Center for Gastrointestinal Cancers Annual Lectureship: "Colorectal Cancer Disparities: Understanding Biological & Environmental Interactions"

June 01, 2021

Information

Yale Cancer Center Grand Rounds | June 1, 2021

Marcia Cruz-Correa, MD, PhD, AGAF, FASGE

ID6663

To CiteDCA Citation Guide

00:00Young presentation that I have
00:02lined up here right back to
00:05the share screen and let's see.
00:07I guess this is the one share.
00:11Let's see here we go and
00:14then we connected this.
00:15There we go. Excellent
00:18Doctor Chris Korea.
00:19So nice to see you so we I did I did
00:24your lovely intro before but and we
00:27have actually I will just say verbally
00:29but we have a plaque to give you.
00:31You are actually officially our
00:34inaugural annual speaker for
00:36our new Center for GI cancers,
00:39so we're happy to invite you and.
00:42Really excited to hear you today so.
00:45And we appreciate everyone who
00:48waited and I think Doctor Cruz
00:50Correa will probably need to end.
00:52Maybe like 5 minutes before
00:55the hour or 10:10.
00:57I mean, if you, I'll let you figure that out.
00:58We'd love to have time for questions,
01:00but if not, we understand.
01:01Alright.
01:02Yeah, wonderful and well, I'll do.
01:04You know, the last part I can skip.
01:06And yes, I'll stop more or less when
01:08I see that the time it's it's there.
01:10So we have about 2025 minutes.
01:11OK, well, so good afternoon to everyone
01:14and and thank you very much for.
01:16Dealing with the with life right?
01:19I mean we plan many things in our lives
01:21and there are things that you learned.
01:23I think the older that we get that
01:25there are things that you can control.
01:26That there are things that you cannot control
01:28so later and I'll tell you what happened.
01:29But you know, the good news is that
01:31we're here and I'm delighted and
01:33honored to be part of this presentation.
01:35So briefly, address some of the concepts
01:38that our group have been working on
01:40for the last years over a decade.
01:42At this point,
01:43and we have been focusing on Latinos and.
01:47Family communities,
01:47and specifically in GI cancers,
01:49and I'm going to, you know,
01:51narrowed the topic to colorectal
01:53cancer as one of the areas that
01:56we have been no witness of,
01:58the disparities that we have seen across
02:00the different ethnic and racial groups.
02:03So the talk has three main areas and
02:05I will briefly discuss some of the
02:08epidemiological data that we have.
02:10Then I'm going to talk about some of
02:12the environmental factors and then
02:14the molecular aspects and then putting
02:15that together trying to understand,
02:17you know.
02:18How much do we know of the reasons
02:21behind these academic that we're
02:24seeing across different groups,
02:26including the Hispanics?
02:27So this chart comes from the
02:30national databases where you can
02:33see that by the year 2050, right?
02:35You can see where the places where you're
02:38going to have larger groups of Hispanics,
02:40and you know colorectal cancer.
02:42It's one of those answers that
02:44continue to increase this.
02:45Find the available at screening
02:48methods that we have.
02:50And when you look at,
02:51you know the world right in the in
02:54the US we see that many Hispanic U.S.
02:58citizens have this high burden of this.
03:01So is the second most common
03:03cause of cancer among US Latinos.
03:05You can see the number there,
03:07the third most common cause
03:09of cancer worldwide.
03:11And then the fourth most common
03:14cause of cancer related death.
03:16So clearly this is a disease
03:18that continues to.
03:20You know to to take the life of
03:22so many people every single year.
03:24And here I described right where we
03:26go from the public to the cancer and
03:28this takes close to 10 to 15 years for
03:31people without having to re cancer.
03:33And when you put this into perspective right?
03:36And this is,
03:37I'm thinking about Latinos in America.
03:39You see that depending where you are,
03:42the burden of colorectal cancer
03:44changes dramatically.
03:45So if you look at,
03:46you know I put some arrows in order
03:48why at him? Tina and Puerto Rico.
03:50You can see the differences in
03:52incidence and mortality both
03:53for male and and female,
03:55and you know places like autowire,
03:57jentina, and Puerto Rico.
03:58We have things in common.
04:00Not only do we speak the same language,
04:01but with different accents, right?
04:03For those of people that know the
04:06different Hispanic communities.
04:08But we also eat a lot of meat, right?
04:10So that that's one of those factors
04:12that might come into play or might
04:14be contributing at this point and
04:16then looking at the data from the US.
04:18This is actually age adjusted.
04:20Incidence rates are in
04:22colorectal cancer in the US.
04:24Looking at the different races and
04:26Hispanic communities so you can see that
04:29the bias burden for both male and female,
04:31it's in the black community.
04:33However,
04:33when you look at what American Hispanics,
04:35it's very closed to when you
04:37combine all the races and is.
