORITY HEALTH,
AND THIS REPORT ULTIMATELY
CAUSED A NUMBER OF THINGS TO
OCCUR.
IT LED TO PIVOTAL LEGISLATION,
FUNDING, POLICY, RESEARCH, AND
INITIATIVES FOCUSED ON MINORITY
HEALTH AND LATER HEALTH EQUITY.
IT LED TO THE ESTABLISHMENT OF
THE OFFICE OF MINORITY HEALTH,
FIRST WITHIN THE DEPARTMENT OF
HEALTH AND HUMAN -- THE NIH
OFFICE OF MINORITY HEALTH UNDER
THE LEADERSHIP OF JOHN ROFFEN
ULTIMATELY BECAME AN INSTITUTE.
NOW HERE'S LOU SULLIVAN,
SECRETARY OF HEALTH AND HUMAN
SERVICES IN THE GEORGE H.W. BUSH
ADMINISTRATION, AND BEFORE THAT,
WAS A MEMBER OF THE CANCER
ADVISORY BOARD.
HE WAS A REAL MOVER AND SHAKER
IN THIS AREA OF MINORITY HEALTH.
THIS TIME THE EMPHASIS WAS ON
RACE, AND MINORITY HEALTH
CULMINATED WITH THE 1993 NIH
REVITALIZATION ACT, WHICH WE
STILL LIVE WITH, WHICH SAYS THAT
ALL NIH FUNDED PHASE 3 STUDIES
SHALL BE DESIGNED SUCH THAT
VALID SUBSET ANALYSIS CAN BE
DONE BETWEEN THE RACES.
HERE WE HAVE THAT SAME THEME OF
RACE, RACIAL DIFFERENCES, AND
BLACK-WHITE BIOLOGY BEING
DIFFERENT.
INDEED THERE WERE CONGRESSMEN
WHO SAID THE BLACK-WHITE
DISPARITIES ARE DUE TO
MINORITIES NOT BEING INCLUDED IN
CLINICAL TRIALS.
I ACTUALLY THINK THAT'S WRONG.
AND WE'VE DEVELOPED TREATMENTS
FOR WHITE AND NOT BLACKS.
THAT'S A DIRECT QUOTE FROM JESSE
JACKSON, JR., WHO WAS THEN A
CONGRESSMAN.
THESE MANDATES FOR SUBSET
ANALYSIS WERE MADE BECAUSE DRUGS
MAY NOT WORK IN MINORITIES AS
THEY WORK IN MAJORITIES, IT WAS
SAID.
TRUTH IS, AND WE'LL SHOW SOME
DATA ON THIS, FOR MOST PART, THE
DRUGS DO NOT WORK BECAUSE
UNDERSERVED PEOPLE DON'T GET THE
DRUGS.
ONE OF THE THINGS THAT MOTIVATED
THIS LEGISLATION, THERE WERE
SEVERAL, BUT ONE THAT MOTIVATED
THIS LEGISLATION, AN EXAMPLE OF
HOW THIS CAN REALLY CAUSE THINGS
TO BE MUCKED UP, IS THIS STUDY
WAS PUBLISHED IN JAMA IN 1991.
IT WAS ONE OF THE FIRST
RANDOMIZED STUDIES TO SHOW THAT
THE DRUG WAS EFFECTIVE IN
DELAYING THE PROGRESSION OF
HIV/AIDS.
THERE WERE SEVERAL STUDIES THAT
WERE PUBLISHED BY JAMA IN THAT
YEAR, ACTUALLY IN THE SAME
ISSUES, THAT SHOWED THAT WHITE
PEOPLE BENEFITED MORE SO THAN
BLACK PEOPLE FROM AS TEE., AND
ZIDOVUDINE THERAPY.
NOW, THE FOLKS WHO WROTE THIS
PAPER WERE ACTUALLY SUCH THAT
THEY DID EVEN FURTHER STUDY TO
TRY TO FIGURE OUT WHY AZT WAS A
BETTER TREATMENT FOR WHITES
VERSUS BLACKS.
THEY WERE ACTUALLY ABLE TO NAIL
DOWN THAT THE BLACKS IN THE
STUDY WERE SOCIOECONOMICALLY
LESS SUPPORTED THAN THE WHITES
IN THE STUDY, AND THE BLACKS IN
THE STUDY DIDN'T TAKE THE DRUG
AS OFTEN AS THE WHITES IN THE
STUDY.
INDEED ADHERENCE TO TAKING THE
DWRUG WAS SOMEWHERE
DRUG WAS SOMEWHERE AROUND 50% OF
WHITE ADHERENCE TO TAKING THE
DRUG.
AGAIN, IF YOU DON'T TAKE THE
DRUG, NOW THEY PUBLISHED THIS
AND WENT ON TO PUBLISH OTHER
STUDIES TO SHOW THAT AZT OR
ZIDOVUDINE IS EFFECTIVE IN
TREATING BLACKS OR NEGROES, BUT
IT IS A FACT TO THIS DAY IN MANY
OTHER URBAN CITY, I HEARD IT IN
BALTIMORE LAST WEEK, THERE'S
FOLKLORE THAT NIH DRUGS HAVE
BEEN PROVEN NOT TO WORK IN
BLACKS.
NOW, IT INTERESTING, AZT ISN'T
EVEN USED TO TREAT HIV ANYMORE,
BUT THIS FOLKLORE THAT ANTI-AIDS
DRUGS DON'T WORK IN BLACK PEOPLE
IS STILL PERSISTENT, AND STILL A
REASON MANY BLACKS AND
ESPECIALLY IN AMERICA'S INNER
CITIES, DON'T TAKE THE DRUGS.
NOW, LEGISLATION LED TO MANY
EFFORTS TO INCREASE MINORITY
ACCRUAL.
THERE HAVE BEEN NUMEROUS
NIH-SPONSORED MEETINGS ON
RECRUITMENT, ACADEMIC
INSTITUTIONS ACTUALLY HAD TO
DEVELOP RELATIONSHIPS, THAT'S
THE ONE GOOD THING OUT OF THIS,
AND THEN THERE'S SOME CLINICAL
RESEARCH ORGANIZATIONS THAT MADE
IT INTO A BUSINESS.
THAT MAY NOT BE SUCH A GOOD
THING.
I'M ALSO PERSONALLY CONCERNED,
I'VE BEEN OUTSPOKEN ABOUT THIS,
THAT THE FEDERAL MANDATE PUTS
UNDUE PRESSURE ON NIH-FUNDED
RESEARCHERS, ESPECIALLY DATA
MANAGERS, TO GIVE WHITE PATIENTS
THE OPTION OF ENTERING A
CLINICAL TRIAL AND GIVE BLACKS
AND OTHER MINORITIES THE HARD
SELL BECAUSE THEY REALLY NEED
THE MINORITIES ON CLINICAL
TRIALS.
NOW, THE OTHER PROBLEM, OF
COURSE, IS THERE'S NO SUCH THING
AS A VALID SUBSET ANALYSIS, IT
SCIENTIFICALLY IMPOSSIBLE.
LET'S LOOK AT A CLINICAL TRIAL
THAT I WAS INVOLVED WITH IN THE
EARLY 1990s, WHEN I WAS AT THE
NCI.
THAT IS PACLITAXEL AND CISPLATIN
VERSUS CYCLOPHOSPHAMIDE AND
CISPLATIN.
THE OLD STANDARD WAS
CYCLOPHOSPHAMIDE AND CISPLATIN
AND WE THOUGHT MIGHT BE
PACLITAXEL AND CISPLATIN.
WOMEN WITH OVARIAN CANCER WERE
ENROLLED, 386 WERE FOUND TO BE
ELIGIBLE AND RANDOMIZED TO
EITHER GETTING PACLITAXEL AND
CISPLATIN OR CISPLATIN AND
CYCLOPHOSPHAMIDE.
