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Charles Ryan: Hello from the Milken Global Conference, 2021. We are in Los Angeles, California and I am delighted to be joined by Prof. Lynn Goldman. She is the Michael and Lori Milken Dean of the Milken School of Public Health at George Washington University. We just got done sitting on a panel, which brought up a number of important issues related to cancer, cancer care, the future of cancer therapy, and cancer research. I think most importantly for what I want to talk to you about today is disparities in cancer care and cancer research. We are sitting here, it's October 2021 as we record this, and we are in the 20th or so month of the COVID pandemic. We've learned so much about disparities in healthcare over the course of this time. You as a researcher and a public health deep thinker, what do you think are the pieces of what we have learned in the COVID pandemic around healthcare in general, healthcare disparities? How are we going to move forward having learned that?

Lynn Goldman: Well, I think we've learned so much from COVID, and especially, I think the public has become more aware of the issue of health disparities as every day almost we have learned new things about COVID, and especially the fact that certain communities, I would say, the black, Hispanic and honestly, American Indian communities have such high rates of COVID. Why is that? It's very much like cancer. One thing that we see is the opportunity for exposure to COVID. The people in lower-income communities who live in crowded conditions, or are doing work where they are out in the front line, they can't stay at home and protect themselves, have been more exposed to COVID just as those very same communities are more exposed to conditions that cause cancer, whether that's tobacco, whether that is through having obesity, having poor nutrition. The factors that we know are cancer risk factors that are also risk factors for COVID.

But we also see how some of these underlying conditions have made COVID much more likely to kill you, that you are less likely to survive, have a good outcome. The same is true for cancer. If you go into a cancer diagnosis already having diabetes, or already having high blood pressure, or already having obesity, then you have a less good chance of either being cured of your cancer or being healthy after you've gone through your cancer therapy. The other thing that I think has been very fascinating is the resistance in many communities to obtaining a vaccine, the lack of trust in healthcare. The fact that during the pandemic, many people were not only afraid to get the COVID test or to get the COVID vaccine but also afraid to then show up in healthcare for other conditions.

We saw cancer screening go way down. We've known for a while that this is also true that many communities that have disparate health outcomes don't trust healthcare to the same extent as wealthier and whiter communities do. They don't participate in clinical trials. We've talked about this before, the participation in clinical trials is way too low anyway. But it is particularly low in certain communities of color, poorer communities, also rural communities. Some of the communities in our country that have been very resistant to vaccination and more likely to believe in fake therapies for COVID, also are those that are very skeptical about getting into clinical trials and are slower to get in and get cancer screening.

And then at the end of the day, the outcomes, the differential access, and resources, having financial resources make a tremendous difference in terms of having opportunities to have a good diet, physical activity. That helps you when you're going through cancer. It won't cure your cancer at this point necessarily, but it is an extremely important aspect of cancer therapy that we are taking care of the whole person, the same is true for COVID. It is part of why we see these differences, who winds up in the hospital with COVID? Who winds up dying from COVID? Those are the same people that have a shortened life expectancy when they're diagnosed with cancer as well.

Charles Ryan: Right. I was in a conversation recently where I, as an MD, a medical oncologist at an academic setting, used the term social determinants of health, which is a term that's been around for a while. COVID exposed how social determinants of health are such key drivers of so many health outcomes. It just did it so acutely in such a short timeframe that it made that phrase if you're a medical person, I think, a household phrase if that makes sense.

Lynn Goldman: Yeah.

Charles Ryan: I used this on a Zoom call with somebody from our public health school, and she said, "Well, we've been using that term for 30 years." I was thinking, well, it's a new term for medical school and MDs. I hope really what you're bringing out is how the social determinant of health, determines health.  Whether it's COVID, whether it's cancer, and all these other things. So I remain hopeful that greater attention to some of these social determinants by medical doctors, like myself and practicing physicians all over the country, may help get us to the next level. So I guess what I'm asking now is, do you see a greater role for public health schools, public health officials, in helping to guide the narrative, to guide the trajectory of how we develop not only therapies for infectious diseases in the acute case of a pandemic, but also in the cancer case, which I think is needed?

Lynn Goldman: I do see such a role. I think it's extremely important. We're seeing a huge surge and interest in public health among our students. Our enrollments at GW are up 20%, but that's true across the country. It's put a lot of strain on me and my faculty keeping up with that. But the good news is that we need highly trained people coming into public health. Not only that public health has a bigger role, but that people in public health have a deeper understanding of some of the biology around diseases, as well as what we've always been good at, the epidemiology, the statistics, the behavioral science. I think behavioral science is sometimes missing in medicine and needs to be there because part of the social determinants is, how do we treat people when they come in for service? Do we understand how to listen to everyone, or do we do a better job listening to those people who look like us, who share our characteristics in terms of socioeconomics? Sometimes we don't.