04:39I'm close to.
04:42I Landers, or are Native Americans, right?
04:46So you can see how.
04:48Even within the Hispanic communities,
04:50there are differences depending
04:51where the Hispanic is coming from,
04:54so it's not the same thing as when
04:56you look at Hispanics that are are
04:58from Mexico versus those that are
05:00from the Caribbean and you can
05:02hypothesize many of the reasons
05:03why we're seeing those differences.
05:05So this article was is,
05:07or over 10 years old.
05:08But I still look at this because
05:10it was mesmerized actually met
05:12Doctor Pinheiro in a presentation.
05:14And basically you know when
05:16they were looking at,
05:17he was evaluating the incidents.
05:19Rate for cancer and he looked at
05:22different groups and he looked at the
05:24incidence rate of cancer in their
05:26native community and then when they
05:28move to the US and this is data from Florida.
05:31So you can see that you know Mexicans
05:34and Mexico had a lower incidence rate
05:36as compared to Mexicans that move to the US.
05:39The same thing happened for Puerto Rican's.
05:41You can see how they you know
05:43when they are native Puerto
05:45Ricans living in Puerto Rico.
05:47The incidence is slower but
05:48when they move to the US this.
05:50Number goes up the same thing for
05:52Givens and look at how very close to
05:55their incidents for incidence rate for
05:57those that are native from Florida,
06:00so you know it's impossible to
06:02have this huge change based on the
06:05on the genetic changes, right?
06:07So so of course,
06:08environment is what really comes
06:10over and over into place.
06:12So I started working with several
06:15groups from the US including an
06:18Doctor Mariana Stern from University
06:21of Southern California.
06:22Anne Marie Anna published this article.
06:25A few years ago where she look
06:27at the disparities in colorectal
06:28cancer incidence among Latinos.
06:30But California is a melting pot.
06:32Don't know, right?
06:33So we have Latinas from South America,
06:35Central America and of course
06:37also from the Caribbean.
06:38So she was able to identify that 17% of
06:42all Latinas from California presented
06:44with colorectal cancer before the age of 50.
06:47So early on set colorectal cancer
06:49and this was published before the
06:51recent guidelines,
06:52right where?
06:53Now we start performing colorectal cancer
06:55screening at the age of 45 according
06:58to the US Preventive Services Task Force.
07:00So this is before,
07:01you know,
07:02five years before that happened
07:04and you know she had a good
07:06representation from Puerto Rican's
07:07and also Mexican Americans.
07:09And then of course the other you
07:12know worrisome factor was at
07:1449% of Latinos presented with
07:16colorectal cancer and advanced age.
07:18So not only younger,
07:19but also an advanced age.
07:21And this is data from our group.
07:23When they presented with early
07:25onset colorectal cancer,
07:27this survival is is less.
07:29So now let's let's chip gears
07:30and talk a little bit about.
07:32You know some of the environmental factors
07:34that we and others have been evaluating so.
07:37Things like tobacco are fabulous
07:39diet right which sometimes can
07:41not be as good as it could.
07:43It could be obesity, which is, you know,
07:46a common risk factor for many diseases,
07:48including cancer and of course is
07:50sedentary lifestyle an you know.
07:52Looking at the different aspects
07:54right a few years ago in 2015 The
07:58Who for the first time you know
08:01classified red and processed meat as
08:04part of the carcinogenic risk factor.
08:07So specifically.
08:08Processed red meat was classified
08:11as a carcinogenic class one,
08:13and to put everyone into context,
08:15this is the same category where you have H.
08:16Pylori where you have asbestos where we
08:20have other other factors like tobacco,
08:23so they're all carcinogens.
08:25Class one,
08:26but the risk associated to exposure of
08:29this particular environmental factor.
08:32It's much less that that you know
08:34that observed in other risk factors
08:36such as asbestos, for instance.
08:39Nonetheless,
08:39you know this started as supported
08:42on the role between the exposure
08:44of these carcinogens because they,
08:46you know we know now know that there
08:48are changes that occur at the level of
08:51the DNA where you get a heterocyclic
08:53amines and you know changes that
08:55increase carcinogenesis at the level
08:57of the colon and in the colony sites.
09:00So few years later there were also articles
09:03that started to put together the role
09:06of the diet with the role of the microbiome,
09:09right?
09:09And we've seen.
09:11This on our group have also evaluated
09:13the potential link between the
09:16MICROBIUM and the cancer risk,
09:18so this article was one of the few first
09:22rather articles that started to look at
09:25the role of the microbiome and cancer,
09:28and this beautiful paper by the group
09:31at Pittsburgh presented data looking
09:34at the different they phylogenic
09:36differences in the gut microbiome
09:39between Africans from Africa.