YOU CAN SEE OF 216 WITH
MEASURABLE DISEASE, YOU CAN SEE
73% VERSUS 60%.
MEDIAN PROGRESSION-FREE SURVIVAL
WAS ALSO BETTER.
PROPORTIONAL REPRESENTATION OF
BLACK WOMEN WAS THERE, BY THE
WAY.
THERE WERE 26 BLACK PATIENTS.
IF ONE BELIEVES THE ANSWER IS
DIFFERENT IN BLACK WOMEN VERSUS
WHITE WOMAN, YOU ACTUALLY NEED
216 BLACK WOMEN COMPARED TO 216
WHITE.
YOU CAN'T DO IT WITH 26 OF THE
216 BEING BLACK.
NOW, WE NEED TO WORRY ABOUT
TREATMENT EFFECTIVENESS,
ESPECIALLY IN A POPULATION, WE
ALSO NEED TO WORRY ABOUT
EFFICACY.
WHEN I TALK ABOUT EFFECTIVENESS,
WE'RE TALKING ABOUT IN AN IDEAL
SITUATION LIKE IN CLINICAL
TRIALS, WHERE THE DATA IS MORE
PERFECT, THE PATIENT ARE
HEALTHIER, EVEN THOUGH THEY HAVE
CANCER, THEY'RE HEALTHIER, THEY
VOLUNTEER TO GO INTO THESE
TRIALS.
THE PHYSICIANS ARE OFTEN MORE
EXPERT AS WELL.
EFFICACY IS HOW IS IT WORK --
DOES IT WORK IN THE REAL WORLD.
SO OUR SEER AND POPULATION BASED
REGISTRIES TELL US ABOUT
EFFICACY, CLINICAL TRIALS TELL
US ABOUT EFFECTIVENESS.
NOW, FOR GENERALIZABILITY, WE
WANT A POPULATION THAT MIRRORS
THE POPULATION IN GENERAL, BOTH
IN CLINICAL SETTING AND SOME OF
THE EPIDEMIOLOGY I GET INVOLVED
WITH, WE WORRY ABOUT PEOPLE
TREATED AT UNIVERSITY HOSPITALS
VERSUS PEOPLE TREATED IN
COMMUNITY HOSPITALS.
RICH VERSUS POOR, AS WELL AS
WITH GENETICS, WE SHOULD PAY
ATTENTION TO THINGS LIKE RACE.
THE CLINICAL TRIALS PARTICIPANTS
NEED TO BE A REPRESENTATIVE
BIOPSY OF THE GENERAL POPULATION
IF THIS MEDICAL AUDIENCE WILL
LET ME GET AWAY WITH USING THE
PHRASE "REPRESENTATIVE BIOPSY,"
IN ORDER FOR A FINDING TO BE
GENERALIZABLE TO THAT ENTIRE
POPULATION.
THIS IS VERY DIFFERENT FROM
APPLICABILITY.
APPLICABILITY, BY THE WAY, IS A
WORD NEVER SEEN IN THE NIH
REVITALIZATION.
APPLICABILITY IS SPECIFIC TO AN
INDIVIDUAL OR THE PEOPLE WITH
SPECIFIC GENETICS OR SPECIFI%
TARGETS.
THIS IS PERHAPS THE MOST
WONDERFUL, GENTLE, SMART MAN I
PERSONALLY HAVE EVER MET.
DAVID IS SATCHER WAS THE 16TH
SURGEON GENERAL OF THE UNITED
STATE AND 11TH ASSISTANT
SECRETARY OF HEALTH.
HE MOVED US INTO THE AREA OF
HEALTH DISPARITIES.
HE BROADENED IT MUCH MORE SO
THAN BLACK/WHITE BUT INTO OTHER
RACES, SOCIOECONOMIC STATUS.
I'M GOING TO SHOW YOU SOME DATA
TO SHOW EVEN GEOGRAPHY.
HE IS THE PERSON WHO YOU'D FIRST
PUT THE TWO WORDS "HEALTH" AND
"DISPARITIES" TOGETHER.
IN MY FORREST GUMP LIFE, I WAS
ACTUALLY IN MONROE WHEN HE SAID,
I WANT TO START CALLING IT WHAT
IT IS.
DISPARITIES IN HEALTH, OR HEALTH
DISPARITIES, AND LET'S SEE SOME
POLITICIANS SAY WE WANT PROGRAMS
TO HEALTH REDUCE DISPARITIES IN
HEALTH.
THE CONCEPT THAT SOME
POPULATIONS, HOWEVER YOU DEFINE
THEM, HAVE DIFFERENT OUTCOMES.
AND POP LAILINGS ARE POPULATIONS CAN BE D EFINED
IN A NUMBER OF WAYS.
NOT JUST RACE.
SEX OR GENDER, AREA OF
GEOGRAPHIC ORIGIN, WHICH IS
DIFFERENT FROM RACE, FAMILY OR
TRIBE, ETHNICITY AND CULTURE.
KEEP IN MIND, ETHNICITY AND
CULTURE INVOLVES SOME
ENVIRONMENTAL INFLUENCES ON HOW
WE GET CANCER.
ITALIANS ACTUALLY SMOKE
CIGARETTES DIFFERENTLY THAN
GERMANS.
AREA OF RESIDENCE.
SOCIOECONOMIC STATUS.
ALL DIFFERENT WAYS OF DESCRIBING
POPULATIONS, AND WE CAN SHOW
DISPARITIES BY ANY OF THESE.
NOW AGAIN, DISPARITIES ARE THE
CONCEPT THAT SOME POPULATIONS DO
WORSE THAN OTHERS.
WORSE CAN BE INCIDENCE OF
DISEASE, IT COULD BE MORTALITY,
IT CAN BE SURVIVAL, IT CAN BE
QUALITY OF LIFE.
HERE I'M GOING TO SHOW YOU AGAIN
SEER DATA LOOKING AT RACE,
BLACKS IN BLUE, WHITES IN
ORANGE, NATIVE AMERICANS,
HISPANICS, AND ASIAN PACIFIC
ISLANDERS, AND THIS IS DEATH
RATE FROM 1990 TO 2017.
NOW YOU CAN SEE THE BLACK DEATH
RATE WAS HIGHER THAN THE WHITE
DEATH RATE, BUT OVER TIME, IT'S
GOTTEN CLOSER AND CLOSER
TOGETHER.
IF ONE IS INCREDIBLY OPTIMISTIC,
ONE CAN IMAGINE A TIME ABOUT
2030, 2035, WHERE BLACK AND
WHITE AND NATIVE AMERICAN DEATH
RATES WILL ACTUALLY ALL KIND OF
MERGE TOGETHER.
WITH HISPANICS AND ASIAN PACIFIC
ISLANDERS AND THEY'D STILL BE
BELOW.
NOW THESE CATEGORIES ARE DEFINED
BY THE U.S. OFFICE OF MANAGEMENT
AND BUDGET EVERY 10 YEARS.
THEY ARE SEWS YOASH POLITICAL
AND NOT BIOLOGIC BY OMB
DEFINITION.
RACE AS DEFINED IN BIOLOGY OR AS
A BIOLOGIC CATEGORIZATION, HAS
BEEN REJECTED BY THE
ANTHROPOLOGICAL COMMUNITY AS
NON-SCIENTIFIC.
SOME CALL IT PSEUDOSCIENCE.
RECENTLY, THE AMERICAN MEDICAL
ASSOCIATION HAS ISSUED
STATEMENTS REGARDING THE
BIOLOGIC -- IT IS INCREDIBLY
BROAD.
AREA OF GEOGRAPHIC ORIGIN, ON
THE OTHER HAND, WHICH IS
DIFFERENT FROM RACE, IS MORE
SPECIFIC AND A LITTLE BIT MORE
SCIENTIFIC.
