Hispanic and Latino people comprise nearly 20% of the U.S. population, but less than 6% of physicians nationwide identify as Hispanic.
“The pipeline issue continues to be a huge issue for us,” Amelie Ramirez, of UT Health San Antonio and Mays Cancer Center, said during a panel discussion convened by The Cancer Letter to mark Hispanic Heritage Month. “As our population continues to grow, in terms of the Latino population, we definitely need more [Latino physicians].”
Ramirez joined five other cancer experts for a conversation about cancer in Latinos, health equity, and how to support Latino clinicians and researchers. The discussion was moderated by Ruben Mesa.
Mesa agreed to serve as The Cancer Letter’s guest editor for Hispanic Heritage Month.
Panel participants included:
Luis Carvajal-Carmona, PhD
Professor, Auburn Community Cancer Endowed Chair in Basic Science,
Associate vice chancellor for the Office of Academic Diversity, University of California, Davis
Marcia Cruz-Correa, MD, PhD
Lead investigator and director, Clinical & Translational Research,
University of Puerto Rico Comprehensive Cancer Center;
Chief medical officer, PanOncology Trials;
Professor of medicine and biochemistry, University of Puerto Rico School of Medicine
Edith Perez, MD
Professor emeritus, Mayo Clinic
Amelie Ramirez, DrPH, MPH
Professor, Director, Institute for Health Promotion Research,
Chair, Department of Population Health Sciences, UT Health San Antonio;
Associate director of cancer outreach and engagement,
Mays Cancer Center
Yolanda Sanchez, PhD
Director and CEO,
University of New Mexico Comprehensive Cancer Center
Since trust plays a huge role in recruiting participants, the dearth of Latinos in health care affects clinical trials and translational research, said Cruz-Correa, of the University of Puerto Rico and PanOncology Trials. “For our patients, for our communities, language is still important—that concordance between the physician that is telling you about the study and the patient’s background.
“Studies have shown that Latino patients want to have, if possible, someone that comes from a Latino background. But that’s one of the biggest barriers,” Cruz-Correa said.
Still, it’s important to remember that Latinos are a very diverse group, said Carvajal-Carmona, of UC Davis. “Here in the Central Valley of California, where Davis is, a lot of the migrant farm workers—one in 10 of them—speak a language that is not Spanish.”
The pipeline issue continues to be a huge issue for us. As our population continues to grow, in terms of the Latino population, we definitely need more [Latino physicians].
– Amelie Ramirez
A lot of them speak languages from Oaxaca. They speak Mixteco, Zapoteco, Triqui; right? So, if you think about cancer disparities in Latinos, the disparities in these Indigenous groups are even higher,” he said.
Latino people of the myriad ethnicities throughout the Americas have a variety of histories, cultures, and cancer risk factors, Carvajal-Carmona said.
Only about 10% of NCI-funded clinical trial participants and about 4% of FDA-run drug trial participants identify as Hispanic or Latino (The Cancer Letter, June 26, 2020).
“Our community really doesn’t talk about cancer. They still are fearful of being diagnosed with cancer, so they don’t share that information with many individuals,” Ramirez said. “What I learned is that we really need to do prior education. Our community feels at clinical trials that they’re being tested as guinea pigs.”
Ramirez and her colleagues have been providing that education through community-based listening sessions and videos that explain how clinical trials work, as well as by distributing cancer prevention and other health information nationwide through Salud America!.
“It’s getting them ready to at least hear the terms, understand what those terms mean, so that when they meet with the provider, they at least have some knowledge about what is a clinical trial, what does randomization mean, and for them to be able to come up with their own questions that they would like to ask the clinician,” Ramirez said.
Creating that strong foundation is crucial, agreed Yolanda Sanchez, of the University of New Mexico Comprehensive Cancer Center. “When we approach patients for this representation, and we try to increase, we have to start with trust, and we have to build the trust. We can’t just launch into ‘give me your data, and let’s create a specimen.’”
Latinos working as oncology professionals need that level of care and support, too, said Sanchez, who is the first Latina director of an NCI-designated cancer center. The day before her new role was announced, Sanchez said she received a flood of emails from fellow directors from underrepresented groups offering their cell phone numbers and telling her to reach out whenever she needed help.
“That is how we create the leaders of tomorrow,” Sanchez said. “We show up for them. We are there as their sponsors. We don’t just nominate them for roles, but we also follow through with the support that they need.”
For instance, UNM’s cancer center has an emerging leaders program to uplift and coach younger faculty members who have the potential for leadership roles. “What is very important to note is that this cannot be a minority tax on our young members,” Sanchez said.
She and her colleagues remain mindful of the participants’ time commitments and help them distribute their tasks so that they do not become overburdened.
“This is very important, because what we want to do is we want to develop the leaders that are going to find joy in leading at our cancer center and at other institutions—and also not burn them out,” Sanchez said.
Regardless of career stage, it’s vital to continue to make Latinos’ professional presence in oncology known, especially through participation in organizations such as the American Society of Clinical Oncology and the American Association for Cancer Research, said Perez, of Mayo Clinic.
“We are part of the population. We are part of the intellectual minds that exist in this nation. And we’re here to help lead and collaborate.”
