Read the Full Video Transcript

Samuel Washington: Hello, everyone. I'm Dr. Samuel Washington, urologic oncologist, the University of California, San Francisco, as well as the new editor for the Center of Excellence on Healthcare Disparities. I'm joined today by Dr. Randy Vince Jr. urologic oncologist, who recently joined University Hospital Case Western as a faculty member of the Urology Institute and Seidman Cancer Center, as well as Minority Men's Health director for the Cutler Center for Men.

Thankful to have him today in order to discuss his recent publication, JAMA Network Open, titled "Evaluation of Social Determinants of Health and Prostate Cancer Outcomes Among Black and White Patients: A Systematic Review and Meta-Analysis". Thank you for coming today. Hopefully we can have a good discussion about what you found.

Randy Vince: Yeah, Dr. Washington. Samuel, my good friend. It's a pleasure to be here with you today.

Samuel Washington: Perfect. This was an exciting article and I had a few questions as we slowly change our understanding of the context of what's happening with disparities and how we can look at them in a way that moves us towards action and away from observation. Just to start out, would you be able to give me kind of a quick summary of the purpose of the meta-analysis?

Randy Vince: Absolutely. So as you are aware, and as many people who will listen to this are aware, racial disparities have existed for a very long time when we talk about health outcomes, particularly within prostate cancer. Prostate cancer health disparities are perhaps the most pronounced in all of the whole field of oncology.

And when I was going to medical school, and I'm sure it was the case when you were going to medical school, it was just one of those things where, okay, yeah, we know these racial disparities exist within prostate cancer, but it's just a result of men just having black skin essentially. Do your skin color determine that you just had this innate biology that was going to cause you to have worse prostate cancer and be more likely to die from it, and all of these other things.

And from a researcher's perspective, we've put so much money and time into trying to identify this exact biological cause so that way we could say, "See, I got you. It was this one gene the whole time that black people would over express or under express, and this was the reason why we had these disparities."

And within doing that, what we do is we just outright ignore the fact that race is a social construct. All right? So we have all these ambiguous blood fractioning laws, especially in the United States, which determine somebody as being black like the one-eighth rule or something like that.

And so we have just tried to assign a biological consequence to a social construct, which biologically, scientifically doesn't make sense. So in this meta-analysis, what we aim to do is just look at the association of societal factors, which we now talk about as social determinants of health and prostate cancer outcomes.

There's been an increasing amount of data that shows the impact of things like environmental exposure, stress as it relates to trauma or racism, discrimination, and what it physiologically does to one's body, and how that can ultimately have an impact on tumor biology.

And so for us, it was simple. We haven't done many studies like this within prostate cancer, even though we have perhaps the most pronounced racial disparities in outcomes within all of cancer. And so it was just really to evaluate that association between social determinants of health and prostate cancer outcomes, and with the hope of adding to the growing amount of literature now that is showing these associations, but then to take that one step beyond is to change the narrative.

So the narrative of, "Oh, well, you have dark skin so you are more likely to have all these worse health outcomes, and it's nothing we could do about it." So there's a lot that we could do about it and the goal was to really change that narrative and to keep pushing towards achieving equity. So that was the purpose behind the whole study.

Samuel Washington: Very exciting. Very exciting. Now, I know social determinants of health has become somewhat of a buzzword, and it's commonly been framed as patient levels, education, insurance, income, so on and so forth, despite the CDC World Health Organization definitions that these are really conditions in which people exist. So how did this meta-analysis differ from the more common approach in the literature when presenting social determinants of health?

Randy Vince: Yeah. It's funny because I oftentimes tell people, I say social determinants of health as a term has become in vogue, if you will. Everybody is talking about social determinants of health. And one of the things that I often tell people just in regular everyday conversation is many people now in literature are talking about structural racism, they're talking about social determinants of health. They're talking about racial disparities within health outcomes.

And sometimes I think it gets muffled, if I'm being completely honest with you. This is more of a continuum, not just isolated things. So we have a history that has resulted in structural racism, which has placed certain populations of people, mostly Black, indigenous and certain Latinx communities, in a place where there are all these societal inequities, which we call social determinants of health. And then we know that those social determinants of health ultimately impact racial disparities in health outcomes.

We just have done a bad job of actually digging into the details and being comprehensive about it, and it's not anything new. So there was a book published by W.E.B Du Bois called "The Philadelphia Negro", and even though he didn't use the term social determinants of health, he was talking about how housing, lack of employment, lack of healthcare access, the environment in which you live in can have a detrimental impact on someone's health and this was in the early 1900's.

So again, this is nothing new, we just talk about it more. It's more popular to talk about it now. But as it relates to our study, we wanted to be more inclusive about how we did social determinants of health and how we talked about it. So the Department of Health and Human Services actually that Healthy People 2030 initiative, if you go to their website, they list definitions for social determinants of health.

