The Complex Interplay of Factors Driving Prostate Cancer Disparities - Steven Patierno

November 20, 2023

Steven Patierno delves into his 25-year journey tackling cancer disparities, with a focus on prostate cancer. Beginning in Washington D.C., Dr. Patierno's work highlighted the stark impact of socioeconomic factors and healthcare access on cancer care. At Duke, he leads a comprehensive approach addressing the intricate mix of social inequities, healthcare access, and ancestry-related biology. He emphasizes systemic racism, lifestyle choices, and institutional barriers as key disparity drivers. Dr. Patierno highlights Duke's innovative screening algorithm, which significantly improved prostate cancer screening, particularly among African-American men. He also stresses the importance of diversifying clinical trials, citing the Panther trial's groundbreaking results. His efforts have influenced policy, leading to the adoption of his screening algorithm as a state guideline in North Carolina. Dr. Patierno's dedication has been pivotal in bringing cancer health equity to the forefront of research and clinical practice.


Steven Patierno, PhD, BS, Duke University School of Medicine, Durham, NC

Alicia Morgans, MD, MPH, Genitourinary Medical Oncologist, Medical Director of Survivorship Program at Dana-Farber Cancer Institute, Boston, Massachusetts

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Alicia Morgans: Hi, I'm so excited to be here today with Dr. Steve Patierno, who's joining me today from Duke University. Thank you so much for being here.

Steven Patierno: It's great to be with you.

Alicia Morgans: It's great to be with you too. And really to dig into some of the body of work that you've worked on for at least the last 25 years and the way that you have influenced and shaped the research of prostate cancer disparities and disparities, I think, across many other areas. So if you could just start and give us a lay of the land, tell me a little bit about the problem here?

Steven Patierno: Sure. Well, our work actually began in Washington, DC where I was the former director of the cancer center at the George Washington University for 10 years before I moved to Duke. And in DC I was faced up close and personal with the huge chasm between how cancer care is given to certain populations versus other populations and the impact of poverty and socioeconomic deprivation and lack of access to care on the health of the residents of Washington DC. We implemented a lot of successful community programming to address those issues. And then we took some of that as I moved to Duke in 2012 to be Deputy Director of the Duke Cancer Institute and we really began a multi-level and multi-pronged approach to trying to mitigate, I like to say, just eliminating cancer disparities. We've learned over the years that cancer disparities are driven by a complex interplay between multi-level drivers of social inequity, but also healthcare access and also ancestry related biology.

And so what you have are things like social issues at the societal level. For example, systemic racism and implicit bias, which are still embedded inside of our healthcare systems. And then social issues at the neighborhood level, including socioeconomic status, access to fresh food or lack of access to fresh food, the ability to exercise or not be able to go out perhaps because the neighborhood is unsafe. Issues related to lifestyle choices, being the target of aggressive advertising by the tobacco industry. And then across that spectrum, we also see issues related to institutional barriers, and that would be access to care, insurance issues, being underinsured or uninsured, distance. It turns out that even today in 2023, travel, transportation is the number one barrier to quality cancer care. So there are practical issues that face patients that we call barriers to getting access to care. There are sociocultural aspects, including in some populations, particularly African-American populations, fear and medical mistrust based on things that the healthcare providers or the whole group of us historically have done wrong and lost trust in certain communities.

And then all of that together can also be influenced by what we call ancestry related biology. Now, we're very careful when we use that term. We're not conflating race with biology or genetics. Race in and of itself is a sociocultural construct. But what we also know is that ancestry describes the human diaspora essentially, when and in which direction our ancestors left Africa. And we can trace at a very deep molecular level how that genetic heritage influences our susceptibility to disease, also how well we react to certain drugs and to therapies. All of those factors, we call them multilevel drivers of cancer disparities, actually can work together. There's a new term we've begun to use, convergence science, where we're starting to understand that these factors don't occur independent of each other.

For example, we know that obesity is a risk factor for multiple cancers. No one questions that anymore, but where did obesity come from? Is it possible that growing up in an environment, in a community where you did not have access to fresh food or green and yellow vegetables and that most of your diet was coming from sources of pre-made, processed foods and you were not able to get out and exercise because there may be violence in the community and there might be some genetic predisposition to diabetes or other comorbidities. All of these things can come together to drive something like obesity, which is now a risk factor for cancer, and also impacts all of the other comorbidities which make it difficult to treat cancer. So we have outcome disparities, that is differences in the mortality, the survival rates for people with cancer. Where does that come from? It is likely to be and more and more data is showing it is this conflation of all of these factors acting with each other, sometimes exacerbating the problem.

And what that means is to mitigate cancer disparities or eliminate them, we have to approach every single one of those drivers of the disparity. At Duke, we are doing that. While there are multilevel drivers of cancer disparities, we have launched a multilevel campaign against cancer disparities. We'll use prostate cancer as the example, since this is a prostate cancer forum. We are number one out in the community. We have an Office of Health Equity led by Dr. Angelo Moore, who oversees a team of community facing navigators who spend all of their time out in the community. Part of that is rebuilding and building trust in the community, but also educating the community about the importance of screening for early detection, about the importance of clinical trials, building that level of trust so that when a cancer diagnosis is made, we're not having to start from scratch and we have built some trust and we can move people into the care that they need.

They also, these community facing navigators, are embedded in our health system. So they can not only educate about prostate cancer and other cancers and screening for early detection, but they can also help people get to and through the front door of our health system. We can get them into the screening that they need, we can get them, if there's a suspicious finding, we can accelerate the process of diagnostic resolution. And if by chance there's a diagnosis of cancer, we can rapidly move that person into therapy. So we start at the community level, building trust. We want to implement screening for early detection. As most of your readers know, there's been a controversy in the field about prostate cancer screening using PSA, stemming from the US Preventative Services Task Force ruling in 2012 against prostate cancer screening. But what we now know is happening, as has been spoken at the meeting this week over and over again, we are now seeing a serious uptick in both the number and the percent of men being diagnosed with late stage, sometimes already metastatic prostate cancer.