Transcript
Ruben Mesa: Hello and welcome. My name is Ruben Mesa, and I’m president of Atrium Health Levine Cancer and the executive director of the Atrium Health Wake Forest Baptist Comprehensive Cancer Center.
I’m joined with many wonderful friends and colleagues today as we take a deeper dive into issues of cancer in Latinos and Hispanics, marking this Hispanic Heritage Month as part of a podcast and discussion for The Cancer Letter.
Now, I’m mindful as we acknowledge Hispanic Heritage Month, it goes from Sept. 15 through Oct. 15. And I think the fact that it sits in two months, as opposed to being in one month, is somewhat of a microcosm of being a Latino in and of itself.
When one thinks about the Latino community, it’s fabulous, it’s diverse, but it’s many cultures. It clearly includes many, many different genetic ancestries from Europe, from Africa, from the Caribbean, from Indigenous populations throughout Mexico, Central, South America, and beyond.
And all of this richness makes for both a very vibrant community, but also one that’s difficult to really think of in a homogeneous way.
It’s also, clearly, as we think about this through the lens of cancer, one that experiences both significant challenges in terms of issues with health equity that are both challenging and distinct.
So, for our discussion today, we really have some wonderful national cancer leaders in the area of cancer, as well as in health disparities, and all who have both been leaders as Latinos and Hispanics in cancer research, in cancer care, but also in their own personal research.
So, we have Dr. Marcia Cruz-Correa, professor of medicine at the University of Puerto Rico, Dr. Luis Carvajal-Carmona, professor and associate vice chancellor of academic diversity for UC Davis, Dr. Amelie Ramirez, good friend and colleague from the University of Texas Health San Antonio, where she’s been the director for the Institute of Health Promotion, the associate director for community outreach and engagement, as well as the chair for the Department of Population Science, Dr. Edith Perez, emeritus professor at Mayo Clinic, world-renowned medical oncology expert in breast cancer, as well as been an important leader in industry as well, both with Genentech in Bolt, and then Dr. Yolanda Sanchez, director and CEO of the University of New Mexico Comprehensive Cancer Center.
So first, why don’t we go around just a little bit and have each of our panelists just say a little bit—what are some of their top thoughts as we think about Hispanic Heritage Month and issues of cancer in Latinos. So, Dr. Cruz-Correa, why don’t you start us off?
Marcia Cruz-Correa: Thank you. Thank you, Ruben. Thank you for the opportunity of being with this prestigious group of investigators that for many years, we’ve had the opportunity of really highlighting those diseases and those, particularities that we as Latinos have.
I am in Puerto Rico. And Puerto Rico has its own political and territorial and other factors, as well as a different culture. So, Puerto Rico is one of the groups that are part of what we call Latinos in the USA. And by definition, there are some cultural similarities that we all share, but there are other certain differences that we see in each particular subgroup of Hispanic populations.
My dream is that we apply the same urgency and innovation that we had during the COVID-19 pandemic to solve the access problem, because the whole country, the whole world, mobilized around that, and we really need to solve that problem if we’re going to solve the equity problem.
– Yolanda Sanchez
And in the Caribbean, Hispanics that are… The Caribbean Hispanics are across the USA, but especially in the east, northeast, and also south of the USA, we do see differences even in the type of cancers that we take care of. So, when I think about Latinos in the U.S., I always think about, a large community that continues to grow. I think we represent about 65 million people right now, but by the year 2050, one out of every four U.S. citizens will be from a Latino background. So, you know, it’s an important community.
So, when we think about this community, we share a lot of culture. We share a lot of common exposures as well, and there are things that really affect us all.
One of the areas that we need to think more is that when you think about cancer in Latino communities, you have to think about those cancers that are associated with infectious agents. So, I still see—I’m a gastroenterologist, and I still see patients—we see patients with chronic liver disease, hepatitis C, Helicobacter pylori, which is something that people don’t think about for the non-Hispanic whites, and those patients present with gastric cancer.
So, cervical cancer, gastric cancer, liver cancer—those are cancers that are not common in non-Hispanic whites, but we still see them. And many of them are related to infectious agents. Some of them are related to obesity and diet, right, that we continue to see as a driver of cancer.
So, it is true that we share a lot of commonalities. It is true that there are opportunities to prevent, detect early, and treat cancer, but there’s still a long way ahead of us, and I’m hoping that this conversation will allow us to talk about that.
Fantastic. Luis, perhaps tell us a bit about yourself, but also, let me throw a question in there as well.
The Latino community is very diverse in of itself. It clearly is, as Marcia was raising. What are some of the major drivers of health disparities that we see in Latino patients?
Luis Carvajal-Carmona: Thank you, Ruben. So, I’m a professor here in Davis and a bench-to-community researcher.
So, I’m based in California.
As Dr. Cruz-Correa mentioned, Latinos are very diverse. One in three Latinos is an Afro-Latino; right? So, people don’t talk a lot about that. And depending on where you are, the Latino community has a different history.
So, here in California, most of our Latinos are Mexican-Americans, or, you know, children of Mexicans or Central Americans, particularly Guatemalans, Salvadoreans, Hondurans, and a lot of them also are Indigenous.
