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Quoc-Dien Trinh: In three minutes, let's just go over our commentary on a couple of papers that I selected. Let's talk about a framework for understanding underserved populations and racial and ethnic minorities, and the outcomes of active surveillance. Maybe a roadmap or a conversation about what can be done to fill in the gaps.

So, what's the current situation regarding active surveillance in racial ethnic minorities, specifically Black men? All the data that we know about Black men show worse mortality for prostate cancers.

For active surveillance, and this was published in the New England Journal of Medicine a couple of years ago, what it shows is that there is a difference between Black men and non-Black men.

Black men were actually more likely to receive active surveillance or watchful waiting in later years, in this case, 2015, but that is largely driven by socioeconomic status differences, at least in this SEER-based analysis.

There's some interesting data across the continuum of care of active surveillance showing that there may be a difference that could lead to a difference in outcomes between Black and non-Black men. In this study from the Hopkins group, what we see is that there were significant differences in the reclassification rates on active surveillance between Black men and non-Black men, as evidenced in these two graphs here.

This paper has been cited, I think, 300 times and is often quoted as evidence that maybe active surveillance for Black men is not necessarily a good idea, but is this about biology or access to care? In any case, what this study showed is that Black men with very low-risk prostate cancer experienced significantly higher rates of upgrading and adverse pathology than white men. You can flip the data different ways, but the data seems to point in this direction. Next slide.

To really culminate this conversation, you see all this evidence about reclassification and adverse features. This is a study that was published in JAMA in 2018, and what you see is that the racial disparities, because on the left is Gleason six and on the right is Gleason seven to 10, were greatest in low-grade Gleason six disease.

And this difference, interestingly, increases over time. As you can see on the left, the curves are actually separating over time. Now, I do want to point out, these are really small numbers. We don't want to get overly focused on this, but it is an interesting point. Next slide.

Yep, this slide. You can stay here. When you look at all these data, and interestingly you can look at all the letters that were written to the editor about this, you have to wonder what is exactly driving these differences. Because on the one hand, if this is really a biological issue and there are inherent differences in the natural history of Gleason and grade grouping six comparing, for example, Black men and non-Black men, then we need to take that into account if we're going to reclassify or however we name this disease. On the other hand, a lot of these differences could be driven by access to care issues. And what do I mean by access to care? We're talking about access to MRI, access to fusion biopsy, access to appropriate follow-up on surveillance, right? There's compelling data showing that there's a twofold difference in appropriate surveillance in certain racial ethnic minorities compared to white men, and what does that exactly mean? That will probably drive the roadmap of what kind of research needs to be done to fill in the gaps.

Essentially, there are certain questions that probably we need to explore further. Is it a question of modeling the relative contribution of biology versus access to care in underserved populations and how much that affects active surveillance outcomes? Is it about defining thresholds of disease, imaging, genomics, as many have mentioned? But that threshold, will it be different according to race, for example? Maybe the gene panels or whatever we're looking for may not be the same across different races.

I do think that it will be important to do some qualitative research on attitudes toward active surveillance, and doing this according to certain populations, seeing how people react to surveillance.

Because if we really think that there's a twofold difference in the receipt of appropriate active surveillance depending on populations, then what are the repercussions of calling this no longer cancer, and what would this mean? If I do have 20 seconds, I would like to point out, and I don't want to sound too woke or anything, I am, after all, a left-leaning Canadian living in the US.

But I do want to point out that it's certainly important that if we're going to do this kind of change that is not driven by biology, but rather by public health, that all stakeholders be involved, grassroots organizations, patient representation. I know we have some here, but... Because, ultimately, imagine if this nomenclature change led to increased mortality, actually widening the gap in certain racial groups, this would be terrible, right? So probably something to think about in the research.