09:41That's on the left panel and
09:43Africans from North America.
09:44So you know the classic African U.S.
09:48citizens so you can see that even
09:51if we don't know that much about,
09:53you know these statistics, right?
09:55You can see that the colors right of
09:58these beautiful figures were different,
10:00right?
10:00So the Africans from Africa have it?
10:03How distinct microbiota as compared
10:06to the North American Africans?
10:09Right there African Americans rather.
10:11So and then you know when you look
10:14further down and he did and you look
10:16at you know what type of metabol I'm
10:19a metabolomics was present in the God
10:22from people that were in Africa and
10:25those North American African Americans.
10:28Not only was where the bacteria
10:30different but also the mandible.
10:32You know the type of metabolomics
10:34that that were present.
10:36So for instance he looked.
10:37He looked at short chain fatty
10:39acids and he looked also in bile
10:41acid and you can see that.
10:42Africans had a higher good short
10:45chain fatty acids versus the African
10:48Americans had more carcinogenic bile
10:51acid and you can see how the different
10:54compounds that he look at where
10:57higher Lee were present at a higher
11:00prevalence among individuals that had
11:03the microbiome was a distinct microbium.
11:05So we started looking.
11:07You know,
11:08of course, motivated by this group of
11:12investigators at Pittsburgh and some others.
11:14We started to evaluate not only the
11:17bacteria nor the microbiome composition,
11:19but also the jeans that are
11:22present because depending on the
11:24Organism that it's in the bowel,
11:26the jeans that are produced and the
11:28answer the proteins that are produced
11:29by the jeans and the specific genes
11:31that we can find that are bacterial
11:33genes may also modify the risk of having
11:36inflammation and the risk of cancer.
11:39So we started looking at this particular
11:41group of genes which are bacterial.
11:44Jeans specifically PKS,
11:47CTD and jealous,
11:50and eyes Ian such toxic necrosis factor
11:54necrotizing factor rather an USB,
11:56and you can see here is summary of what is
11:59the role of this particular bacterial genes,
12:02and our hypothesis was that in patients
12:05that have colorectal cancer had had
12:07colorectal cancer or those with polyps.
12:10We may see a difference not only
12:11in the bacterial composition,
12:13but also in the bacterial genes.
12:16And we set ourselves to do
12:18a series of experiments,
12:19and we published recently an you
12:22know from this group of of bacterial
12:24genes we were able to start to
12:27see some differences right?
12:29So I can show you here the USP was we saw,
12:33you know a small signal.
12:35We are repeating this sample and
12:38adding additional bacterial genes
12:40to try to understand whether or
12:42not you know is it bacterial.
12:45You know the the microbiome per say.
12:47Or it is are those bacterial genes,
12:49the ones that are really increasing the risk?
12:52So there's a lot more that
12:54is happening in this arena.
12:56But you know,
12:57I'm a physician scientist and you know
12:59you always have to think about you.
13:01Know if we can modify certain things
13:03like you know what we eat and if we're
13:06able to show that a particular dysbiosis
13:09in your God is associated with you.
13:12Know with the inflammation
13:13and changes in the genome,
13:16then you know we'll work on that.
13:17But there are things that are like low,
13:19you know,
13:20low hanging fruits and you know access to
13:22healthcare which we all know that it has.
13:24If it's you know,
13:26huge impact in this part is that
13:28we have been observing,
13:29including disparities,
13:30that we see in colorectal cancer.
13:33I said it help collaborating with them
13:37several investigators at the University
13:39of Puerto Rico that were focusing
13:41on delays in access to healthcare.
13:43So basically there are three main
13:45belays that that could occur that could.
13:47Interfere with the outcome of a patient,
13:51so you have what's called primary delay.
13:53Secondary Lillian tertiary deley so
13:55primary deley is from this the time
13:58that the patient has a symptom to
14:00the first contact with the primary
14:03care physician.
14:04Secondary dilay is from the first
14:06contact with that primary care
14:08physician to a confirmed diagnosis
14:10and then the third chair is.
14:12Delay is the time from their confirm
14:15diagnosis to the start of treatment
14:17an disparities in any of these
14:19areas right between one group of
14:21patients and another group of patients,
14:23or or across segments of the population
14:26like rural versus urban or people
14:29you know with Medicaid versus those
14:31that are on commercial insurance.
14:34Will result in differences in outcomes,
14:36and in fact that was the hypothesis
14:39ANAN we we examined my patients with
14:42colorectal cancer and this was published
14:44a few years ago where we saw in this
14:47graph we were looking at relative
14:49survival 1/3 and five years of colorectal
14:52cancer among Hispanics from Puerto Rico.
14:55An in orange you can see in the
14:57top line you can see the relative
15:00survival among individuals that were
15:02on a private insurance an.