So, here in the central valley of California, where Davis is, a lot of the migrant farm workers—one in 10 of them—speak a language that is not Spanish. A lot of them speak languages from Oaxaca. They speak Mixteco, Zapoteco, Triqui; right? So, if you think about cancer disparities in Latinos, the disparities in these Indigenous groups are even higher.
As it was mentioned before, depending on the location and history, we have different communities. So, here we have Mexicans or Central Americans, Indigenous people, and migrant workers; right? So, Latinos, around two in three Latinos are now U.S.-born. So, there are more U.S.-born Latinos than migrant Latinos.
But that doesn’t mean that we don’t have a lot of migrants. And migrant Latinos, they have different disparities than U.S.-born Latinos, so there are a lot of differences there, and the main drivers of disparities have been historically, infectious diseases, as Dr. Cruz-Correa said. You know, things like Helicobacter pylori, HPV, etc., those have been the main ones.
It doesn’t mean that Latinos are not affected by the big four cancers that are common in whites, by breast, prostate, lung, and colon; right? Actually, colon cancer is the second cancer killing Latinos; right? And this is influenced by social determinants of health, by lack of insurance, by lack of screening, etc.
And also, more recently, with the obesity epidemic, we are seeing an increase in obesity-related cancers, a lot of them things like colon, breast cancer, stomach cancer. So, there are a number of drivers that depend on where you are, if you are an immigrant Latino or a U.S.-born Latino.
Also here in California, something that we experience a lot is environmental health disparities. Okay? So, most Latinos in California are based either in the LA area or in the Central Valley, and those are the areas with the highest air pollution; right?
So, even though things like, Latinas have very low rates of a common cancer risk factor, like low rates of smoking, so, we have lower smoking rates.
A lot of them are now developing more and more lung cancer in never-smokers, probably because they are living in highly polluted areas. So, there are multiple causes of disparities that are either environmental, determined by social factors, or in some cases, also have a biological basis.
Wonderful, wonderful. It’s a fantastic kickoff for us.
Now, one of the key things I think we recognize that is important, is having patients who enroll on our clinical trials be reflective of the people who are going to get the therapy later on. I think it’s important both in terms of understanding the safety and efficacy of therapies as well as it’s clearly a very important need for our patients.
In cancer, clinical trials are clearly, for my end, an extension of our standard of care. You know, because the standard of care as we go through options, clinical trials play an essential role. And access to clinical trials is crucial if we’re going to provide great health care for everyone in our society.
Now, Dr. Ramirez, I know that you played a very important role in this, and have been very, very active in a variety of both kind of understanding the problem and interventions. So, perhaps share, from your perspective, what have been some of the effective strategies you’ve seen to help recruit Latinos onto cancer clinical trials?
Amelie Ramirez: Great. Well, thank you. Thank you, Ruben, thanks for that question. I’ve spent the last many years kind of focusing and kind of establishing a database on the importance of getting Latinos to participate in clinical trials.
Part of it has been, also, what have been some of the barriers? What we have found is that our community really doesn’t talk about cancer. They still are fearful of being diagnosed with cancer, so they don’t share that information with many individuals.
And the first time I tried to educate about clinical trials, it really brought tears to people’s eyes, because they said, “No, I don’t want to think about it, because I don’t want to will it on myself, and I don’t want to will cancer on any of my family members.”
And so, what I learned is that we really need to do prior education. Our community feels at clinical trials that they’re being tested as guinea pigs. That it’s not a true offering of a new treatment that they might be eligible for.
They don’t understand randomization. So, I feel that one of the biggest barriers we have in clinical trials is the need for prior education about what are clinical trials and why is it important for communities to participate?
And I think both, as Marcia and Luis have described, that talking about the diversity of our population, we span everything from Euro-Hispanics to Hispanics with an African descent to also Native American descent, and as we do more precision medicine, we really need our Latinos to participate. And less than 5% of Latinos are participating in clinical trials.
When we approach patients for this representation, and we try to increase, we have to start with trust, and we have to build the trust. We can’t just launch into ‘give me your data, and let’s create a specimen.’
– Yolanda Sanchez
So many things that we are trying now, with support from Genentech, is we actually developed an interesting program that had three levels. One of them was educating at the community setting—just going out into the community and recruiting different groups to have listening sessions on about what are clinical trials?
Another one was actually educating one on one at the clinic level, as patients are waiting to see their clinicians and exposing them to a videotape on what are clinical trials, giving them a brochure and having a community health worker available to answer any questions. And the third level has been on a national level, working through our Salud America! platform that reaches over 500,000 Latinos with preventative cancer and other health topics information.
So, it’s getting them ready to at least hear the terms, understand what those terms mean, so that when they meet with you, the provider, they at least have some knowledge about what is a clinical trial, what does randomization mean, and for them to be able to come up with their own questions that they would like to ask the clinician.
And so, we feel that this has been an important element in getting the patients ready and informed about clinical trials when it is important for them.
So, this is just one approach, but it has been effective. We now have other centers calling us and asking us, “Will you help promote our trials on glioblastoma, on different other health issues?” They’re coming to us and asking for assistance in recruiting to their trials.