They have five different domains, which they talk about for social determinants of health, economic stability, healthcare access and quality, education access and quality, neighborhood and built environment, social and community context. So we said, "Okay, if we're going to be comprehensive about the way we include or the way we analyze social determinants of health, we need to have variables across all five of these different domains."

And so I think that's kind of what separates this study that we just did from previous studies that just include education or insurance status. And I think that's important because saying something about insured or uninsured, that doesn't really point to whether or not there was equitable care, whether there was standardized care. And so that's why I think it was more important for us to be a little more comprehensive in the way that we did this analysis.

Samuel Washington: This is exciting, particularly because me being a stats nerd, you obviously knowing statistics, we always try to isolate it down to one variable and that doesn't reflect anybody in the real world. So we have this disconnect between social determinants of health, social risk, the downstream effects of those social determinants of health that we isolate as a single factor and remove or adjust for all context.

So that led me, an interesting aspect of this study was your scoring system. So could you describe a little bit about the social determinants of health scoring system that you use to quantify kind of the cumulative effect of these different variables?

Randy Vince: Yeah, yeah, that's a great point. So we just talked about how we wanted to be comprehensive about it. And so as we went through all of these different studies that were prepared, excuse me, performing comparative analysis between Black and white men, well, you know it, that a substantial number of studies did not even include things like disease status.

And so for me, that was a head scratcher, right? Because it said, "Okay, well the goal is to look at the difference in outcomes between Black men and white men, and you're going to do this comparison, but you're not even going to make sure that disease status is the same between these two populations of patients?"

So it just didn't make sense to me. And so when we looked at it, we said, "Okay, we want to include things like," so our scoring system included age, comorbidity, insurance status, income, geography, because geography is a part of the community you live in and the context of that community. But we also wanted to do things like standardized treatment.

So was this the study that was done in a clinical trial where the treatment was the same for everybody? Because that gets back to the healthcare access and quality. And we know from previous literature that even when diagnosed at the same stage, receiving standard of care treatment is substantially lower for Black men.

And last was the equitable harmonized insurance benefits. And so as we just talked about the whole insured versus uninsured, that doesn't necessarily mean equitable access to treatment. So I'll give an example. If you are a Medicaid patient, the chances of you, even though you're technically insured, chances of you receiving the same access to benefits and treatment as someone who has commercial insurance is a lot less.

So we wanted to, again, to not only just have, "Oh, do you have insurance or not?" But actually break that down a little bit more so that way we can be a little more comprehensive about each one of those five individual domains of social determinants of health.

Samuel Washington: Yeah. It's exciting because there's so many different aspects to it that all enrich the context in which they exist, which has been kind of the missing data aspect of a lot of the studies that we've had thus far. So pushing all of us to flesh that out more, talk about where people are getting care, the type of care that they're getting, how that may change depending on where they are or their insurance or these other things. But before I digress, what would you say are the main takeaway points or key findings from this meta-analysis?

Randy Vince: Yeah, no, I mean, you're touching on something that we even found and when we did some of our tables, we've said, "This is important to put in here," is that even with the missing this of data, if you will, people were still publishing massive amounts of disparities literature when it's like, okay, well a lot of this data is just flat out missing, but somehow, someway it was still getting pushed through and still being published.

And within science and medicine specifically, one of the things that I think we need to be very conscientious of is the fact that it doesn't start and stop within medicine. So if we put out a publication and it's a high impact publication, chances are it could be used on the news, it could be used when it comes to determining policy, all of these things.

So I think we have to be a little more responsible about the comprehensiveness of our data sets and how we do our analysis rather than just trying to be self-serving, if you will, and publish stuff for academic promotion because it has more of an impact than what we think of commonly in the research field.

But to answer your question about the main findings, I think for our study, it was just the showing that there was a significant interaction between race and social determinants of health, and that this has a real influence on the disparities we see in prostate cancer outcomes.

I think it was that simple, at least for me. And this finding doesn't just exist within prostate cancer, it exists within various health conditions. And I think it's about time that as physicians, as researchers that we actually start to dig in and do the heavy lifting because without it, we're not going to achieve equity.

Samuel Washington: And I think that's a great segue to the implications of this. We know that when a paper comes out, the implications that are not just on the patient, it can change our practice patterns systems. So it alludes to the multi-level results or sequelae of the findings, but also you have to acknowledge the multi-level drivers or factors associated with the observations we're seeing.

Randy Vince: Right.

Samuel Washington: And there's one part of the study where you mentioned moving away from a race-based to a more race conscious framework. Would you be able to speak a little bit more about that?

Randy Vince: Yeah. So this, man, this is great that we're having this conversation because I actually was just talking to a friend of mine who's a social scientist about the use of race in clinical algorithms. And so his view was that, "Oh, I don't know that it should be removed because the history of medicine and racism, and we need to continue to collect data around race and as well as all these other societal factors."