15:04On the Gray or the second line you
15:06can see their relative survival
15:08for individuals that diagnosed with
15:10colorectal cancer at different,
15:12you know time points and you can
15:14see that at 1/3 and also five years,
15:17this survival associated, you know,
15:20seen and observed among people that
15:22had the public insurance was lower as
15:24compared to the private insurance,
15:26and this was adjusted for buy as many
15:29factors as we could possibly adjust for.
15:32But of course lifetime exposure.
15:34Right to die it to the place that you
15:36were raised to the community that you leave.
15:39We cannot account for that,
15:41so you know there might be things
15:43that occur much before we're able
15:45to classify patients according to
15:46the health insurance that we can
15:48actually not measure.
15:49That is beyond their the.
15:53Environmental variables we couldn't.
15:55We can't control for,
15:57so I want to finalize.
15:59You know, I now focus on an area that
16:01is extremely important, which is.
16:04Can we modify the genes?
16:06Can we blame the genes right?
16:07And when you think about Hispanics,
16:10Hispanics, we are a group of
16:12individuals that are a mix race.
16:14Hispanics have a mixture on depending
16:17where you find the Latinos in
16:19the US or or in Latin America.
16:21The composition of our genes
16:23berries dramatically.
16:24So if you go to places like in the Caribbean,
16:2720% of our genes are from African ancestry
16:30and in fact I did genomic ancestry and
16:32I have 14 and you know if you go to.
16:35South America there places that
16:36most of the genes are Europeans,
16:38but there are places where there
16:40is a significant percentage of the
16:42genes that come from Amerindian,
16:44so places like in Central America and
16:46and some areas in South America as well.
16:49So when the TSJ it started,
16:53you know years back now and
16:55this was published years ago.
16:57Yeah, as part of the Cancer Genome Atlas,
16:59one of the questions that we
17:01had and we had hoped for,
17:03was that when this samples
17:04the tumor samples were.
17:06We're going to be analyzed that there
17:08would be good representation from
17:10different racial and ethnic groups,
17:12and we all know now that that's not the case.
17:15So this is basically for colorectal cancer.
17:18There was no data on Hispanics from
17:21you know that were included when
17:24they evaluated colorectal cancer,
17:25but you know, overall we learned that
17:2816% of the tumors were hyper mutated and
17:31and there was no molecular difference
17:33when we look at rectal cancer rectal.
17:36You know cancer in direct
17:38numbers is cancer in the colon.
17:39And of course you know later on papers
17:43were published where you know we saw the,
17:45you know the differences in the
17:48percentage of tumors that came
17:50from individuals from minorities.
17:52Both racial an Hispanic minority.
17:54So of course, you know we need
17:56to continue to collect my data.
17:58There's a lot of great efforts that
18:00I applaud many of the institutions
18:02and including the NIH, NCI,
18:04and some other, you know,
18:06large populations like the.
18:08Breaking Cancer Society a CRM,
18:10others that have now started
18:12funding like that,
18:13you know as part of the up the effort to
18:15try to understand tumors from minorities,
18:18some including the Genie project
18:20that I'm sure that you guys are
18:23also information are involved with.
18:25So this was a publication we've had
18:28a few years ago doing a whole genome
18:32sequencing for patients with colorectal
18:34cancer data from the Puerto Rican
18:36Hispanic was included in this server.
18:38A fifth of all.
18:39Hispanics were from Puerto Rico
18:41and you can see that we were able
18:43to replicate some of the GI.
18:45You know the slaves that were
18:47seen in non Hispanic groups,
18:49but there were some that were only
18:50pressing in or his family community.
18:52So again there are some differences
18:54that may might be drivers of this is,
18:57but there's still a lot to do.
19:00We started evaluating this
19:02somatic that was German profile.
19:04We also started violating this
19:07melodic profile of Latinos
19:08with colorectal cancer and.
19:10This is the first publication we
19:12had years back and now I have.
19:14We have more recent data and I'm
19:16going to share with you and the first
19:18thing we notice was that Puerto Rican
19:20Hispanic with colorectal cancer.
19:22Those tumors were not.
19:24No, we're not.
19:25You know, we're not similar in several.
19:28You know? Key biomolecular markers,
19:31like you know, microsatellite instability.
19:34Right now it is.
19:35We know that MSI is so important because
19:39it really defines a phenotype that
19:43responds beautifully to certain agents,
19:46right?
19:46Like immunotherapy.
19:47So in our regulation,
19:49we started seeing that our patients,
19:50you know,
19:51had very little microsatellite instability.
19:53And when you look at the.
19:55CPG Island Middle Asian phenotype was also,
19:58you know,
19:59lower as compared to non Hispanic
20:02whites and also are African American.