And I see Marcia has got her hand up.
MCC: Hi, if I may. Thank you, Ruben.
As I’m listening to you, Amelie, one thing that comes to mind, especially because of our cultural background, is the element of trust. And there’s a lot of things that go into this trust, you know; right? And for our patients, our communities, language is still important.
You know that concordance between the physician that is telling you about the study and the patient’s background. So, studies have shown that Latino patients want to have, if possible, someone that comes from a Latino background. But that’s one of the biggest barriers; right?
I was looking recently into the percentage of men and women that are medical oncologists that come from Latino communities. And in fact, it’s less than 5%. For Latino women medical oncologists, it’s 2%. I say, “Oh, my God.”
I mean, how can we match the number of people in the Latino community, if you have less than 5%—you know 2%, I think, for women, and like, 3% for men.
So, that’s really an important aspect that we need to think about. How can we train more Latinos that incorporate it, from the nurses, the physicians, anyone that is part—scientists—that is this part of the whole program that creates clinical trials.
So, I think that that was just something that I wanted to highlight, because the element of trust is key to increase participation.
AR: The pipeline issue continues to be a huge issue for us. Less than 6% of Latinos are clinicians nationwide. So, anywhere the matching, and as our population continues to grow, in terms of the Latino population, we definitely need more.
Wonderful, wonderful. Hold that thought we’re going to get around to the education and training piece in just a moment.
But first, just to continue on the theme of clinical trials, we now are in a period as well, kind of building on some of the great work from Dr. Ramirez and many others, as it relates to diversity in clinical trials, where there’s now a congressional mandate that was passed with a law that drugs seeking FDA approval really need to have at least a plan for trying to have more representative populations on those studies.
And indeed, there’s even further legislation, kind of currently being considered. I think the Clinical Trial Modernization Act to again, help to better support patients fiscally for the expenses and challenges of kind of participating on clinical trials.
And now, Dr. Perez, you bring many, many different experiences to this discussion. As a leading investigator in breast cancer clinical trials, as a—you really even played a very important role across now a couple different important companies really investigating investigational products, both in cancer and non-cancer.
First, share just a little bit of your experience with those.
But, two, you probably see this issue a little bit from both sides. What do you think both about the new laws, but do you think they’ll be helpful? How do you think we try to navigate that in the most positive way?
Edith Perez: What a fantastic question. And I guess I’ll start by saying how honored and humbled I am to be part of this meeting today. And one of the greatest aspects I would like to highlight is the opportunity that we all have to bring the best that we can and collaborate with others for progress, which really fits in very well with the topic of discussion.
For our patients, for our communities, language is still important—that concordance between the physician that is telling you about the study and the patient’s background.
– Marcia Cruz-Correa
And as you said, Ruben, bringing together the thinking of academia, together with big pharma, small biotech companies, and also putting my other hat, which is participation in a variety of national academies projects, as well as being a trustee for the Puerto Rico Science, Technology, and Research Trust, helps me create an idea of how important it is for the FDA to have taken the initiative to really put ideas into paper with an action-driven directive, so that companies think about equity and representation in clinical trials, really from the very beginning of drug development, starting with the IND process.
So, it’s more than thinking about the representation in phase III trials, but thinking about early drug development in terms of equity. So, I completely favor this, and I am very encouraged that so many companies are really looking at how they can change their quote, unquote “old ways” to address not only what is morally and scientifically right, but also address the FDA directive.
And if I may, one more issue here is that I had the pleasure to participate in one of the national consensus meetings that was released, actually, just a year and a half ago, and it was actually titled Improving the Representation in Clinical Trials and Research: Building Research Equity for Women and Underrepresented Groups.
And the main editor of this was Kirsten Bibbins-Domingo, who, as you know, is now the lead editor for JAMA. So, in that report, we came up with a variety of, I think, well-structured assessments and recommendations for how to improve representation of all ethnic groups and underserved populations in clinical trials that can serve as a model to be added to the amazing amount of work that all of the persons participating in today’s podcast are involved in.
Wonderful, wonderful. Thank you so much. And we’ve mentioned a couple times, really, this issue of both the developing leaders, developing clinicians as a key strategy.
Dr. Yolanda Sanchez is—I’ll do this shout-out for her—is the first Latina director of an NCI Cancer Center and Comprehensive Cancer Center at University of New Mexico. So, Dr. Sanchez, you bring such a unique role to this. Why don’t you share just a little bit of your background and what it’s like to be in such a trailblazing role. And two, how do you think we help to build and support the up and coming Hispanic and Latino leaders and our emerging leaders of cancer centers?
Yolanda Sanchez: Thank you, Dr. Mesa, and thank you to all my fellow panelists. I’m really—it’s a joy and honor to be here with you today.
I am, yes, the first, the first Latina, Hispanic woman, first Chicana. How did I get here? It was through a lot of curiosity, mentorship, sponsorship. I have a story about the day before it was going to be announced that I was going to be the director and CEO of this cancer center, I received emails from my fellow directors from underrepresented groups with their cell phone numbers saying, we’ve got you. You know, this is our number.