I'M GOING TO SHOW YOU SOME
EXAMPLES OF AREA OF GEOGRAPHIC
ORIGIN AND SOME GENETIC
DIFFERENCES.
BUT ALZHEIMER'S BUT ADMIXTURE COMPLICATES
BOTH.
I'M REMINDED BY THE FACT THAT
THEY CONSIDERED BARACK OBAMA
BLACK IN 1970 AND WHITE IN 1980.
THERE ARE 109 AREAS OF
GEOGRAPHIC ORIGIN IN AFRICA,
MORE THAN 600 IN EUROPE.
AS WE STUDY MORE, THERE WILL BE
MORE AREAS OF GEOGRAPHIC ORIGIN,
BUT YOU CAN SEE SOME OF THESE
NAMES AND SOME OF THESE AREAS,
AND THIS IS TO SAY THAT -- TO
CALL ALL BLACK PEOPLE AFRICAN IS
WRONG.
BY THE WAY, MOST AFRICAN
AMERICANS ARE ABOUT 20 TO 30%
EUROPEAN.
SO ADMIXTURE IS INCREDIBLY
IMPORTANT.
IT'S NOT WHAT GENES YOU HAVE AS
MUCH AS IT IS WHERE SPECIFIC
GENES CAME FROM.
RACE AS FACTOR IN OUTCOME.
FREQUENTLY CONCERN IS EXPRESSED
ABOUT BIOLOGICAL DIFFERENCES IN
TREATMENT OUTCOME BY RACE.
IN MOST CASES, DISEASE, CLINICAL
TRIALS AND SINGLE INSTITUTION
EXPERIENCES, I'LL SHOW YOU A
FEW, SHOW THAT EQUAL TREATMENT
YIELDS EQUAL OUTCOME AND RACE
SHOULD NOT BE A FACTOR IN
OUTCOME.
NOW, RACE SHOULD NOT BE A FACTOR
IN OUTCOME BECAUSE EQUAL
TREATMENT YIELDS EQUAL OUTCOME,
BUT THERE IS NOT EQUAL
TREATMENT.
IT IS RARE THAT A DRUG OR
THERAPY DOESN'T WORK, IT IS
COMMON THAT MINORITIES DON'T GET
THE DRUG.
RACE SHOULD NOT BE A FACTOR IN
OUTCOME, BUT IT VERY FREQUENTLY
IS.
IT SHOULD NOT BE A FACTOR
BIOLOGICALLY, AND IT IS NOT
USUALLY A FACTOR BIOLOGICALLY,
BUT IT IS A FACTOR
SOCIOPOLITICALLY.
THIS IS A NON-CANCER EXAMPLE,
AND THIS IS FROM THE LITERATURE
RIGHT NOW.
WE HAVE FOR THE LAST 20 TO 30
YEARS USED A RACE-BASED ESTIMATE
OF RENAL FUNCTION.
WE'RE STARTING TO REALIZE THAT
THAT RACE BASED ESTIMATE OF REAL
FUNCTION IS WRONG, AND THE END
RESULT OF US ASSUMING THAT BLACK
RENAL FUNCTION IS BIOLOGICALLY
DIFFERENT FROM WHITE RENAL
FUNCTION IS A LARGE NUMBER OF
PEOPLE WHO ARE BLACK WHO WOULD
HAVE BEEN ELIGIBLE TO BE KIDNEY
DONORS HAVE BEEN TOLD YOU HAVE
KIDNEY DYSFUNCTION, YOU SHOULD
NOT BE A DONOR.
NOW, POPULATIONS DO DIFFER, AND
THIS SHOULD BE KEPT IN MIND WHEN
WE STUDY VAIR VARIOUS TREATMENTS.
CYSTIC FIBROSIS, VERY COMMON,
ESPECIALLY IN NORTHERN EUROPE,
THE AREA AROUND DENMARK, THE
NETHERLANDS.
ALCOHOL DEHYDROGENASE
DEFICIENCY.
VERY COMMON IN EAST ASIA.
PORTIONS OF CHINA AND PORTIONS,
NOT ALL, OF JAPAN.
AND PROSTATE CANCER INCIDENCE IN
MEN FROM NORTHWEST SUB-SAHARAN
AFRICA, NOT EAST, NOT SOUTH, BUT
NORTHWEST SUB-SAHARAN AFRICA.
OTHER EXAMPLES OF GENETICS AND
VARIATION.
G6PD DEFICIENCY.
WE ALL KNOW IN MEDICAL SCHOOL
WHEN YOU GET SOMEONE BACK FOR
URINARY INFECTION, YOU ASK ABOUT
G6PD DEFICIENCY BECAUSE CERTAIN
PEOPLE HAVE VARIOUS TYPES WHERE
CERTAIN DRUGS, QUININE OR BACK
BACTRUM, FOR EXAMPLE, CAN CAUSE
A HEMOLYTIC MALARIA.
20% OF PEOPLE WHO LIVE WITHIN
100 MILES OF THE BORDER.
YOU GO 150 CAN KILOMETERS, IF YOU
GIVE THEM THE ANTISEIZURE DRUG
TEGRETOL, THEY WILL GET A FEVER,
HANDS AND FEET START PEELING.
THIS IS NOT THAI PEOPLE, 20% OF
THAIS OR -- IT'S PEOPLE WHO LIVE
IN THAT ONE, THIS IS ALL TO SAY,
WHEN WE LOOK AT RACE, IT'S JUST
TOO BROAD.
BUT THERE ARE DIFFERENCES
AMONGST POPULATIONS.
BY THE WAY, THERE'S A SICKLE
CELL MUTATION FOUND IN GREECE,
SOUTHERN ITALY, MIDDLE EAST AND
SO FORTH.
INDEED IN THE UNITED STATES,
THIS IS HOW WE HAVE THESE RACIAL
BLINDER, WE ALL THINK OF SICKLE
CELL DISEASE AS A BLACK DISEASE.
TRUTH BE TOLD, ABOUT 50,000 KIDS
WILL BE BORN THIS YEAR WITH
SICKLE CELL TRAIT.
8,000 OF THOSE 50,000 AMERICANS
WERE SICKLE CELL TRAIT ARE WHITE
PEOPLE.
NOW, LOOKING AT POPULATIONS AND
DIFFERENCES IN DRUG, YES, THEY
DO EXIST, THEY ARE RARE BUT THEY
DO EXIST.
THE CANCER DRUG USED IN THE
TREATMENT OF COLORECTAL CANCER,
CAPECITABINE, AMERICANS TEND TO
HAVE MORE SIDE EFFECTS FROM THIS
DRUG COMPARED TO EUROPEANS.
IT'S ACTUALLY NOT A RACE THING,
IT'S AN ENVIRONMENTAL THING.
IT'S THE FACT THAT THE AMERICAN
DIET IS VERY HIGH IN FOLATE, AND
FOLATE POTENTIATES CAPECITABINE.
YOU CAN MAKE FOLATE A HARSHER
DRUG BY GIVING IT ALONG WITH
FOLATE.
WE FREQUENTLY GIVE IT WITH
LEUKOVORIN.
AGAIN, POPULATION DIFFERENCES,
IT'S BEEN WELL STUDIED THAT SOME
OF THE TYROSINE KINASE
INHIBITORS, DIFFERENT RESPONSES
IN CERTAIN ASIAN POPULATIONS.
PATIENTS OF ASIAN ORIGIN DO
HARBOR MORE FREQUENT EGFR
MUTATIONS IN CERTAIN AREAS.
THIS IS AN ARGUMENT FOR LEARNING
WHAT THE DRUG'S TARGET IS AND
LEARNING WHAT THE DISTRIBUTION
IN THE TARGET IS IN VARIOUS
POPULATIONS.