20:05So are tumors were little bit
20:07different so we decided in the last
20:10three years we decided to replicate
20:12this effort and now with the
20:15availability of commercial testing an
20:17in several organizations that have
20:20this information publicly available,
20:22we conducted a an analysis that
20:24was just probably not published.
20:26Was just a presented at the
20:29ACR annual meeting.
20:30Trying to have better understanding a
20:33better grasp of those actionable somatic
20:35mutations that are key now of what we
20:39all calls precision oncology right?
20:42When you think about large institutions,
20:45not minorities serving institutions,
20:47but those that serve other.
20:49You know non minority communities
20:51access to precision oncology within
20:54the framework of patient care.
20:56It's routine.
20:56However, when you look at,
20:58you know smaller centers community.
21:01Hospitals or even you know,
21:03minorities every institution.
21:04If this is something that
21:06it's starting to occur,
21:07and thanks to the technology that now
21:10has become more financially accessible,
21:13we're now being able to incorporate this,
21:15you know. River care for patients?
21:18Then why is this important?
21:20Because there are molecularly
21:21targeted therapies that we have
21:23seen that not only in GI cancer,
21:24but you know in non squamous
21:27cell lung cancer.
21:28And I'm just showing you some of the
21:30key articles that actually change the
21:32way that we practice medicine nowadays.
21:35So like just zoom up for her two
21:37positive and you can see right?
21:39Of course for the BRAF mutated Melanoma,
21:42which now we've seen some other tumors.
21:44So it's key because the.
21:47Pharmacol from the pharmacogenomics
21:50are being studied,
21:53but are almost like a secondary.
21:55It doesn't start with the pharmacogenomics,
21:58it starts with the farmac
22:01pharmacodynamics of one group,
22:02so this is key.
22:04Because if we don't know how prevalent
22:06are those biomarkers where we have?
22:10Therapies that we can use.
22:11Then you know our patients
22:13will never benefit.
22:14So the first thing that we have to
22:16do is to try to understand and we
22:18actually were able to do a this.
22:20This analysis which I just alluded to
22:23and that was burned there is here and
22:26we evaluated close to 1929 hundred
22:28thirty one individuals and you can
22:30see here the distribution of the tumors,
22:33and you know,
22:34we we look at, you know,
22:36the how many most of you know 60% male,
22:38I mean female and you can see the.
22:40Age distribution for the
22:42people that we evaluated.
22:43We used commercially available testing
22:45and we did it in collaboration with
22:47the Precision Oncology Alliance and
22:49we look at actionable mutations
22:52specifically for colorectal cancer,
22:54and you can see you know if you
22:56look at your patient population.
22:58We saw, you know,
23:00find different prevalence of some
23:02of the key oncogenes and some
23:04of the key markers.
23:06So for instance,
23:07video one was only present
23:08in 1% of our patients MSI.
23:11In 2%, which is much less than other groups,
23:14you can see how Keras,
23:16which entered be rough,
23:19was also highly prevalent.
23:22So what we did was that we compare
23:24our data from patients data that
23:27was available for non Hispanic
23:29colorectal cancer tumors that
23:31were reported as part of the PGA.
23:33And here you can see the actionable genes.
23:36Queiroz be rough interests or
23:39her to Intrax Ann.
23:41You can see in green we have the
23:44Puerto Rican Hispanics and in
23:47blue we have the non Hispanic
23:49tumors from the TSJ and for some
23:52of the key oncogenes like Keras,
23:55ambera you can see that Hispanics
23:57from Puerto Rico who are more
24:00likely to present with mutations in
24:02this particular oncogenes.
24:04And that's terrible because then we
24:06have less access to some of the you know
24:10antibodies against EGFR for instance.
24:12This same thing, you know lack of certain
24:16biomarkers like PDL one or or Ms one.
24:19Among you know, this Hispanic
24:22community really also affects right?
24:24The availability of therapies to finalize.
24:28I want to very briefly show you some of
24:32the data that we have been working again
24:35with a group of collaborators, actions,
24:37collaborators from different places,
24:40including them rikidozan.
24:42Garner
24:45from inside and now he's in New York,
24:47so we actually look at African ancestry.
24:50Why? Because we know that African
24:53Americans have a higher risk
24:55of having colorectal cancer.
24:57They're having higher mortality as compared
24:59to other non African American groups,
25:02so we look at on the association
25:06between having African ancestry in
25:09Puerto Rican Hispanics and certain
25:12phenotypes and also molecular markers.
25:15In our patients with rectal cancer,
25:17so we were able to identify that individuals
25:21with African ancestry were more likely
25:24to have tumors located in thatis.com.
25:26So two times more likely than those
25:28Puerto Ricans without African ancestry.
25:30We also saw that the differentiation,
25:32they weren't the tumor from Puerto
25:35Rican's with higher African ancestry had
25:37a higher likelihood of having a low to
25:40moderate tumor difference differentiation.