You call, you text whenever you need us. We’re here for you. And I think that is how we create the leaders of tomorrow. We show up for them. We are there as their sponsors. We don’t just nominate them for roles, but we also follow through with the support that they need.
So, one of the programs that we started here at the University of New Mexico Cancer Center is the Emerging Leaders Program, which is a program that also other cancer centers have, where we nominate really younger faculty members of the cancer center who have the potential for leadership into this program, and they’re supported by mentors and also supported with demystification of what leadership is.
They come to the table, they sit at the table where the decisions were made, which is the way I was brought into leadership as well. And then we provide executive coaching and support for these roles.
What is very important to note is that this cannot be a minority tax on our young members. This cannot be one more responsibility that we put on their shoulders that they’re already taking on at this point in their career.
So, we have to be mindful of the time that they spend in this program. We also have to take other things away from them, if that means some support in the form of an administrator or support in the form of someone for their labs or their programs.
This is very important, because what we want to do is we want to develop the leaders that are going to find joy in leading at our cancer center and at other institutions, and also not burn them out.
So, we have to be very conscientious of this. And we have to show up for them.
I am now doing the same thing—when I see a new leader, a dean or a director, I send them my cell phone number and I say, “We’ve got you. We’re here for you.” That’s important. Thank you.
Fantastic, fantastic. Now, let’s circle back to many of the aspects of some of the challenges we see, both with health equity, but also some important differences we see in the populations.
I know, Dr. Carvajal-Carmona, you have been very active in the area of diversity, but also in the genomics and differences in populations as it relates to cancer risk. And I think it’s striking as we think about the issue of cancer in Latinos. There are certain cancers that are overrepresented. There are certain cancers that seem like they have been underrepresented.
There are certain cancers—I know that I was involved with a project looking at leukemias in south Texas and the prevalence was lower, but the outcomes were worse, you know, kind of regardless, because of issues of access, delayed access to emergency antibiotics, delayed presentations, etc.
From the genomics piece and your very robust work, what are some of your thoughts, or maybe a key observation or two that your team has made?
LCC: Yes, so I think the fact that Latinos have been severely underrepresented in large cancer genome sequencing efforts is a big problem.
Colon cancer is the second killer of Latinos, and only one of 500 tumors sequenced by TCGA was from a Latino right? And we have been discovering through our science that Latinos, they tend to have unique patterns; right?
We published a study on gastric cancer, and we show that one in two tumors from Latinos have the most aggressive molecular subtype called genomic stable, and that wasn’t shown before by TCGA.
So, genomically stable tumors don’t respond to chemotherapy, they don’t have targets for targeted therapies, and they are immunologically cold, and they tend to associate with diffuse histology; right? So, those are the most common cancers in Latinos.
By doing equity-focused cancer genomic research, we are highlighting this issue.
The challenge now is to come up with signs that address this and identifies the vulnerability of this difficult-to-treat gastric cancer tumors, which are—gastric cancer, which we’ve mentioned it before—it’s the top cancer health disparity in Latinos and it’s severely underfunded by NCI; right?
So, having these types of gastric cancer is the top disparity for us Latinos, and also for many populations of color.
It is important to address one gap, which is the lack of data. That lack of data in genomic cancer, genomic data to identify subtypes that are common in Latinos and come up with better science that can be used to treat them; right? Better risk prediction data.
We have done a few GWASs on colon cancer and on breast cancer in Latinos, and we have published a risk-prediction model for breast cancer in Latinos with collaborators in the U.S. and Latin America, we are about to publish a risk-prediction model for colon cancer in Latinos; right?
But we cannot predict cancer in Latinos using PRSs or polygenesis modeling, because the data is not there. There are no large-scale genome-wide association studies. For treatment and for prevention, the lack of data, genomics and genetic data is an important gap.
Something that is important that we address is the lack of patient-derived models.
Things like organoids, things like patient-derived xenografts, PDXs. We are lucky to have been funded by the NCI for the past six years to make models from minority patients; right?
I can tell you, for the top cancer disparities in Latino, we just published a paper in Cancer Research Communication showing that there are no models. I mean, if you want to do ethnic-focused research or ethnic-appropriate research, you cannot do it.
We have been making more. We have made something like 50 gastric cancer models with funding from the NCI from Latinos. Okay, so, preclinical research also has a number of gaps; right?
These organoids, these PDXs, are very effective to come up with effective, good combinations; right?
But if we don’t have the mutations and the genomic alterations that are common in Latinos in those models, we cannot advance preclinical research, and therefore we cannot have equity, minority-focused clinical trials.
Those are two gaps: data and models.
MCC: Yes, completely agree with your reasoning. You hit the nail on the head.
One of the areas that needs to also be considered—and we were all aware that less than 3% of all patients that were evaluated as part of the TCGA were actually from Hispanic communities. But now we have a great opportunity to collaborate.
And one way to go around this lack of information is really to collaborate with large genomic sequence companies; right? So, there are certain companies that have the data available, and that’s how we have done it.
We have been working with groups like Caris Life Sciences. They have the Precision Oncology Alliance, which is the not-for-profit organization that allows us to pull data and really look at our patients.
And in fact, we did that for the gastric cancer community. So, we had over 1,000 patients from the island that had undergone full genomic sequence from the stomach. We also did it for the colon. We published last year for the colon one, and we did see differences. And those differences are important.