And much of that is driven by this massive fallout in screening. So how can we address that issue? Well, at Duke, I pulled a group of experts in and did something a little crazy. I not only invited the expected players, the urologists, the GU medical oncologists, the radiation oncologists, the navigators, but I also invited our primary care physicians to join us. And I will tell you, this is a little embarrassing for Duke, for myself, I contacted the Director of Duke Primary Care and one of the things he told me on the phone is that he'd been serving in that position for more than 10 years and had never been contacted by someone in the cancer center. That tells you something that also needs to be addressed because primary care is where the cancer journey should begin. That's where screening for early detection, that's where prevention and good health should begin.

So we need to work hard and be purposeful to bring our primary care docs back into the continuum of cancer care. So we did that. And what we did is we created a screening algorithm that took high risk men into account, that includes black men who are at more than a twofold increased risk of getting prostate cancer and over a twofold risk of dying from prostate cancer. We created an algorithm that initially was just called the Duke Algorithm. We put it into our electronic health record program, our EMR, and we put it into the maintenance tab so that our primary care docs couldn't go by it without acting on it. And then we sent teams out to over 40 primary care clinics to educate our primary care docs about why we were doing this. They accepted the data and the story that we were telling them.

Over 18 months, we screened 59,000 men, and we were able to improve guideline concordant screening by nearly 30% and even higher in African-American men. And because it was focused on high risk men, it didn't generate unnecessary downstream clinical activity. Absolutely extraordinary. We also found a number of men in their forties that after follow-up, were determined to have clinically significant disease and needed to be treated because it was already advancing towards the stages where it needed to be treated. So we're now addressing the screening for early detection. The next thing I would say is clinical trials. One of the big struggles in cancer clinical trials is that our trials don't reflect the populations in the real world that we need to be treating. On average, less than 5% of clinical trial participants in cancer are African-American or any other minority population from our country. How can we just assume that the results of those clinical trials are going to apply equally or equivalently to all persons when we're basically doing all of the trials on large groups of white men in the case of prostate cancer?

So at Duke, working with Dr. Dan George, who leads our prostate cancer center, Dr. Andy Armstrong and a whole host of others, we became one of the nation's leaders in running clinical trials using a model that we call Equal Representation by Race. So our trials are done not with just trying to match our demographics of our patient population, but actually being purposefully to over sample. And to give you an example of how powerful that is, last June, Dr. George and I and a group involved in that trial, presented at ASCO in June this year, the results of our Panther trial, which is a combination therapy of apalutamide and abiraterone, combination hormone therapy. The results were extraordinary. When we broke the code, we almost couldn't believe it. Nearly every patient of African ancestry came into the trial with worse disease, but the results in response to therapy were mind-blowing.

African-American men, despite coming into the trial with worse disease, responded dramatically better to this dual hormone therapy. That result alone shows how important it is for us as a cancer community to diversify our clinical trials and be purposeful to enroll people from multiple ancestral backgrounds because we may be missing something really important. And in fact, a previous trial of that same combination, that actually enrolled less than 5% of persons of African ancestry concluded a lack of superiority of the dual therapy compared to monotherapy. But our trial showed that a subset of those patients, in our trial 50% of those patients, actually responded dramatically better. So I mean, how exciting is that to be able to show that we have therapies now that can actually benefit black men to a greater extent than persons of other genetic backgrounds? We want to be very careful with this. We're not interested in practicing what is sometimes very negatively called race-based medicine. What we are interested in practicing is precision medicine that's sensitive to ancestry and might allow us to take advantage of the biological and genetic diversity created by the human diaspora.

So we've done all of these multi-level approaches. We also have been able to affect policy. So back to that screening algorithm that I mentioned to you, we were able to take the data that we published, that I just described to you, and present it to our colleagues at UNC, the Lineberger Cancer Center, just up the street from us, the cancer center at Wake Forest in Greensboro, the cancer center in Charlotte, now Atrium Levine Cancer Center. The experts, urologists, rad-oncs, everybody involved in screening, looked at that algorithm as we published it and adopted it as their own. I have the privilege of having been the governor appointed advisor to the State Cancer Committee for the last 10 years and chair of it for the last four years. I was able to present that algorithm and that data to the North Carolina State Legislature and they unanimously voted to adopt it as the state screening guideline, and it's now being contemplated by 11 other states as their screening guideline.

So we're really excited. The cancer research community and the cancer care community now has issues related to achieving cancer health equity forefront. It's right in the center of the radar screen as people like to say. That's very exciting for me as a person that has been doing this for 25 years, long before it was popular or in vogue. It's so exciting to see the new generations of people coming up, both clinicians and researchers and nurses and practitioners at every level who are cognizant of this issue of cancer disparities and are working purposefully and deliberately to address it. We're so excited. I had the great privilege in 2007 to co-chair the AACR/NCI Think Tank on Cancer Disparities, and that actually launched what is now the annual meeting called the Science of Cancer Disparities, the AACR meeting, now in its 17th year. And to see this field grow and to see it become more and more at the center of how we're conducting ourselves as researchers and clinicians is incredibly exciting, rewarding and we're looking forward to achieving cancer health equity in the next few years.

Alicia Morgans: Well, I could not be more excited by all of the things that you're doing and I think our listeners are too. So many questions that could be asked and so much work still to be done. But it is really nice to know and hopeful to know that you and your team are continuing in this battle and are helping to level the playing field in all the ways that you are. So thank you so much for your time and your expertise.

Steven Patierno: Thank you.