PERHAPS ASIAN IS THE WRONG
CATEGORY, PERHAPS WE NEED TO GET
A LITTLE BIT MORE GRANULAR.
THIS RAISES THE ISSUE OF
POPULATION DIVERSITY IN THE
PATHOGENESIS OF VARIOUS
DISEASES.
THE IMPLICATION OF THESE
FINDINGS IS THAT AREA OF
GEOGRAPHIC ORIGIN MAY INDICATE
DIFFERENT GENETIC BACKGROUNDS
AND COMMON DISEASES THAT MAY
UNFLEUNS CLINICAL OUT COME AND
RESPONSE TO THERAPY.
CLINICAL STUDY OF MOLECULAR
TARGETED THERAPIES SHOULD
INCLUDE A DIVERSE POPULATION AND
SCIENTISTS SHOULD BE ON THE
LOOKOUT IN THINKING ABOUT THESE
THINGS.
THE STUDY OF BLACK VERSUS WHITE
OUTCOMES IN THE PAST IS
INCREASINGLY MOVING BEYOND THE
BLACK AND WHITE AND
SOCIOECONOMICS.
WE HAD SOMETHING CALLED THE
BLACK AND WHITE STUDY.
WHEN WE LOOK AT ECONOMICS,
HOWEVER, I WANT YOU TO LOOK AT
THE PERCENT OF PEOPLE IN THE
UNITED STATES WHO LIVE UNDER THE
POVERTY LEVEL.
9% OF WHITES, THAT TRANSLATE
INTO 17 MILLION PEOPLE.
21% OF BLACKS TRANSLATES INTO
8 MILLION.
17% OF HISPANICS TRANSLATES INTO
10 MILLION.
MANY PEOPLE DON'T REALIZE THERE
ARE MORE POOR WHITES IN THE
UNITED STATES THAN THERE ARE
POOR BLACKS.
CANCER INCIDENCE DISPARITY DUE
TO DIFFERENCES IN ENVIRONMENT
ARE INCREDIBLY IMPORTANT.
THAT'S DIET, EXERCISE, SMOKING
AND ALCOHOL USE, POLLUTION.
CANCER OUTCOME DISPARITIES, ON
THE OTHER HAND, ARE DUE TO
DIFFERENCES IN ACCESS TO QUALITY
CARE AND UTILIZATION OF
AVAILABLE CARE.
THEY ARE MUCH MORE INFLUENCED BY
SEWS YOASH ECONOMICS.
SOCIOECONOMICS.
HERE WE HAVE BRITISH DATA, THEY
ARE VERY GOOD AT THEIR 10-YEAR
CENSUS AS DEFINING PEOPLE AS
AFFLUENT AND DEPRIVED.
THEY HAVE AN INDEX WHERE 1 IS
VERY AFFLUENT AND 7 IS VERY
DEPRIVED.
THEY SHOW THE FIVE-YEAR SURVIVAL
OF THE AFFLUENT FOR ALMOST EVERY
CANCER, ALL THE MAJOR CANCERS,
IS BETTER THAN THAT FOR THOSE
WHO ARE DEPRIVED.
IN THE UNITED STATE, AND THIS IS
NCI INTRAMURAL DATA, PEOPLE WHO
LIVE IN COUNTIES THAT HAVE
PERSISTENT POVERTY HAVE A MUCH
WORSE OUTCOME IN TERMS OF
MORTALITY SINCE THE YEAR 2000
COMPARED TO PEOPLE WHO LIVE IN
WEALTHIER COUNTIES.
JUST LOOK HERE AT ALL KEAN CANCERS,
THE DOTTED LINES ARE THE HIGH
INCOME COUNTIES, THE SOLID LINES
ARE THE WEALTHIER COUNTIES, AND
THESE DECLINES ARE DECLINES IN
AGE STANDARDIZED MORTALITY RATE
PER 100,000.
PEOPLE WHO LIVE IN THE WELFARE
COUNTIES HAVE A MUCH GREATER
DECLINE IN MORTALITY COMPARED TO
PEOPLE WHO LIVE IN THE
NON-WEALTHY COUNTIES.
MORE ON THAT, AGAIN, AND I
SHOULD JUST POINT OUT, I'M NOT
GOING TO SPEND A LOT OF TIME ON
THIS, THIS IS TRUE FOR VIRTUALLY
EVERY DISEASE.
NOW LOW SES AND LACK OF
INSURANCE IS ASSOCIATED WITH
HIGHER STAGE OF DIAGNOSIS FOR
VIRTUALLY ALL CANCERS.
FOR ADULTS, THE AFFORDABLE CARE
ACT ORO'BAMA CARE IS ASSOCIATED
WITH REDUCTION IN DISPARITIES.
THERE HAVE BEEN DOCUMENTED
REDUCTIONS IN STAGE OF DIAGNOSIS
AND IMPROVEMENTS IN OUTCOME, BUT
UNFORTUNATELY, OBAMACARE IS
CAUSING AN INCREASE IN STATE BY
STATE DISPARITIES AS WE LOOK AT
STATES THAT HAVE IMPLEMENTED
DOING BETTER THAN STATES WHO
HAVE NOT IMPLEMENTED MEDICAID
EXPANSION DOING WORSE.
THE POOR, INCLUDING POOR WHITES,
ARE MORE OFTEN PRESENT WITH
DISTANT DISEASE.
THEY'RE LESS LIKELY TO RECEIVE
RADIATION.
WHEN THEY RECEIVE RADIATION, THE
QUALITY IS POOR, IN TERMS OF
AIMING OF THE BEAM, POOR PEOPLE
ARE MORE LIKELY TO BE TREATED
WITH LOWER ENERGY OLDER
RADIATION THERAPY MACHINES IN
THE UNITED STATES.
HERE YOU HAVE SOFT TISSUE
SARCOMA, WHICH IS LARGELY A
PEDIATRIC DISEASE.
THOSE WHO HAVE PRIVATE
INSURANCE, THEIR SURVIVAL
PROBABILITY IS HERE ON THE SOLID
LINE OVER TIME, THIS IS 200
MONTHS, AND THE DOTS LINE, LOW
INCOME, OR WITH PUBLIC
INSURANCE, SURVIVAL PROBABILITY
IS MUCH LESS.
SOCIOECONOMICS IS INCREDIBLY
IMPORTANT.
THERE'S INCREASING UNDERSTANDING
OF THIS FOR CANCER CAUSATION,
EVEN ITS EFFECT ON GENOMES AND
BEHAVIOR.
I'M GOING TO SHOW YOU SOME DATA
ON WHERE SOCIOECONOMIC STATUS
ACTUALLY ULTIMATELY TRANSCENDS
INTO CHANGING AND HOW CANCER
EXPRESSES ITSELF GENOMEICALLY.
PROSTATE CANCER, EVERYONE KNOWS
TWOFOLD INCREASE RISK OF DYING
FROM PROSTATE CANCER FOR BLACK
MEN IN THE UNITED STATES.
FACTORS THAT WE KNOW ARE
INVOLVED IN THIS INCLUDE
INCREASED AGGRESSIVENESS OF
TUMOR RELATED TO THE MED BOLG METABOLIC
SYNDROME, HIGH CARBOHYDRATE
DIET, MORE COMMON IN BLACKS THAN
WHITES, HIGH BODY MASS INDEX.
EPIGENETICS OF PROSTATE CANCER
IS A FIELD OF OPPORTUNITY FOR
YOUNG PEOPLE THINKING ABOUT WHAT
TO PUT IN THEIR CAREER.
HERE WE HAVE SOME ASSESSMENTS OF
CLINICAL TRIALS.
NOW THIS IS SOMEWHAT INSPIRED BY
THE NIH REVITALIZATION ACT, AND
THIS IS A GOOD THING, I THINK,
AND WE SHOULD TAKE THIS AND
CARRY THIS BALL.