In fact, in the Latino community from Puerto Rico with gastric cancer, we saw that Epstein-Barr Virus was present in 25% of all samples, which, when you look at the TCGA or the non-Hispanic communities, the percentage was about 10%.
So, that’s a big difference to start with. And that’s important that the information on the genetic background is available in the tumors—it’s available—so that then the FDA mandate, when they ask the pharmaceutical companies to actually have a plan to increase diversity, it makes biological sense as well; right?
Because you can say, “Well, this is present in the community. You’re looking at biomarker X, and biomarker X is present in the Latinas.”
Then, you close the circle; right? You have to have the data, just like Dr. Luis Carvajal was saying, but you also have to incorporate that into the clinical trials for the sponsors that you know are working very hard to really bring those new agents to the community. Thank you.
EP: This topic of representation in the context of biospecimens as well as genomic analysis, is going to be, in my view, amplified by the fact that artificial intelligence is increasingly being incorporated in all aspects of life, medicine, and specifically cancer medicine.
Not only, certainly from the administrative issues from diagnosis utilizing blood specimens, diagnosis using hematoxylin, and using slides to be able to determine… genomic profilings, using just H&E stains, as well as the incorporation of clinical data with biomarkers.
As this will be amplified, it’s very important that all of us involved in promoting health equity, including Latinos, that we are part of the discussion related to the development of these algorithms that will be ultimately utilized by many, including the FDA for drug approvals, that there is appropriate inclusion of all ethnicities in these algorithms so that the recommendations that ultimately are issued, are representative of the population.
One aspect is that, as the awareness of artificial intelligence has increased, I am also very encouraged by what the FDA has recently done under the thought to unify all the different projects that they have with AI under one umbrella.
The NIH is doing the same, certainly the NCI as an institute of the NIH is very involved in this area, in addition to many companies, both public companies, and actually early companies trying to develop new AI platforms. So, I’m actually very encouraged, and this discussion today will help remind all of us how we have to be part of the solution.
It’s really an outstanding point. As we think about those evolving technologies, again, ones that are really able to kind of capture the full richness of everything that makes an individual as we consider, let’s say, in your arena of breast cancers, as we consider genetic risk, as we think about ancestral risk, as we think about risks from obesity, diabetes, tobacco use, etc., how do we weave all of these things in?
And again, all that, to some degree, kind of pulls retrospectively for what is out in the ether. How do we adjust for that? To again, try to correct for some of the potential intrinsic biases that can be in that data. Very much as Luis had said, we’re challenged that pre-existing models and pre-existing genetic data can be limited.
Dr. Sanchez?
YS: Yes, I just want to make a—all wonderful points—a brief point that ties Luis’s and Marcia’s discussion from earlier.
And that is that I do acknowledge that there’s a lack of representation and data in biospecimens, but I have to take it back to the previous comment that when we approach patients for this representation, and we try to increase, we have to start with trust, and we have to build the trust. We can’t just launch into, “give me your data, and let’s create a specimen.”
I think we have to go back to that point that with special populations, we have to start from the point that we have to build the trust first.
It really is an outstanding point for our cancer center at Wake Forest Baptist, our new associate director of COE, who’s the current president of ACCC, Nadine Barrett. She’s wonderful, and she likes to say, “How do we focus on, how do we become more trustworthy before we ask others to just increase their trust in us?”
I think very much, as Dr. Ramirez had done with the Institute for Health Promotion, I think one of the things to really celebrate about your efforts with that Amelie is that it’s not about going in for kind of one transactional solution: “Boy, we really want to increase accruals on the cancer clinical trials.”
It was about, “Boy, we really want to partner with your community to promote health. And there will be derivative pieces in Alzheimer’s and cancer and others that we may work together on in a very elective fashion.” But it wasn’t transactional.
Maybe just share a couple of comments, again, as you intentionally built the Institute for Health Promotion to have a broader relationship, be a base for building that trust. What’s that experience been like?
AR: It has really been very rewarding, and part of it is that many of the risk factors that we share for cancer cross over to our other health problems—cardiovascular disease, diabetes, and so forth, and even now, dementia; right? You know, obesity. All of these things are all becoming kind of interrelated, and so, we have a lot to learn and to share from one another.
Most of all, I didn’t want our Hispanic community to feel like, “You’re picking on me. Now, I have more of this or more of that.”
But it’s really the focus of the risk factors, and that they have the opportunity to work on those risk factors to decrease their future risk of developing disease. And that’s where we need to ensure the trust with the community. We’re there to help them. We’re there to promote their health, and not just to ask them to participate in our studies, and so this is where that giving back and forth is extremely important.
EP: A couple of things. But I want to pick up one more aspect related to data aggregation, if I may, because one thing that is being done at the national level, and for all of us to do in our own cancer centers is to think about the incorporation of social determinants of health as part of our medical record documentation.
Because outcomes for Latinos with cancer, with people with cancer, are dependent not only on genomics, proteomics, but also social determinants of health.
So, I wanted to bring it up as part—and I know this is part of the initiative that Amelie, you’re paying a lot of attention to when you have discussions with community members related to the participation in the process.
