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Zach Klaassen: Hello and welcome to the AUA 2023. I'm here with Dr. Kelvin Moses. He's a urologic oncologist at Vanderbilt University. My name is Zach Klaassen, urologic oncologist at the Georgia Cancer Center. I know Dr. Moses and I go way back to my residency days when he was one of my attendings. It's great to have you today. We're going to touch on an important topic and one that's near and dear to your heart as well. We're going to talk about prostate cancer disparities in 2023. So welcome and we're delighted to have you.

Kelvin Moses: Thanks for having me. Really looking forward to the conversation.

Zach Klaassen: So let's start on a high level. How do you define prostate cancer disparities and how does that look in 2023?

Kelvin Moses: Yeah, so if you look at the definition just from a population level, health disparities just means that there's a difference in outcome, incidence, mortality that is not necessarily due to the disease itself, but factors such as race, gender, socioeconomic status. When you talk about prostate cancer, the really specific disparities are really at every level. Black men are less likely to get screened for prostate cancer. Black men, when diagnosed with prostate cancer tend to be at a higher grade or stage of disease. Then those who progress to advanced disease have more than twice the risk of death from prostate cancer compared to white men in the US.

Zach Klaassen: So I know a lot of your research over the last decade and before that has focused on this topic. If you can sort of walk us through some of your higher level projects, what have you been looking at in terms of how to address disparities and some of the work that you've done?

Kelvin Moses: So one of the projects I've done was with the Southern Community Cohort Study SCCS, and we looked at screening patterns. SCCS is really based in community practices throughout the south and covers thousands of men, a lot of them being in rural locations. We looked at the odds of screening for prostate cancer. What we found were that younger black men were less likely to get screened. Again, so some of the things that we've known before about the age of diagnosis, things like that. So work I did in SEER with Willie Underwood, who's a mentor of mine, we looked first at just the odds of receiving treatment overall. We looked at black men, white men, Hispanic and Asian. What we found were that black men were less likely to receive treatment at any risk level, low risk, intermediate risk, and high risk.

Actually for escalating risks disease, the odds of receiving treatment were lower. It was an anti-parallel relationship. We found the same relationship in Hispanic men for intermediate and high risk disease. Then we looked at individual treatments. Other than a 2% increased likelihood of getting radiation, black men were less likely to get any individual treatment, surgery, brachytherapy, cryo, combination. So what it pointed out is that it's not just a screening problem, it's a treatment problem. When we look at sources for this, there's access obviously. But then there's also differential treatment even when you get in the door. So a lot of the education we do in the community, I now do amongst physicians because we have to make sure that we're treating people equitably.

Zach Klaassen: For sure. You mentioned community, which is a nice segue into my next question. I've done some outreach in local churches and groups in Augusta. I know you've done similar thing in Nashville and you mentioned you're targeting some physicians as well. Can you talk to maybe both sides of taking the message to the people, but also to the community, to community practitioners as well?

Kelvin Moses: Yeah. So in the community, the really important thing is about education. Sort of breaking down the stigma about screening. Let men know they won't die if they get a DRE.

Zach Klaassen: That's right.

Kelvin Moses: They really make the point that if diagnosed with prostate cancer at early stage, survival is 99%, as far as mortality. Recurrence rates obviously as you know, can be different. We encourage the spouses to come out. Families.

Zach Klaassen: Absolutely.

Kelvin Moses: 'Cause sometimes that decision making, it comes from the wife or the partner. As far as educating physicians, it's really about taking now four decades of data about disparities and say, "Okay, it's enough reporting. What are we doing about it?" Really describing why the disparities exist really from a historical perspective and how sometimes our inherent implicit hidden biases will sometimes veer us away from active treatment for somebody or veer them away from surgery.