25:43And you know,
25:45this might also contribute to the.
25:48Observe increased mortality that
25:50we observe in our population.
25:52So to finalize and there's many more data
25:55than we could discuss that may be asking
25:58the QA I want to keep everyone in mind.
26:01Keep everyone in mind that still the
26:03number one tool that we have available
26:06for you know the Christmas parties
26:08is doing colorectal cancer screening.
26:11Having access to die early diagnosis and
26:14you know still to this day there still.
26:18Differences in the optic of
26:21colorectal cancer screening.
26:23When you look at the different minorities
26:25and racial groups and the same thing
26:27we see in Puerto Rican Hispanics and
26:29also you can see it in the US Hispanics
26:31and because of the burden of disease
26:33where we had 10% of our patients with
26:36colorectal cancer in Puerto Rico,
26:37were part of being diagnosed with
26:40colorectal cancer before the age of 50.
26:43We move with the Department of Health,
26:45and in 2015 we.
26:47Put together an administrative order to start
26:50screening for colorectal cancer with feet.
26:53So we have a national feed program
26:56for people without family history to
26:58start performing fit testing at age 40,
27:01we were able to increase our rates to 65%,
27:05which was the highest and that was
27:07just before the Big Hurricane and
27:09then copied came to Puerto Rico.
27:11So now we have where's have started again,
27:13you know,
27:14to continue to promote screening.
27:17So in summary.
27:18We've been able to briefly discuss some
27:20of the Asian associated disparities,
27:23writing incidents and survival for
27:25correct cancer among US Hispanics.
27:27We have shown differences not only
27:30between non Hispanics and Hispanics,
27:32but also across the different
27:35Hispanic subpopulations.
27:36We discuss some of the differences are
27:40at the molecular level that include key,
27:44actionable biomarkers that are not present
27:46or present depending on the biomarker.
27:49Among Hispanics compared to non Hispanic
27:51and you know how non European ancestry,
27:54at least in the Caribbean,
27:55Hispanics from Puerto Rico was
27:57associated with worse colorectal
27:59cancer outcomes and nutrition,
28:01which you know when you think
28:03about the disease,
28:04is front and center might mediate
28:08the microbiome dysbiosis and it.
28:11You know we might be able to modify some of
28:14those risk factors.
28:16This is the team that I work with
28:18and this was this past March.
28:19For the correct awareness dressed in
28:22blue and I would like to finalize by
28:25thinking about the National Cancer
28:28Institute and the NIGMS as well as
28:31local fan from Puerto Rico government.
28:35For some of the work that you have seen,
28:37ankle appears from multiple places
28:39including the friend of mine, Doctor,
28:41Shabbir Yard and hopefully maybe he's
28:44in the call and some other great friends
28:48across different centers in the US.
28:50For what we do, thank you very much.
28:52I think I was trying to make
28:54the time 10 minutes. Let's see.
28:57This is part of our campaign
28:59that we have for.
29:00We call it the other cleavage
29:03so our people to stop,
29:04you know,
29:05to think about the colon and do
29:07colorectal cancer screening.
29:11Can you hear me again?
29:13OK, good good good thank you so much.
29:17You are efficient and I was trying to.
29:20I'm sorry no that's so great.
29:23So I am going to Roy.
29:26I might let you ask a question first
29:28if you're willing while I pull up.
29:30Your Cam has a massive thanks.
29:32So much for being here.
29:33How are you Roy?
29:36Let me ask you a question.
29:37It's something related so you know
29:38I'm working very closely with
29:39the Clinical Trials Office here
29:40and I notice that our accrual.
29:42Of Latin Hispanic patients is really poor,
29:45and that's something throughout
29:47the United States.
29:48Any any tips on how we can improve that?
29:50I know it's a general problem. Yeah,
29:52it's a general problem there.
29:53There's a lot of distrust, right?
29:55And and I think still,
29:57there's a huge Guinea pig concept,
30:00so you know one of the things that
30:02we have done, locali, you know.
30:03And remember, I'm a Puerto Rican
30:05working with Puerto Rican's, right?
30:06So so people shouldn't be discriminated or
30:09feel discriminated because of the you know,
30:10rate, racial and ethnic concordance.
30:13But one of the concepts that we
30:15have started to use is that I don't
30:17like to use the word investigation,
30:20which means research,
30:21because when you put the word
30:24investigation or research,
30:25or you know people immediately, they stop so.
30:28So the word that we're using now.
30:29We used protocols, you know,
30:32National Cancer Institute protocol
30:34or industry treatment protocols.
30:37And then we explained to them what it means.
30:40Of course,
30:40this is before the FDA approves the drug,
30:43so I tell them that.
30:44But it's almost like it's at
30:46least this is what I see.
