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Alicia Morgans: Hi, my name is Alicia Morgans and I'm a GU medical oncologist at Dana-Farber Cancer Institute. I'm so excited to have here with me today, a friend and colleague Dr. Kosj Yamoah who is a Section Head for Genitourinary Radiation Oncology and the Director for Radiation Oncology Health Disparities Research at Moffitt Cancer Center in Florida. Thank you so much for being here with me today, Dr. Yamoah.

Kosj Yamoah: Thank you for having me. It's my pleasure.

Alicia Morgans: Well, I appreciate it. And I am so excited to talk with you today about an issue that we have discussed several times here on UroToday, but I think always needs to be dug into a little bit more and continued to explore so that we can come to some conclusion on this. I'd love to talk with you about health equity and improving health equity, reducing disparities in prostate cancer care, and how we as a field can continue to make strides in that space. Can you tell us a little bit about health inequity, health disparities in prostate cancer care? Set the stage.

Kosj Yamoah: Thank you so much for the opportunity. And I think this is a very important topic that needs to be addressed on multiple fronts. We know the statistics and most people describe it as what we have come to expect or live with for decades that African American men or men of African origin will have an increased incidence of the disease close to twofold and increased mortality, 2.4 fold or 2.2 fold, depending on the statistics you look at and it attempts to address that this has been fraught with a lot of difficulties because we've looked for a linear solution to the problem. And more recently, there is more attention coming to the issue of health inequity, being a complex problem that is not only determined by the color of a person's skin but in some ways, the environmental stresses or the built-in environment and things that are over decades has led to some of the health inequities.

Now, prostate cancer is very unique in a sense that there are differences in the way prostate cancer inequity occurs in a sense of it spans the prostate cancer content right from the incidence, the development of the disease itself, the presentation of the disease when a patient is seen in the clinic, the resources that are offered to patients in terms of the treatment options, the consumption of those resources by patients, the response to the treatment and the resulting survival mortality from the disease. And we have to really, in order to really address a problem, we have to look at each phase of the issue and tease apart the factors that go into exacerbating the disparity. So the way I like to look at it is that prostate cancer is ultimately a biological process because something goes wrong at the cellular level.  Something goes wrong at the tissue level and the organ doesn't function as designed.

Okay. However, we haven't found the exact ideology or the exact cause of prostate cancer because it is a disease of the agents. So we know that a lot of things happen, a lot of insults, a lot of things happen in that microenvironment to cause the disease process, whether it's high-grade pain[inaudible 00:03:27]  through Gleason, through aggressive disease, through metastasis. And if you think about that and you layer on decades of structural racism, decades of neighborhoods with inadequate healthcare resources or health policies that marginalized populations for generations, you can now begin to understand how some of these systems can begin to impact the environment in which the cells are supposed to flourish and cause disease. So when you step back and look at health inequity, and the way I like to describe it is that, the multiple causes are multifactorial.

So there are certain things that will be easy to call to impact access and access to quality care delivery. I mentioned one big one, which is structure racism. There are also the healthcare systems themselves. And this way, providers like myself and you and me coming, how do we make our treatments more accessible? How do we make our systems more accessible to patients that are men of African origin that are supposed to get prostate cancer? Are there neighborhoods influencing them? Are there health policies? Is their insurance not good enough to be seen at Moffitt Cancer Center or Dana-Farber because their coverage is not good enough? Are they not being educated right to really understand what the disease process is and so they are rejecting the treatments that we know work so well, what are these barriers that we are not addressing? Right?

So those things are huge when it comes to the same stage, the same diagnosis, different outcomes when it comes to mortality because they just did not get the same resources they needed. But then when we peel back the layers a little bit, we start looking at why do more 40-year-olds get prostate cancer when they are black? Why? So that's a question that, there's not a question of well because you didn't get treated. In fact, if you got more access to care, you might have picked up the disease earlier, maybe at 39. But you're getting diagnosed at 41 with metastatic disease more often. I'm not saying only that, but more often. And why is that? We can go back to reasons or suggest reasons which could include the built-in environment and whatever might have happened, but this is where then, we need our scientists to also get involved.

But the issue is how do you answer such complex problems by using the term race as a variable? So this is where it becomes very difficult because when you just look at the color of a man's skin and say, "Oh, because you're black, you have a bad disease." That's wrong, that's fundamentally wrong. I think we need to do better. And this is where the field is going through almost like a rebirth, a regeneration of how to really address disparities, by bringing all these different experts to the table, to allow us to really look at this from multiple angles. We need those in health policies to allow us to get better policies, to make sure that there is access for all. We need our scientists to make sure that when they do these studies, that there is representation and diversity on the studies, that our models are representative of populations that are actually plagued by the disease the most.

Currently, we have only one and a half prostate[ inaudible 00:06:46] line that is of African origin. So that's not good enough. We have very little, still continually have very little precision medicine sequencing on men of African origin. That is not good enough. We need more. And those are the things that physicians can participate in, scientists can do. We need more representation in our clinical trials. We need to design our trials so that the eligibility criteria are conducive to participation by men of African origin for prostate cancer specifically.  We need to make sure that our medications are tested broadly in diverse populations to make sure that their efficacy is across the board and in cases where the efficacy is better, we need to prescribe it appropriately, as well because the genomic diversity and the differences in pathways could actually be enriched in some populations more than the other and so we can apply our targeted therapies more effectively.