So a lot of times before I used to preach to the choir, and now I'm sort of preaching to the, I don't know, the pit of hell. I don't know what the right term is. But we as a field we have to change. When we realized the opioid epidemic was rampant and within our field, I remember how many pills we used to send patients home with, and the high dose narcotics for uroscopy. Our field recognized it. We made changes, we implemented protocols. I think we're doing a better job of that. So it's not that we can't do it. It's really about putting the thought and the action together to do it.

Zach Klaassen: I think that's a great analogy. I mean, that's happened, what in the last four or five years, where there's really been task force in the AUA and really big movement on it. So the $64,000 question is, and I know you've sort of addressed it a little bit, how do we change it? What are the steps and what are you guys working on in terms of making differences, in terms of disparities?

Kelvin Moses: So key differences, education obviously, and again, that's on the patient and the practitioners side. We have to be advocates for our patients. Advocacy comes in many ways, but the two main ways are voting and then legislative lobbying, making sure that we're on the hill and letting Congress know. There is such a pushback against the Affordable Care Act for various political reasons, but it's our job to let them know, "Hey, look, we've got data that shows that states that participated in ACA exchanges, outcomes are better screening, better treatment at better stage of diagnosis." That translates not only to saving lives, but it's a cost saving. In the end, Congress is about money.

Zach Klaassen: That's right.

Kelvin Moses: Then the voting booth, we talk about disparities and people write papers, but then when they pull that lever for the candidate who opposes exactly what you're talking about, then you've kind of done your patients a disservice. As far as on the ground level, I mean obviously we need to diversify our ranks, physicians, nurses, we need to have people that reflect our communities when we talk to the patients, treating the patients. We need more diversity in clinical trials and participation.

Zach Klaassen: No question.

Kelvin Moses: Again, clinical trial designers, the research coordinators, and then making sure that we go to the right communities. Because if we say that there's twice the risk of death in black men, then we should be oversampling for that population because that's going to make the biggest impact.

Zach Klaassen: Yeah, you're right. I mean, touch on a good point with the clinical trials. I mean, it's either the trial's not reporting race whatsoever, which is a little less likely now because of the recent FDA mandate to report it. But when you see it's 2% to 3%.

Kelvin Moses: Abysmal.

Zach Klaassen: It's even less if it's a global trial because the North American population gets diluted out. So I mean, it's way below where we need to be.

Kelvin Moses: It is, and it really, like I said, it should be over sample. The black population's about 13% in the US. If it's twice the risk of death, it should be 25%.

Zach Klaassen: Yeah, absolutely.

Kelvin Moses: "So a lot of industry folks will come to me and say, Hey, what do we need to do?" I say, "You need to do what Nick Saban does. He can recruit from any neighborhood that's right in the country. So you need to go to where the people are who you want to recruit." But again, the person who goes there needs to reflect that community too because the justifiable mistrust, especially around clinical trials, you want somebody that you can relate to and ask the honest question and say, "Hey, is this a fair? Is this a just trial?" Make sure that you're not shunting all of us into the placebo arm or you're not shunting us to the most dangerous arm.

Zach Klaassen: Right. No, great points. So just to wrap up, if you can give our listeners two or three take home messages to go home with that be fantastic.

Kelvin Moses: So I would say educate yourselves. I think we are in an era, unfortunately, politically and socially, where the history of how we've gotten to where we are is, it may be unsavory, but it is sort of being suppressed. We all heard the phrase, "If you don't know your history, you're doomed to repeat it." So I think educating ourselves about it, making sure that we're advocates for our patients, but also for diverse voices within our field. Then really making the effort to reach out to the patients that you base your practice or you base your research on. There's plenty of health services and outcomes, researchers, but if you're in the ivory tower and people from across the street can't get in, you need to work on that. So that takes people at higher levels, the deans and the presidents and the CFOs and people like that to say, "Okay, how can we make sure that we're taking care of the people who need us the most?"

Zach Klaassen: Thank you very much. Excellent conversation as always. Enjoyed it. And thank you again.

Kelvin Moses: Thank you. Appreciate it.