And I said, "Yeah, I completely agree with you from a research perspective, we need to continue to collect this data, but from a clinical perspective, from clinical algorithms commonly discussed like the VBAC calculator and all that type of stuff," I said, "there is no reason why someone should look at you and say, 'Oh, you're black. So yeah, this should change the way that I do things for you.'" There is no rationale basis for that.

So for us to get from race-based where simply the race or the color of your skin now influences the treatment that we want to give you to being conscientious about race, that means that we are conscientious of the lived experiences of a lot of citizens.
So specifically we focused on Black men with this study, and rightfully so because of the pronounced disparities within prostate cancer, but Black, indigenous, and again, certain groups of Latinx patients or citizens have just been systematically oppressed and marginalized.

And so take into account those lived experiences when we try to develop different initiatives and efforts to mitigate disparities now shifts us from just looking at somebody and saying, "Oh, based off your race, this is where you need to be," to now, "Okay, I understand the lived experience that you're having." We need to take this into account to mitigate disparities and progress towards equity. So I think that is the shift that studies like ours are trying to push forward.

Samuel Washington: And I think this is really important because it helps us move from just assigning a biologic context to missing data, to acknowledging the social constructs and how that can be contributing to the things we're seeing even in the missing this aspect because we don't have a full idea-

Randy Vince: Exactly.

Samuel Washington: So moving forward, multiple publications will continue to come out about disparities comparing Black and white men whichever disease process, but how should findings be better framed or how should we provide more context to do a more informed race conscious approach to discussing our findings?

Randy Vince: Yeah. So I think the one thing that I get a lot of pushback from different translational scientists is they're like, "Oh, well, you're negating biology." And I tell people, I have never negated biology when it comes to disease aggressiveness or disease formation. I would never do that. But what I have repeatedly said is you cannot assign someone an innate biology based off the color of their skin.

So we know within different chronic conditions like diabetes, hypertension, and it's even being studied more commonly and things like Black maternal health is that your lived experiences really do influence how your genes are expressed. So if again, whether it's health behaviors, whether it is toxin exposure, racism or discrimination, all of these things actually will physiologically impact how your body works.

And so I think that is the thing that we have to get to. Move away from this whole notion that, oh my gosh, soon as you're born, this is your destiny because of the color of your skin. Because that again is a social construct, the race that you're assigned. And so moving away from that and now looking at, "Okay, well, Black men are more likely to present at an earlier age with a chronic condition, what is it about the experiences of these Black men that are causing them to present with this condition earlier?"

So I think of prostate cancer no differently than the other chronic conditions that we talk about, whether it's diabetes, hypertension, I know because it's a cancer, we often don't think about it in those same terms, but for me, there's a definite link there. And that's the research that I continue to partake in is aiming at showing exactly that.

So I think it's more about digging then because if I'm being completely honest, it's more difficult to look at someone's lived experiences and see and tease out, okay, well these behaviors or these exposures, or whatever it may be, these experiences are leading you to have worse outcomes. It is more difficult to do that than it is to just look at someone and say, "Oh, well, this swath of people who all share this certain physical characteristic present with this disease at an earlier age and more aggressively, so it must just be that physical characteristic."

That is way easier to explain than it is to start talking about all of the different issues that exist within society and how it's impacting someone's body. So I think when we talk about these links of exposures to cancer, we have to just be very cognizant of that. We just talked about how throughout research and throughout medicine and our generation, we have devoted all of these different resources to find a difference between, a genetic difference between Black and white individuals.

And so, one of the things is, I don't know if you know this about me, but I studied history a lot because it's the old saying, if you don't know where you're coming from, you never know where you're going. And so because of that, I study history a lot. And in the 18 and 1900's in our country, we had physician and researchers doing everything they could to study differences between Black and white people.

So whether it's measuring the size of their skull, actually taking pieces of skin to show that black people had thicker skin, all as a way to show that there was a difference biologically between Black and whites. And then you had other things like Black people being barefoot, working in fields and developing tape worms and having pica and fatigue.

And so all of these different things were then cast upon black people as being inherently animalistic because they would be craving iron in the soil or being tired and not being able to tend the fields. And so less than a hundred years later, where we are today, sometimes I ask people say, "Well, how is what we currently are doing different from that?"

It might not be as overt in terms of racism, but at the core, its really trying to show a difference between people based off the color of their skin rather than just embracing everyone as humans and seeing, "Okay, what is it about your experiences that are causing us to have these differences?"

Samuel Washington: It's a very exciting change in kind of the paradigm of this type of research because we have the biology we've been doing for decades, we have the cancer registries, which really focus on the individual and then social determinants of health, which impact everyone at a level above the individual, across diseases, across cancers.

So it's an exciting space where there's a lot of missing data. So that means there's a lot of room for growth and exploration. So-

Randy Vince: Absolutely.

Samuel Washington: ... very exciting. Always fun to chat with you. Thank you so much for coming with us and look forward to working with you more in the future.

Randy Vince: It was my pleasure. It's good seeing you again.

Samuel Washington: Thank you.