So there is, I would say, there is room for each person to get involved in the solution for health disparities in our country. It does not matter how, where you train, how you train, what specialty you are in. We are all part of this solution.

Alicia Morgans: I love how you put that together and really give us as a community, I think the language that we need to talk about these issues in a way that is so actionable. And I know that the Prostate Cancer Foundation is very interested in making strides in this area in particular, and certainly supports the work that you are doing here too. How can the Prostate Cancer Foundation funding organizations continue to improve things in addition to having the clinician-by-clinician approach and the patient-by-patient approach that of course, we are trying to do on the ground each day as well?

Kosj Yamoah: The beauty of the Prostate Cancer Foundation is that they are able to bring, they have the capacity to bring multiple disciplines together and have a dialogue on the solutions to the problem. And that is a place of significant impact because having a radiation oncologist like myself, and a medical oncologist, and a urologist, and a molecular epidemiologist, and a health policy expert sitting at a round table, and a patient advocate, for that matter because we often do not want to forget the patients that are front and center to everything we do, at a roundtable talking about the issues and bringing each person's perspective, and looking at the data, and being humble enough to recognize that we do. not have the answers, but also curious enough to listen to the other person's opinions.  That is the way that the Prostate Cancer Foundation would be able to allow us to really come up with tangible solutions that are going to make a difference.

But what I want to caution is that it's very easy to point fingers. So as I talk about our field shifting, is that what has become convenient to do is from a scientific perspective, is to say, "Well, we should not ever use race to define a biological phenomenon". And that's true because race is a social construct. And for that reason, it's a very, very poor surrogate for what is going on. So we need better surrogates and I think finding better surrogates means that we have properly defined a mechanism for which we identify patient populations. If a patient population is self-identified, then we should clearly state that and also add the limitations to it. If we are doing studies based on genomic ancestry or specific polygenic risk scores, then we know we are basing it on genomic ancestry.  Then that is clearly defined.  That way our field has the correct nomenclature to interpret studies that are coming out and the scientists are well educated on when race is being used as a social construct and when genomic ancestry is being used as inherited genetics or genomic principles of disease. And I think once we are able to set up that nomenclature, that will allow us to sit at the round table and communicate with the right language.

It's almost, if you think about it if I speak French and you speak English, and we are trying to talk on a subject matter unless we have a translator, it's very difficult to understand each other. And I think that's where I feel we are having trouble understanding each other because when someone says race, it means a couple of different things to a couple of people. And I think that is where PCF can really help us by allowing panels that can actually begin to set up a nomenclature to really have a common language, common terminology that allows us all to really have dialogue and know what we mean when we say one thing, whether in a publication, the translational of a publication, a clinical trial publication, or a health policy publication, that we all know what we are actually speaking of and I think that is the first step to allow us to now understand each other and then take action on how to solve the problem.

Alicia Morgans: I could not agree more, and I think it's also so important as you also mentioned that the PCF has been able to bring together people who would not otherwise mix and mingle and have these conversations. People who aren't necessarily initially involved in prostate cancer research, but who are pulled in through the long arms of PCF. One group that I think is so exciting and I think you may have worked with them, maybe, maybe not, but Frank Penedo, for example, is a behavioral health scientist who really is understanding or helping to understand the social determinants of health and how stress and how one's environment can impact, and what I think is so interesting in your discussion about language and how important it is that we define how race is defined is that the genetics may say one thing about an individual, but if that individual was raised in an environment with that self-determined racial status, then the environment and what one believes one to be maybe even more powerful than the genetics in some situations, or perhaps they are intersecting and so it is just so important to bring this work together, to bring these experts together.

Kosj Yamoah: Absolutely. I couldn't agree with you more and I think that's the next main step for our community as scientists to really make a difference. We need that desperately.

Alicia Morgans: Yes, absolutely. So if you had to give us, I guess, a call to action, a final message as we think through how we continue this work in health inequities and prostate cancer care, what would your message be?

Kosj Yamoah: One thing I'll say is as scientists, and whoever else is listening as an advocate, or a patient advocate, you are bringing a level of expertise that allows you to be an effective part of this solution. And I would say that whatever you can do focus on that.  Because if each of us plays our role, we can make a bigger difference than if we spend time talking about what others should do that they are not doing. So I think that owning the process, if there's one thing I want to say, we all have to first understand that we play a vital role in the solution to the problem.

We can't look back anymore. The time of looking back and pointing fingers is over.  What can I do? What can you do to change that? Go do that. And I think that is really the message.  Because we all have a part to play. And if we can do our role, play our responsibility, if you're a clinical trialist, then design your trials properly. If you're an advocate, then please advocate as much as you can. If you're a health literacy person, and whatever.  Do it, if you are someone who works with the community, go educate them.  Whatever you do, do it, because if you play your part, we will see change.

Alicia Morgans: I don't think I've heard a more inspiring message in a long time. Thank you so much for sharing your expertise and for leaving us with that thought. I really, really appreciate your time.

Kosj Yamoah: Thank you, Alicia. Thank you for the opportunity here and I'm delighted to be on this panel, on this call, sorry.  And if there are any other opportunities to do this, I would love to do it again.

Alicia Morgans: You are welcome and thank you.

Kosj Yamoah: Thank you.