And Ruben, maybe we’ll want to cover this later, but I’m sure at each one of the cancer centers, there are some specific initiatives that we can highlight related to what we’re doing to enhance the trust and collaborations with others. I know Yolanda mentioned some, Amelie mentioned some, but I can talk a little bit about what Mayo is doing too.
EP: At Mayo, certainly at Mayo Clinic in Jacksonville, Mayo is actually a member of the mayor’s Hispanic advisory board to bring information that can address the cancer needs of the Hispanic Latin community in northern Florida.
Mayo also actually, very interestingly, has a partnership with the Farm Workers of America, many of whom are Spanish-speaking and migrant workers to get them enrolled in a community research registry where they can learn about cancer research studies that may benefit them.
And we have certain initiatives with Spanish-speaking churches to try to help provide education, not only in terms of nutrition aspects that can reduce cancer risk, but also to serve as partners in the process, instead of just waiting until we have a trial available to invite participation.
Wonderful, absolutely wonderful.
Indeed, as our center has grown, we have now merged two cancer centers to become a single NCI Comprehensive Cancer Center, from the Winston-Salem and the Piedmont region in North Carolina, through the Charlotte region.
And that really starts, I think, by truly trying to really understand and listen to our communities, bringing together our community advisory board, really evolving that community advisory board to be representative of that community.
And the health disparities that in this region can add together with rural healthcare needs of Latinos, of individuals who are Black or African American, as well as those that are American Indian. Indeed, each of these populations, there are similarities, there’s differences.
There’s that diversity within diversity.
Let me ask—I was going to ask this a bit later, but I know our time grows short. Dr. Sanchez, your cancer center plays a very unique role in that you have, you know, very significant efforts ongoing through your catchment area of the state of New Mexico, both with American Indians, the nations there, as well as with Latino patients.
What do you learn from each of these communities? How do lessons sometimes from one community help you assist the other and vice versa?
YS: Yes. Thank you for that question. So, my predecessor, Dr. Willman, had been working on building trust with our Native American communities, tribes, and nations for a couple of decades now.
And she did this by really coming to the table with humility and learning about the past and the transgressions with those communities and how those communities wanted to engage in health care and decisions and research.
And through that program, we have now a unanimous decision by the governors of the 19 Pueblos to engage in research and cancer research with the UNM Comprehensive Cancer Center.
YS: And lessons that were learned from those years of building trust, is that people want—it was said before—people really connect with their own and with people who speak their language.
And so, what we have now for Hispanic Latino communities is we have programs that are either bilingual or monolingual, of people who were trained as navigators to go out, and these are cancer survivors themselves, tell their story in the communities, and by doing so, earning the trust of the people in those communities, and then bringing, navigating those patients to either cancer care or cancer screening.
We also partnered with the Mexican consulate, and we have an oncologist who gives talks on Facebook Live about different types of cancers. She reaches a wide audience, gets a lot of questions, and there’s a lot of follow up. So, we go into the communities with humility, and we ask them what their needs are, and then we try to provide culturally sensitive and culturally appropriate engagement.
AR: I just wanted to go back to Edith’s mention of social determinants of health, which is extremely important. And through your support, when you were here with us in San Antonio, we received a grant from the American Cancer Society that really focuses on social determinants of health.
Number one is that we expanded the questionnaire to standardize what kinds of questions we’re asking of our cancer patients, but also that it doesn’t get repeated every time they come in for a new visit, but put it in a standardized format.
We also were able to fund three scholars that are using social determinants of health for their different research projects. One is working with AYA patients, another is working with breast cancer patients, and another going after males that live in persistent poverty, with regards to colon cancer screening.
And then, thirdly, we’re really trying to motivate other researchers to really be more cognizant about what are social determinants of health and what do we need to do to reduce those concerns among our patients.
Patient navigation is now reimbursable. And so, we’re trying to integrate patient navigators to help address those social determinants of health so that our patients can focus more on their situation and get better sooner. And lastly, again, we’re educating all of south Texas about what are those determinants from a policy perspective, and collaborating with ACS CAN to see where we can make some modest changes here in south Texas.
Fantastic. Well, in the few minutes we have left, why don’t we just each go around and just say a couple words about something we’re really hopeful for in this upcoming year that’ll really help to make an impact on our understanding of cancer in Latinos, help to improve health equity, or really assist in our mission. And I’m going to give Dr. Ramirez the final word so she can plug the fantastic Advancing the Science of Cancer in Latinos meeting.
But why don’t we begin with Dr. Cruz-Correa?
MCC: Thank you. Thank you, Ruben. So, I would want to go back to the idea of, how do we increase participation of minorities in clinical trials?
And we have discussed multiple strategies, right, policies like you mentioned, like from the government, from the FDA, from NCI, to try to help us. And also, health insurance right that will cover some of the expenses associated with clinical trial cancer care.
But I also want to talk about how do you provide access within the community? So, not everyone can go to an NCI-designated cancer center or even a healthcare system that has access to infrastructure to provide clinical trials.
One of the aspects that many NCI-designated cancer centers are doing is really going into the community by doing collaborations so that you can provide infrastructure so that someone that is in their hometown can have access to the early-phase clinical trial, not only the phase III clinical trial.