30:47You know, when you use the word research,
30:50most people simply become scared,
30:52so you need to have cultural competency
30:55an you know as much as we can have,
30:58you know someone to speak to
31:00them in the remaining language.
31:01And if you can do that concordance,
31:03it increases your chances
31:05you know dramatically.
31:08During navigators now, and we're
31:09translating all the consent forms.
31:11Salute Lee, you know Roy.
31:13Even there be a you know.
31:15I wish everyone would
31:16imagine that they will have.
31:18You know, multiple language
31:19consent forms they do not sovyet
31:22trials which I have, you know,
31:24and I I was adamant about the fact
31:26that you know they had to have any
31:28more than one language because you
31:29know we have people that are U.S.
31:31citizens that speak another language.
31:33So I said we better than you
31:35know and it's it's working.
31:36So yeah black,
31:37I congratulate you.
31:39For for doing that
31:40where we're trying now,
31:41listen before we go on.
31:42Cam has a little presentation for you.
31:46I mentioned in the beginning that
31:49Russia is our our inaugural inaugural
31:52recipient of this annual Lectureship Plex,
31:56so we will be sending this to you.
31:58We wish it were interested,
32:00but we're we're really grateful for
32:02your presentation and presence today,
32:04so thank you so much for joining us. Thank
32:07you, thank you very much.
32:08It's an honor, and you know.
32:18I'm trying to pull all these things together.
32:20It's it's, you know,
32:21he's really a Humira Chal sometimes.
32:24And you know and we need to work as teams,
32:26so I'm glad that you are. You know,
32:29doing this for thank you. Thank you.
32:30Yes, now we would.
32:31We would love to do that, you know.
32:33And I think that one thing
32:35just to highlight for you.
32:36And I think for potential
32:38future conversations and
32:39collaborations are are greater.
32:41New Haven community is very diverse
32:43and I think we have a lot of
32:46you know Hispanic patients and.
32:48My patients and I think,
32:50as I'm sure you know,
32:51this three year work with doctor
32:53your were eager to make sure that
32:55we're meeting the needs of these
32:57patients in our catchment area.
32:58And I think I was really,
33:01I think I really liked your work on
33:03the microbiome versus bacterial genes,
33:05and I think really trying
33:07to do a deeper dive,
33:09both in terms of that but also
33:11precision medicine to really meet the
33:13needs of a more diverse population.
33:15That's correct, that's correct,
33:16and you know, it's almost like impossible.
33:18You know to try to answer every question,
33:21so the way that we have you know our
33:23approach has been to really collaborate
33:25with teams and you know from basic
33:28scientists and you know to physician
33:30scientists and even the Community, you
33:32know that that work that I show you about.
33:34You know access to care.
33:35I mean, I, I, I was really amazing.
33:38I love the molecules and you
33:40know when you talk about jeans,
33:41I get very excited but but
33:42then I realize that, you know,
33:44we have to also tackle the community.
33:46The access to health care.
33:49It doesn't explain all.
33:50OK, because you sweesy populations
33:52any this has been published many
33:54times over that with the same
33:56access to care you see differences
33:58right using these disparities.
34:00But you know some of the key
34:02factors may be mediated to you,
34:04know those genes that we inherit,
34:06and there was a an article published
34:08maybe three months ago by the group that
34:10blanket and it was published in Nature.
34:12He was about.
34:14Lung cancer an ancestry and you
34:16know it was beautifully presented
34:19that depending on your ancestry,
34:21particular genes that were driver for
34:24lung cancer were present, so you know.
34:26Of course,
34:27if you are exposed to more carcinogens right,
34:30you will have a higher risk
34:31for developing cancer,
34:32but it was not explained by the
34:35environment was explained by the genes.
34:37So this same approach we need to dive deeper.
34:40And now you know,
34:41identify you know what are
34:43those other you know.
34:44Genes that might be related to inflammation,
34:47you know, stress related and not really.
34:49You know, you know Uncle genes,
34:52but maybe just stress related right?
34:54And you get more of you know like
34:56for instance we've been looking into
34:58interleukins and whether or not
35:00having a particular Geno type in key
35:02interleukins that are inflammatory
35:04mediated my increase the risk of
35:07developing cancer once you you
35:09know expose that to two whatever
35:12carcinogen and we're doing that.
35:14Usina organoid models.
35:15It's not my.
35:16My work is part of the team,
35:18so you know there are many more
35:20questions that we could try to attend by
35:23really dissecting all the different areas.
35:28That's great, I don't see any
35:29other questions in the chat,
35:31but please post them if you have any,
35:33and I'll maybe ask.
35:34Ask another one or just a comment
35:37you know I did not know that the
35:39TGA had really like such little
35:42diversity and zero Hispanics,
35:44and I think that I'm wondering
35:46as you can in your sort of
35:48leadership roles in the survey,
35:50CR and other organizations.