We hear again and again, especially in our country, black people, that they don't feel that people hear them. That they talk about their pain, they talk about their symptoms, then we make errors and we lose people because of that, but we also lose their trust. We get them to believe that it's a system that won't listen to them, and therefore they are wary about coming into it. I mean, one thing I'd like to see, our public health experts need to work more closely with people like you. People who understand the biology of disease. Many of the people in public health traditionally didn't have much training in things like genetics, DNA sequencing, tumor biology. When we develop our screening guidelines and other public health measures, which are so important, but we're doing these things in a way that is almost like a meat cleaver approach, the same guideline for everybody. Is that actually the right way to do it?

Could we, if we understood more about biology and public health, have a more precise approach to how we screen? I mean, maybe you needed to start your colorectal cancer screening earlier than I did because of something about your genome, your past life experience, your family history. Maybe I never needed a mammogram because I actually personally have zero risk of breast cancer. But both of us, how we proceed through the system is based on the average person and not on us, just like in medicine, we've based treatment on the average person.

Charles Ryan: Right. We've wasted a lot of dollars. We've wasted a lot of time, and probably overtreated a lot of people by applying a one-size-fits-all process to cancer screening and other things. We have, as a society, a lot to gain from doing this. Really what you're saying is to take the public and make it personal. To take the epidemiology and just focus it on, when I'm sitting in the room with a patient, or when a primary care doctor is sitting in the room with a patient, or a pediatrician is talking to a child, how do they integrate what is known to be for the population into this one individual case? Boy, we could talk all day on that front because of the statistical issues and all those other factors.

Lynn Goldman: But the jillions of data points that we have now in health records systems that could be mined to inform those kinds of decisions and that we should be mining. We should be using that information. You're right. I mean, we probably are sometimes overtreating, but I'm sure sometimes we are missing things. I think I hear that sometimes when we... for example, in some of the public commentary around the mammography guidelines, there are people at a younger age who developed breast cancer and who wouldn't have been picked up by the guidelines. You want to pick everyone up, right?

Charles Ryan: Right.

Lynn Goldman: So, I think it goes both ways and it does end up not in the best way using the resources.

Charles Ryan: On that point, I need to bring it back to cancer and cancer screening a little bit. We heard that during the first couple of months of COVID, mammograms went down 90%.

Lynn Goldman: They did.

Charles Ryan: Colorectal cancer screening, I think went down by 60% or so. PSA screening for prostate cancer dropped by about a third. It's estimated, I believe that there will be several 1,000 deaths from cancers of many types due to delayed screening.

Lynn Goldman: Exactly.

Charles Ryan: Just for that couple of months drop, there were things that fell apart for a few months. What can we do to catch up on that from a public health perspective? Or is this going to be a blip on the map, if you will, epidemiologically for many cancers that will just naturally recover from? Or how do we move forward from this point?

Lynn Goldman: Well, I do think it will be a blip in terms of we will see an uptick of these cancers over the next several years because of delayed diagnosis, especially prostate, breast, and colorectal cancer. We also have a pile-up of delayed procedures in those areas. It's almost like what happens if you have a traffic accident on the freeway, and then the traffic is still crawling long after it's all been cleaned up. You can't figure out what caused it.

Charles Ryan: It's a good analogy, yeah.

Lynn Goldman: This is happening in the system. Unless there is real effort to speed the system up, that we are going to see a tail end of this, where there's going to continue to be these delays and more death than there should have been.

Charles Ryan: Well, it's going to be hard to speed it up, of course, because we don't have enough urologists. We probably have enough people doing colonoscopies, I would imagine. But we have a human resource issue, we have a supply chain issue. What I said before was the screening dropped, the bottom dropped out, and then we recovered. Because of the pile-up analogy that you put, it's going to take a while.

Lynn Goldman: It is going to take a while.

Charles Ryan: Thank God we have public health schools helping us to learn how to study these things and implement them into our policies and into our practices. It's a delight getting to know you and to sit on a panel. Always a pleasure to talk about what the future of cancer care is with anybody, and in particular with you, Prof. Goldman. So thank you for joining us.

Lynn Goldman: Thank you so much.