And that requires building infrastructure that goes beyond training the physicians, training the nurses, but also the infrastructure with regards to laboratories and so forth and so on.
So, I want to plug in the concept of building a community research network so that we not only do cancer research at the large urban centers, but also at the community that will also help with the trust, because most patients will say yes when the person that invites them to participate in a clinical trial is their own doctor.
You know, the trust is already there so, the concept of going to the community to recruit, engage, and build trust, I think it’s important also to develop for the Hispanic community. Thank you, Ruben.
LCC: I would say it is important to grow the next generation of Latino cancer researchers, clinicians, and scientists. As it was mentioned before, only 6% of medical students in the country [are Latino] and 30% are Latinos here in Davis.
But we haven’t been able to change it where one in three medical students is Latino, despite being in California, where we have been working with affirmative actions for decades.
So, there are ways, structural changes that can be implemented or graduate programs and medical programs to come up with strategies that provide opportunities to more groups like Latinas.
So, I would say it is important to re-double our efforts in training the next generations of scientists and clinicians that will help us address—move from disparities to equity in the Latino community.
EP: For me, in this area, there are several components to consider. Number one, what can we do in our immediate surrounding areas of where we live? How are our institutions?
Think about what can be done at the national level if we’re part of the discussion and even thinking globally, of initiatives or projects where we may enhance mentorship opportunities for training generic students and junior investigators to conduct cancer research, prevention, diagnosis, and treatment.
And I can think also of our participation in organizations, such as ASCO, AACR, particularly, who are drivers of clinical, translational, and basic research in the area of cancer.
For us to tell people we are here—continue to tell people we are here. We are part of the population. We are part of the intellectual minds that exist in this nation. And we’re here to help lead and collaborate.
YS: So, I guess this is where I can just talk about my dream; right? So, I think a lot of the disparities that we spoke about—in addition to the underlying biological and environmental and behavior and social determinants of health that contribute to disparities. I think that one of the problems we have to solve is the access problem; right?
My dream is that we apply the same urgency and innovation that we had during the COVID-19 pandemic to solve the access problem, because the whole country, the whole world, mobilized around that, and we really need to solve that problem if we’re going to solve the equity problem.
Fantastic. Let me throw in mine so we can end on Dr. Ramirez highlighting what really is a fabulous event, the Advancing the Science of Cancer in Latinos.
For myself, I’m really excited about the teamwork that is going on to try to advance health equity, because it’s a huge issue. And cancer health equity, I think, really takes an all-on-board approach.
There is clear and, I think, genuine contribution from our colleagues in industry, from Genentech and BMS and J&J and many others that are really committed to trying to advance this in a variety of ways—everything from the support of new scholars, like the Winn scholars program to diversity in clinical trials; including the tremendous leadership efforts at the NCI, even the rebranding of now the Center for Cancer Health Equity with Dr. Sanya Springfield, and that entire team is really doing extraordinary work in many different ways; to our centers, to our physicians, to our organizations, our researchers in our community.
It really takes an all-on-board approach, and really thinking about every aspect of this, from health policy to how we really provide care, from screening and prevention through survivorship to education to the research questions that we ask. They’re all really important, from the true genomic probative questions that Dr. Carvajal and his teams are asking to really outcomes-based research.
And one place where we bring this all together to discuss issues particularly pertinent for this community is the Advancing of Science of Cancer in Latinos meeting. So, I have the honor of intersecting during part of this meeting’s history with Dr. Ramirez. Why don’t you share this a little bit about what’s on board for the next one, and some of the great impact that this meeting has had, Dr. Ramirez?
AR: Thank you. Thank you so much, Ruben. It was really a dream come true to be able to have the first conference back in 2018, and we offer it now every two years. Our next one will be in February, the 18th through the 20th in 2026.
It is really the first time where Latino researchers doing Latino cancer research get a chance to share what their experiences have been and everybody that leaves has just felt really, truly honored to be there to share their stories, and they just don’t see themselves at other conferences.
And so, being able to see the variety—we cover everything from prevention through survivorship—it’s really been very wonderful. We’re hoping that this will increase that realization that we need to do more research with Latinos. So, we hope you all can join us.
And my other just two small wishes, Ruben, is that we expand Medicaid equitably; right? It’s the lack of insurance, the lack of access, that’s really hurting our population. And Texas is in the middle of that. So, I would just love to see that.
Also, biases still continue. Some people have implicit biases that keep our community from participating in trials or keeping them from getting involved in research. So, hopefully we can do more of that.
But thank you all. What a pleasure to be here with all of you.
Wonderful. Well, first, let me thank our tremendous panelists. Really, each individual we have on here, is a tremendous leader in their own area of research, as well as clearly leaders in the Latino cancer community, making a tremendous difference.
Also, a huge shout out to Paul Goldberg and the entire team at The Cancer Letter.
This provides, I think, kind of the town square for us in the cancer community, and the ability to really discuss important issues that relate to our cancer patients, to our cancer community, and I’m grateful for this opportunity to have this discussion in the shadow of Hispanic Heritage Month.
Thank you.