35:52What are some ways that you
35:55are going to propose basic and
35:58translational researchers?
35:59To conduct more diverse research,
36:02yeah and and you know,
36:03thank God that this has started already,
36:06so you know they said,
36:07you know when when we were all like you know,
36:09looking at the data and you know seeing
36:12the the lack of diversity right at the
36:15same time a huge effort started on the ACR.
36:20Really, you know, promoted the genie,
36:22the project Genie right?
36:23Which now when you look at the
36:26centers that contribute to tumors.
36:29Much more diverse centers,
36:30and now we have close to
36:3310% in certain cancers.
36:34We have 1015% representation and
36:36then the same thing is happening
36:38with the prostate cancer right there.
36:40Large cohort of prostate cancer.
36:42Men that had our 2000 and it's it's
36:45halfway there in the collection
36:47and it's really focus on African
36:49Americans with prostate cancer.
36:51Because I mean,
36:52how can we understand and better serve our
36:55community of patients if we don't know?
36:58You know what is the molecular?
36:59Profile for these groups so I will know.
37:02I will tell you that the change has
37:05been dramatic and you know communities
37:07like the ACR and you know and even
37:10you know inside NCI because you
37:12would say why didn't we think about
37:14this right when we put it together?
37:15Well, there's something called subliminal.
37:18You know bias right?
37:19I mean some sometimes subconsciously
37:20messed up conscious.
37:22Sometimes you don't even think
37:23about it because there's nobody on
37:25the table to remind you, right?
37:27So you know when you look at
37:29institutions like you know the.
37:30NCI that represents,
37:32you know the whole USA America
37:35right 350 million,
37:36whichever number we are right,
37:38we need to have representation and
37:39you know when you look at the NCI.
37:41For instance,
37:42there are two important bodies like
37:45they they NCIB right in the baby.
37:49I forgot the whole nomenclature
37:50is one of the groups that advisory
37:53boards with the National Cancer
37:55Institute Advisory Board.
37:56And then we also have the Board
37:58of scientific advisors.
37:59So you know,
38:00those are the group of individuals
38:02that are scientists that represented
38:03different segments of our community of sign.
38:06That it's important that we start
38:08having representation from the top,
38:10because if we are not at the table right,
38:13you know you know what they idiom says.
38:15So I think that that's one of the
38:16things that has started to happen,
38:18and you know the same thing
38:20applies for women.
38:20And you know, I always have to,
38:22you know, remind people that you
38:24know 50% of us are they look like me,
38:27but sometimes when you look at the
38:29leadership,
38:29you only see 10% of us,
38:31so you know it's important to
38:34promote diversity.
38:36Across religion ethnicity,
38:37you know gender and you know race
38:40and I'm starting with leadership
38:42positions and when we are there
38:44you know then we make,
38:46you know we we make our point.
38:47We make sure that we know we're
38:49not oblivious to that.
38:50So I think you know the short
38:52answer is that we're doing better.
38:53We're going to have good data in the next few
38:55years and that data that I just showed you.
38:58I mean, that was commercial data,
39:00so we basically took RSR group
39:01of patients and you know,
39:03in 10 years before that would have been.
39:06Impossible for anyone to afford.
39:08You know, over $1000 that that
39:10cost about $3000 per patient.
39:12And you know that we're required
39:14a large or one to do it right?
39:16But now we can use those
39:18commercially available databases,
39:19which you know allows an investigator you
39:22know to start comparing and pulling data.
39:25You know DJ is only one of the databases.
39:27We have multiple lines.
39:29I mean, there are multiple lines that.
39:32Smart people can I get?
39:33You know people that you
39:34know have good questions,
39:36can pull an evaluate,
39:38so hopefully soon will have much more.
39:41Great, well we are just
39:43about at the hour or so.
39:45Thank you Doctor Cruz Correa
39:47for joining us today.
39:49Thank you for tonight.
39:50We're excited to continue the
39:52conversation with you and other forums.
39:54Roy any other words?
39:57It's wonderful to have you here
40:00and hopefully someday in person and
40:02looking forward to working with you,
40:04you've given us many things to think
40:06about that are really important
40:07for our community and for patients.
40:08And and thanks so much for your time.
40:11Thank
40:11you very much. We are really
40:13privileged group to be able to,
40:14you know, do something that we
40:16love and I think that's for me.
40:18That's the key and am I see
40:20that you guys are also,
40:22you know doing the same.
40:23So thank you for the invitation
40:24royal pleasure to see you again.
40:27We will be sending you that plaxo.
40:29OK, you're gonna love your office about
40:32be delighted to I'm right here so
40:35thank you. Thank everyone and
40:37goodbye. My friends are there
40:38as well. So happy to see
40:40you all bye bye thank you.