YOU SEE IN A NUMBER OF STUDIES
WHERE THEY TOOK
MULTI-INSTITUTIONAL -- THIS IS
NOT CLINICAL TRIAL, THIS TOOK
LARGE NUMBERS OF MEN TREATED IN
A NUMBER OF INSTITUTIONS, GOOD
PLACES THAT STUDY PROSTATE
CANCER, THEY LOOKED AT 188 BLACK
MEP COMPARED TO 1474 WHITES, WHO
GOT TREATED WITH RADICAL PROS TA
TECT
PROSTATECTOMY AND THEY FOUND NO
DIFFERENCE IN BIOCHEMICAL
OUTCOME.
THIS STUDY, BLACK MEN HAD BETTER
SURVIVAL VERSUS WHITE MEN.
AGAIN, THIS SHOWS YOU -- THIS
WAS THE HAZARD RATIOS.
UNADJUSTED AND IN MULTIVARIATE
MODELS.
BLACK MEN ACTUALLY DID SLIGHTLY
BETTER WITH TREATMENT.
COMPARISON OF RESPONSE TO
DEFINITIVE RADIOTHERAPY FOR
LOCALIZED PROSTATE CANCER IN
BLACK AND WHITE MEN.
HERE, A LARGER TRIAL, 1630 BLACK
MEN, 7200 WHITE MEN WITH MEDIAN
FOLLOW-UP OF GREATER THAN 10
YEARS, ALMOST 11 YEARS.
BLACK MEN WERE LESS LIKELY TO
DIE OF PROSTATE CANCER AFTER
TREATMENT AND THERE'S NO
SIGNIFICANT DIFFERENCE IN ALL
CAUSE MORTALITY.
NOW, THERE'S AN ASSOCIATION
BETWEEN RACE AND RECEIPT OF
DEFINITIVE TREATMENT.
I THINK YOU'RE GETTING MY GIST
HERE.
EVEN IN PROSTATE CANCER, YES,
BLACK MEN ARE MORE LIKELY TO
DEVELOP IT, BUT ONCE DIAGNOSED,
AT EVERY STAGE EQUAL TREATMENT
YIELDS EQUAL OUTCOME, BUT THERE
IS NOT EQUAL TREATMENT.
THAT NEEDS TO BE A FOCUS.
MUCH MORE SO THAN SUBSET
ANALYSIS IN CLINICAL TRIALS NOW.
NOW THERE IS RACIAL DIFFERENCES
IN DEVELOPING PROSTATE CANCER.
THE INCREASED RISK COULD BE --
AND THERE DOES APPEAR TO BE
INCREASED RISK AMONG MEN WITH
GENETIC LINKAGE TO NORTHWESTERN
SUB-SAHARAN AFRICA.
NOT EAST AFRICA, NOT SOUTH
AFRICA, BUT NORTHWESTERN
SUB-SAHARAN AFRICA.
WHILE THE RACIAL DIFFERENCES IN
RISK OF DEVELOPING PROSTATE
CANCER, EQUAL TREATMENT YIELDS
EQUAL OUTCOMES AND THERE IS NOT
EQUAL TREATMENT.
LET'S LOOK AT BREAST CANCER.
THESE ARE THE NUMBER OF IN 2019
WHICH CALL THE LAST YEAR OF
NORMAL TIME THAT I CALL COVID.
THESE ARE AMERICAN CANCER
SOCIETY ESTIMATES FOR DIAGNOSIS
AND DEATH.
THERE'S BEEN 40 TO 50% DECLINE
IN RISK OF DEATH SINCE 1990.
I'VE SHOWN YOU THIS ALREADY, THE
BLACK/WHITE DISPARITY IS GREATER
TODAY THAN IT HAS EVER BEEN, AND
IT DIDN'T EXIST BEFORE WE KNEW
HOW TO SCREEN AND TREAT FOR
THIS.
THIS IS THE BLACK/WHITE
DISPARITY.
IF YOU INTEGRATE ALL OF THIS,
THERE'S A 40% DECLINE IN RISK OF
DEATH SINCE 1990.
40% DECLINE IN RISK OF DEATH FOR
THE UNITED STATES AS A WHOLE,
AND THE UNITED STATES WAS VERY
HOMOGENEOUS INTERESTINGLY IN THE
1980s.
BUT SINCE 1988 OR SO, THESE
PURPLE STATES HAVE HAD A 20 TO
29% DECLINE AND THE DARK BLUE
STATES HAD A 44 TO 501% DECLINE.
IT'S MOVING INTO THE RICH/PORE
AND EVEN MORE SO IN THE
MISSISSIPPI VERSUS
MASSACHUSETTS.
YOU'VE SEEN THIS BEFORE.
THERE ARE SEVEN STATES WHERE
BLACK/WHITE MORTALITY
DIFFERENCES ARE NO LONGER
STATISTICALLY SIGNIFICANT.
HERE IN THE UNITED STATES TODAY,
WE HAVE THE GREATEST DISPARITY
OVERALL FOR BLACKS AND WHITES,
BUT THERE'S SEVEN STATES WHERE
BLACK/WHITE DIFFERENCES ARE NO
LONGER STATISTICALLY
SIGNIFICANT.
INDEED THERE ARE 12 STATES WHERE
WHITE WOMEN HAVE A HIGHER RISK
OF BREAST CANCER DEATH COMPARED
TO BLACK WOMEN WHO LIVE IN
MASSACHUSETTS.
AND THERE HAS HAS BEEN THIS
INCREDIBLE EMPHASIS ON SCREEN,
SCREEN, SCREEN.
I DON'T HAVE TIME TO GO INTO IT
FULLY.
I JUST WANT TO POINT OUT THERE'S
DATA THAT SHOW THAT A LARGER
PROPORTION OF THOSE WHO DIED,
THE 45,000 OF THOSE WHO DIE FROM
BREAST CANCER, 21 TO 27% DIE
BECAUSE THEY DON'T GET
APPROPRIATE TREATMENT AFTER
DIAGNOSIS.
IT'S ONLY ABOUT 10% WHO DIE
BECAUSE THEY DIDN'T GET
SCREENED.
SO I LIKE TO SAY THERE'S AN
UNDEREMPHASIS ON GETTING PEOPLE
ADEQUATE CARE.
A SUBSTANTIAL NUMBER OF PEOPLE,
BLACK, WHITE, AND POOR, DON'T
GET APPROPRIATE SURGERY
CHEMOTHERAPY HORMONES IN
RADIATION.
MARROW JOE LUN WAS ONE OF MY
FELLOWS AT EMORY, AND WE
PUBLISHED THAT IN ATLANTA,
7 1/2% OF BLACK WOMEN WHO GOT
SCREENED AND DIAGNOSED WITH
BREAST CANCER DIDN'T GET TREATED
IN THE FIRST YEAR.
IT'S 3%, BY THE WAY, OF WHITE
WOMAN, ALL POOR, ALL
DISENFRANCHISED FROM THE SYSTEM.
THEY DIDN'T GET ADEQUATE
TREATMENT.
IN MILITARY DATABASES, BY THE
WAY, THERE'S TREMENDOUS DATA
THAT SHOWS THAT BLACKS AND
WHITES ARE ACTUALLY GETTING
CLOSER AND CLOSER TOGETHER.
THE BLACK/WHITE DISPARITY OF
WOMEN WHO GO TO A WALTER REED
ARMY HOSPITAL IS FAR DIFFERENT
FROM THAT IN THE UNITED STATES.
VERY INTERESTING, A WOMAN WHOSE
HUSBAND RETIRED AFTER 20 YEARS
IN THE MILITARY, HER RISK OF
DYING FROM BREAST CANCER, FAR
LOWER THAN HER SISTER THAT MIGHT
LIVE IN SOUTHWEST D.C. .
THERE'S TALK ABOUT ESTROGEN
RECEPTORS, TRIPLE NEGATIVE
DISEASE.
IT IS TRUE THAT 24% OF BLACK
WOMEN AND 12% OF WHITE WOMEN IN
THE U.S. HAVE TRIPLE NEGATIVE
DISEASE.
IN IS JUST THE AMERICAN CANCER
SOCIETY'S GRAPH OF THE RACIAL
DIFFERENCES IN VARIOUS TYPES OF
BREAST CANCER.
NOW, FEW, BY THE WAY, APPRECIATE
THAT WHILE 24% OF BLACK WOMEN
HAVE TRIPLE NEGATIVE DISEASE,
THE BIG BLACK/WHITE DISPARITIES
ARE IN TREATMENT OF ESTROGEN
RECEPTOR POSITIVE NON-TRIPLE
NEGATIVE DISEASE.
IT'S THE 76% OF BLACKS WHO DON'T
HAVE TRIPLE NEGATIVE DISEASE WHO
ARE GETTING INEFFECTIVE THERAPY
OR MORE LIKELY ARE GETTING
INEFFECTIVE THERAPY, I SHOULD
SAY, WHICH ENDS UP MEANING THAT
THEY'RE MORE LIKELY TO HAVE A
BAD OUTCOME.
SOCIAL DEPRIVATION STUDIES IN
EUROPE OVER THE LAST 25 YEARS
HAVE SHOWN THAT POOR WOMEN IN
EUROPE ARE MORE LIKELY TO HAVE
TRIPLE NEGATIVE DISEASE.
WITHOUT THE BLINDERS OF RACE IN
SCOTLAND, WHERE THERE ARE VERY
FEW BLACK PEOPLE, THEY REALIZE
THAT POOR WOMEN, OR WOMEN WITH A
HISTORY OF POVERTY, ARE MORE
LIKELY TO HAVE TRIPLE NEGATIVE
BREAST CANCER IN THEIR 40s AND
50s.
THEY'VE BEEN ABLE TO CORRELATE
IT WITH OBESITY, THEY'VE BEEN
ABLE TO CORRELATE IT WITH
DIETARY DIFFERENCES, ESPECIALLY
WEIGHT GAIN AND HIGH
CARBOHYDRATE DIET IN CHILDHOOD.
INTERESTINGLY, WEIGHT GAIN FROM
BIRTH UNTIL THE EARLY TEEN YEARS
INCREASES RISK OF BREAST CANCER
IN ONE'S 40s AND 50s AND
60s.
IT HAS DO WITH THE AGE AT WHICH
A WOMAN STARTS MENSTRUATING.
REPRODUCTIVE PATTERNS ARE ALSO
IMPORTANT.
WOMEN WHO HAVE LOTS OF CHILDREN
AND THEN DON'T BREASTFEED ARE AT
HIGHER RISK OF TRIPLE NEGATIVE
DISEASE.
THESE ARE ALL SOCIOECONOMIC
THINGS, AND WHEN WE LOOK AT THEM
BLACK VERSUS WHITE, WE
FREQUENTLY, BECAUSE OF OUR OLD
WAY OF THINKING, START THINKING
THIS IS BECAUSE THEY'RE BLACK.
THIS IS WEIGHT GAIN FOR BLACK
WOMEN VERSUS WHITE WOMEN VERSUS
BLACK MEN AND WHITE MEN.
YOU CAN SEE OVER THE LAST 40
YEARS OR SO INCREASING OBESITY
IN EVERYONE BUT ESPECIALLY IN
BLACK WOMEN.
SUBSTANTIAL NUMBERS OF PEOPLE
GET LESS THAN OPTIMAL CARE.
WE'RE STARTING TO TALK ABOUT
EQUITY AND JUSTICE.
NOW LET'S TALK ABOUT NOT JUST A
PAPER ON HOW IN CHICAGO THEY'VE
ACTUALLY CHANGED THE NUMBERS FOR
BLACK WOMEN WITHIN THE LAST 20
YEARS.
IN COLORECTAL CANCER, HERE ARE
THE NUMBERS.
THESE ARE THE DEATH RATES, BLACK
VERSUS WHITE, THE DISPARITY IS
GETTING BETTER FOR BLACKS AND
WHITES, AND IT'S REALLY GETTING
CLOSER AND CLOSER FOR EVERYONE.
HERE YOU SEE IT FOR WOMEN, HERE
YOU SEE IT FOR MEN.
NO DISPARITY IN THE 70s, WE
LEARNED TO SCREEN AND TREAT, NOW
THERE'S A DISPARITY.
50% DECLINE SINCE 1980 IN THE
UNITED STATES.
THE U UNITED STATES WAS VERY
HOMOGENEOUS IN 1980, NOW WE'VE
GOT A 12 TO 31% TEE KLEIN IN DECLINE IN T HE
PURPLE STATES.
A 56 TO 63% IN THE DARK BLUE
STATES.
AGAIN, WHAT SEPARATES
MISSISSIPPI FROM MASSACHUSETTS?
THIS IS JUST TO SHOW INSURANCE
MATTERS.
THE STAGE ONE IN RED, STAGE TWO
IN BLUE, THE DIFFERENCES MEAN
THAT THOSE WHO ARE UNINSURED OR
GOT MEDICAID AFTER DIAGNOSIS ARE
MORE LIKELY TO NOT DO WELL OVER
FIVE YEARS.
THIS IS FIVE YEAR SURVIVAL.
AND YES, YOU'RE BETTER OFF
HAVING STAGE TWO COLORECTAL
CANCER WITH INSURANCE THAN STAGE
ONE WITHOUT INSURANCE.
KIM RHODES HAS SHOWN US, AND
THIS EVEN BLEW MY MIND, THE
HOSPITAL THAT YOU GO TO AND THE
HOSPITAL -- IS REALLY IMPORTANT.
IN CALIFORNIA, SHE WAS ABLE TO
SHOW THAT AFTER COLORECTAL
SURGERY, BLACKS AND HISPANICS
AND POOR PEOPLE WERE LESS LIKELY
TO HAVE ADEQUATE PATHOLOGY SUCH
THAT BLACKS WHO WERE UNDERSTAGED
WHO WERE CALLED STAGE II WERE
JUST AS LIKELY TO RELAPSE AS
WHITES WHO WERE CALLED STAGE
III.
IT'S BECAUSE THE BLACKS WERE
UNDERSTAGED.
KIM IS A SURGEON, SHE SAID I
NOPA THOL GISTS ARE I
KNOW PATHOLOGISTS ARE NOT
RACIST, WHO'S GOING ON HERE?
SHE WAS ABLE TO FIGURE OUT
BLACKS WHO HAVE COLORECTAL
CANCER, BECAUSE OF INSURANCE AND
OTHER THINGS, ARE MORE LIKELY TO
BE TREATED IN HOSPITAL THE,
WHERE THE PATHOLOGIST HAS SIX
CASES TO DEAL WITH A DAY,
WHEREAS WHITES IN A HOSPITAL
WHERE THE PATHOLOGIST HAS TWO
CASES TO DEAL WITH A DAY.
HUGE, HUGE DIFFERENCES IN
QUALITY OF TREATMENT.
I'M GOING TO WIND UP BY JUST
NOTING THAT COLLEGE EDUCATION
LOWERS RISK OF CANCER DEATH
DRAMATICALLY.
YOU GIVE A COLLEGE EDUCATION TO
A BLACK MAN, HIS RISK OF DYING
FROM CANCER GOES DOWN BELOW THAT
OF THE AVERAGE WHITE MAN IN THE
UNITED STATES.
HERE YOU CAN SEE LESS THAN OR
EQUAL COLLEGE EDUCATION, RATE OF
DEATH, VERSUS COLLEGE EDUCATION.
NOW, AS I LEFT THE AMERICAN
CANCER SOCIETY, I CHALLENGED THE
EPIDEMIOLOGISTS WHO DO THOSE
ESTIMATES OF NUMBERS EVERY YEAR,
HOW MANY PEOPLE WOULD DIE IF
EVERYBODY HAD THE RISK OF DEATH
OF A COLLEGE-EDUCATED PERSON?
THERE'S NOT A NEW DRUG, NOT A
NEW TREATMENT.
THIS IS IF EVERYBODY GOT WHAT
COLLEGE-EDUCATED PEOPLE GOT.
WHAT I CAME BACK WITH IS,
THERE'S 468,000 INSTEAD OF
600,000 WOULD DIE IN A GIVEN
YEAR.
132,000 DEATHS WOULD BE AVERTED
IF EVERYBODY GOT WHAT
COLLEGE-EDUCATED PEOPLE GOT.
AND THAT INCLUDES A LOW SMOKING
RATE.
BLACKS ARE MORE LIKELY TO SUFFER
FROM DISPARITIES, BUT WHITES
NUMERICALLY OUTPACE THEM.
WHEN WE TALK ABOUT DISPARITIES
BY STATE, THIS IS UTAH VERSUS
KENTUCKY FOR DEATH RATE.
WE NEED TO START THINKING ABOUT
DIFFERENCES IN PREVENTION,
DIFFERENCES IN SCREENING,
DIFFERENCES IN DIAGNOSTICS AND
TREATMENT, NOT JUST DIFFERENCES
IN BIOLOGY AMONGST THE RACES, AS
WE START MOVING TOWARD -- MORE
TOWARD SOCIAL JUSTICE AND MORE
TOWARD FIGURING OUT WHAT THE
REAL PROBLEMS WITH AND
OVERCOMING THE REAL DISPARITIES.
THE IMPORTANCE OF RISK
REDUCTION, I CANNOT
OVEREMPHASIZE.
WE NEED TO ALSO IDENTIFY THOSE
WHO ARE MOST IN NEED, THOSE WHO
NEED EDUCATION, WHO NEED
CULTURAL CHANGE, THE ROLE OF
MENTAL HEALTH AND OTHER THINGS,
AGAIN, IDENTIFY WHO NEEDS WHAT.
SOMETIMES IT WILL BE BLACKS IN
BALTIMORE OR D.C. , SOMETIMES IT
WILL BE WHITES IN APPALACHIA OR
WHITES IN MISSISSIPPI AND THE
SOUTHERN UNITED STATES.
AS WE'VE MOVED BEYOND RACE,
THERE'S STILL AN EMPHASIS ON
POPULATION DIFFERENCES, WHICH I
THINK ARE GOOD.
THE EMPHASIS SHOULD CENTER ON
EPIGENETICS, GENETICS AND
ENVIRONMENTAL INFLUENCES THAT
INFLUENCE GENETICS, AND THE
EMPHASIS NEEDS TO CENTER MORE ON
PROVISION OF ADEQUATE CARE.
SO THANK YOU VERY MUCH.
IT'S A PRIVILEGE TO BE HERE.
AGAIN, DR. SCHECHTER,
DR. GOTTESMAN AND DR. WANJEK,
IT'S REALLY AN HONOR TO BE ABLE
TO GIVE THIS TALK.
>> THANK YOU, DR. BRAWLEY, FOR
THE SUPERB TALK.
THERE WERE SEVERAL QUESTIONS
THAT I'D LIKE TO BEGIN TO RELAY
TO YOU IF I MAY.
>> SURE.
>> ONE QUESTION WHICH SPEAKS TO
THE LAST POINT YOU MAKE, IF IT'S
THE QUALITY OR AMOUNT OF CARE
THAT'S THE MAJOR FACTOR AMONG
THE DIFFERING GROUPS, IS THERE A
DIFFERENCE, FOR EXAMPLE, BETWEEN
THE OUTCOME IN CANADA AND THE
UNITED STATES WHERE FACTORS DUE
TO COST AND AVAILABILITY OF CARE
SHOULD BE LESS BECAUSE OF THE
GENERALIZED HEALTH SYSTEM THAN
IN THE UNITED STATES OR IN
EUROPEAN COUNTRIES AS WELL?
>> WELL, OVERALL OUTCOME, SO IF
YOU'RE LOOKING AT THE ENTIRE
POPULATION, BETTER IN CANADA
THAN IN THE UNITED STATES.
NOW, THAT BEING SAID, CANADA IS
MUCH BETTER AT PROVIDING AVERAGE
CARE TO THE AVERAGE HUMAN BEING.
IF YOU HAVE AN UNUSUAL DISEASE,
YOU'RE BEST OFF IN THE UNITED
STATES WITH GOOD INSURANCE AND
SOMEBODY LIKE OTIS BRAWLEY TO
GUIDE YOU THROUGH THE SYSTEM.
MUCH MORE SO THAN IN CANADA.
BUT IN IF YOU HAVE AVERAGE GARDEN
VARIETY ILLNESS, YOU'RE BETTER
OFF IN CANADA.
AND BECAUSE OF THE OBESITY ISSUE
IN THE UNITED STATE VERSUS THE
REST OF THE WORLD, YOU'RE LESS
LIKELY TO GET SICK IN CANADA.
>> OKAY.
THANK YOU.
A SECOND QUESTION THAT CAME IN
EARLY, ONE LISTENERS ASKED
WHETHER THE DIFFERENCE IN
ASSUMPTIONS ABOUT YELLOW FEVER
IN COLONIAL TIMES WAS RELATED TO
THE FACT THAT PEOPLE UNDERSTOOD
THAT YELLOW FEVER HAD COME FROM
AFRICA AND THOUGHT THAT THERE
WAS A DIFFERENCE IN THE --
BECAUSE OF THE ORIGIN OF THE
DISEASE RATHER THAN BECAUSE OF
THE NEW GENETIC U.S. SEPTEMBER
IBILITIES.
GENETIC
SUSCEPTIBILITIES.
DOES THAT CONTRIBUTE --
>> I'M NOT SURE.
AT THAT TIME THERE WERE A LOT OF
PEOPLE THAT THOUGHT PEOPLE COULD
GIVE YELLOW FEVER TO OTHER
PEOPLE, THEY DIDN'T UNDERSTAND
WHAT VIRUSES WERE AT THAT TIME.
KEEP IN MIND, WALTER REED, A
CENTURY LATER, IN THE LATE
1800s, WOULD FIGURE OUT THAT
YELLOW FEVER IS CARRIED BY A
MOS.
MOSQUITO.
SO I'M NOT SURE WHAT THE ANSWER
TO THAT IS, BUT THERE HAS ALWAYS
BEEN AND I'M SURE EVEN BEFORE
THE YELLOW FEVER EPIDEMIC, I
CAN'T DOCUMENT IT, THIS BELIEF
IN BLACK/WHITE DIFFERENCES IN
BIOLOGY.
>> LET ME ADD A THIRD QUESTION.
MY OWN THAT I THOUGHT AFTER YOUR
TUESDAY TALK AS WELL AS TODAY,
YOU MENTION OFTEN THE EFFECT OF
OBESITY ON CANCER INCIDENCE AND
OUTCOME.
DO YOU BELIEVE THAT THE OBESITY
IS CAUSAL RATHER THAN A
CORRELATION?
IS THERE A BIOLOGICAL MECHANISM
TO EXPLAIN THE LIKELY EFFECT OF
OBESITY ON ANY DIFFERENT
CANCERS?
>> THERE ARE WEEK-LONG
CONFERENCES WHERE PEOPLE ARGUE
ABOUT THE MECHANISM WHERE
OBESITY CAUSES CANCER.
THERE'S CERTAINLY REALLY GOOD
CORRELATION IN HUMANS AND
THERE'S LABORATORY DATA IN
ANIMALS THAT OBESE ANIMALS ARE
MORE LIKELY TO HAVE CANCER.
SOME OF THE THEORIES ARE OBESE
PEOPLE HAVE MUCH MORE INNATE
INFLAMMATION AND INFLAMMATION
CAN CAUSE CANCER.
OBESE PEOPLE HAVE HIGHER
CIRCULATING AMOUNTS OF INSULIN,
AND INSULIN IS A GROWTH FACTOR
THAT HELPS BLOOD VESSELS TO GROW
INTO AN ESTABLISHED TUMOR.
THERE'S THOUGHT THAT PERHAPS
SOME PEOPLE, BECAUSE OF OBESITY,
MAY HAVE IMMUNE SYSTEMS THAT ARE
IMPAIRED AND WE KNOW THAT PART
OF THE WAY THAT WE PREVENT
GETTING CANCER IS IMMUNE CELLS
ATTACKING EARLY CANCER CELLS
AND, THEREFORE, THEY CAN'T
BECOME A TUMOR.
I THINK THE DATA IS FAIR ENOUGH
TO SAY THAT OBESITY DOES CAUSE
CANCER.
IT'S NOT REALLY OBESITY, IT'S A
THREE-LEGGED STOOL.
IT'S ENERGY IMBALANCE.
TOO MANY CALORIES, NOT BURNING
OFF ENOUGH CALORIES, AND STORING
TOO MANY CALORIES.
THE STORAGE IS JUST ONE LEG OF
THE THREE LEGGED STOOL.
AND INTERESTINGLY, WITHIN THE
NEXT FIVE YEARS OR SO, BECAUSE
SMOKING RATES IN THE UNITED
STATES HAVE GONE DOWN SO
DRAMATICALLY, ENERGY IMBALANCE
WILL BE THE LEADING CAUSE OF
CANCER IN THE UNITED STATE, AND
IT ALREADY IS FOR CERTAIN
SUBPOPULATIONS LIKE HISPANIC
WOMEN.
>> IS THE OBESITY EFFECT SIMILAR
FOR MOST OF THE MAJOR DIFFERENT
KINDS OF CANCERS?
>> THERE ARE ABOUT 12 CANCERS
THAT ARE LINKED TO OBESITY.
THERE ARE 18 CANCERS, BY THE
WAY, LINKED TO SMOKING, BUT
THERE ARE 12 CANCERS LINKED TO
OBESITY.
AMONG THEM ARE SOME OF THE
MAJORS.
THE FIVE MAJOR CANCERS THAT
EVERYBODY WORRIES ABOUT BECAUSE
THEY'RE 50% OF DEATHS ARE, NOT
IN ORDER, LUNG, COLON, BREAST,
PROSTATE, AND PANCREAS.
AND EVEN LUNG CANCER IS LINKED
TO SOME DIETARY ISSUES, BUT THE
OTHER FOUR ARE MORE LINKED TO
OBESITY THAN AS LUNG CANCER.
BUT LUNG CANCER IS LINKED TO
SOME DIETARY ISSUES LIKE LOW
FRUIT CONSUMPTION.
>> OKAY.
I CAN JUST ADD ONE FURTHER
QUESTION OF MY OWN.
DOES THE ASSUMPTION THAT WENT
INTO THE TUSKEGEE STUDY OF
GREATER RESISTANCE TO THE
DISEASE AMONG THE BLACK
POPULATION CHANGE AT ALL YOUR
FEELING ABOUT THE ETHICAL NATURE
OF THAT STUDY, EITHER AT THE
BEGINNING OR AT SOME POINT IN
ITS CONTINUATION, WAS THERE AN
ETHICAL TRANSITION THAT OCCURRED
AT SOME POINT?
>> WELL, I DO THINK THERE WAS --
I THINK THERE WERE ETHICAL
CHALLENGES THROUGHOUT THE ENTIRE
STUDY.
INFORMED DECISION-MAKING AND
INFORMED CONSENT ARE CONCEPTS
FROM THE 1950s.
SO I CAN'T HOLD IT AGAINST THEM
THAT THEY DIDN'T DO INFORMED
CONSENT IN 1930, 1931.
I CAN HOLD AGAINST THEM THAT
THEY LIED TO PEOPLE TO GET THEM
TO PARTICIPATE IN THE TRIAL.
NOT TREATING PEOPLE WAS
CERTAINLY VERY REASONABLE IN THE
1930s.
SO I CAN'T HOLD IT AGAINST THEM
THAT THEY DIDN'T GIVE PEOPLE
MERCURIALS, WHICH TURNED OUT NOT
TO BE HELPFUL ANYWAY AND
ACTUALLY HARMFUL, BUT THERE WAS
PENICILLIN IN THE 1940s, AND I
CAN CRITICIZE THE PEOPLE RUNNING
THE TRIAL IN THE 1940s FOR
HOLDING BACK ON PENICILLIN.
SO THERE WERE ALWAYS ETHICAL
PROBLEMS THERE, AND THERE WAS
ALWAYS A LACK OF DISRESPECT, BUT
IT GOT WORSE IN THE 1940s,
50s AND 60s.
AS YOU MIGHT HAVE HEARD, IT
WASN'T JUST WHITE PEOPLE WHO ARE
TO BLAME.
THERE WERE BLACK PEOPLE WHO
CONDONED THE STUDY, THERE WERE
BLACK PEOPLE WHO WORK ON THE
STUDY FROM THE TUSKEGEE
INSTITUTE.
THEY'RE ALL TO BLAME FOR THIS.
INCLUDING THE LYING TO PEOPLE IN
THE 1930s.
THE IRONY IS THE STUDY WAS
WRITTEN BY AND DESIGNED BY
PEOPLE WHO LITERALLY WANTED TO
PROVE THAT MY BIOLOGY IS
EQUIVALENT TO YOUR BIOLOGY.
THAT THERE IS NO BLACK BIOLOGY
OR WHITE.
THESE PEOPLE ARE TRYING TO PROVE
THAT BLACK PEOPLE DESERVE SOME
ATTENTION IN TERMS OF SYPHILIS,
BUT THAT DOES NOT OVERCOME SOME
OF THE OTHER LAPSES.
>> AND IN THIS SERIES, WE'VE HAD
SEVERAL LECTURES ON EUGENICS,
AND I COME AWAY FROM SOME OF THE
LECTURES WITH, AGAIN, THE IRONY
THAT I THINK MANY OF THE PEOPLE,
ESPECIALLY IN THE LATE 19TH
CENTURY OR THE VERY EARLY 20TH
CENTURY, THOUGHT THEY WERE DOING
GOOD THINGS BY ADVOCATING
GENETIC CHANGES AND THE
POPULATION CONTROL OF
REPRODUCTION AND THE LIKE, BUT
AT SOME POINT, AGAIN, AS
EUGENICS PLAYED OUT, THE
TRANSITION OCCURRED THAT IT WAS
NOW MORE UNETHICAL THAN ETHICAL.
THERE'S A SIMILARITY IN THESE
TWO ASPECTS.
>> VERY MUCH SO.
VERY MUCH SO.
>> BUT I THINK IT'S ALMOST
5 AFTER 1:00.
I THINK -- I WANT TO THANK YOU
ON BEHALF OF THE NIH IN GENERAL,
THE NIH OFFICE OF HISTORY IN
PARTICULAR, AND WE VERY MUCH
ENJOYED YOUR TALK, AND WE'LL
RELAY TO YOU ANY FURTHER
QUESTIONS THAT WE RECEIVE.
THANK YOU.
>> THANK YOU SO MUCH.
IT WAS A REAL PRIVILEGE TO GIVE
THIS TALK, AND IT'S WONDERFUL TO
MEET YOU.