It's a pleasure to be here and also it's interesting that I'm at a liver meeting and I'm a colorectal cancer guy, so I have to twist it a little bit to what I really know. So, as Carla mentioned, this is my title, I have no disclosures, and I'm going to talk just two quick areas, since I have about 20 minutes, disease disparity, so I'm actually going to throw in colorectal cancer, because I know that the best, and then I'm going to talk a little bit about the physician disparity in the field of gastroenterology and hepatology, and this is based on a paper we just recently published this year in gastroenterology. So first, so I work in the field of colorectal cancer, but if you look at all the gastrointestinal cancers, which is one of the highest rates of all cancers in the world, but just looking at the black, non-hispatic, white ratios, you can see that there's disparities in certain cancers. Some of them are reverse disparities, for instance, esophageal cancer, and that's largely because of Barrett's esophagus and adenocarcinoma that favors non-Hispanic whites. But if you look at the incident ratio, for instance, like stomach cancer, you see it's 1.77, meaning there's 77% chance that a black person would have stomach cancer higher than a non-Hispanic white. But you also see in that ratio, or the mortality ratio, an increase in the disparity, meaning that not only there's a difference in incidence, but a difference in mortality, which suggests that there's additional factors beyond incidence that gives it a higher mortality. This is also true in the field of colorectal cancer, a 1.13 ratio for black to non-Hispanic white incidence, and a little higher ratio for mortality. I do want to point out for liver cancer, which you'll hear about later from one of the speakers, that the ratio's pretty high for liver cancer incidence and mortality, but it seems to be that the real difference is at the incident level, not at additional mortality, based on the mortality ratios there. So I know colorectal cancer the best. So this is just broken down by the recognized races by NIH definition, and certainly the American Cancer Society definition, showing that rates amongst blacks are highest in the United States at 46.6 per 100,000 for incidence. But I want to point out that Alaskan and American Indian levels have creeped up over the last several surveys, and I think largely it's because we have better information, and I think there's a speaker later today that's going to talk about this, as well as Alaskan and Native Americans are living longer, and we're seeing the incidence go up. This is true for deaths, highest at 19.4 per 100,000 for African Americans. So why is this? And people have studied this in a number of different ways. One way to look at this, what's the cancer burden in the population? And this is a review paper that we published about a year ago, showing that when Sid Wienauer first put out the first data for the National POLPS Study, probably 20, 25 years ago, and that's the data that selected the age of 50 to start screening for colorectal cancer, it turns out that about 5.5% of all colorectal cancers were under the age of 50, where about 95% of cancers were over the age of 50. But if you look at specific races, in this case blacks, it turns out if you use that same data, almost 11% of blacks had cancers under the age of 50, compared to about 90% over the age of 50. And if you equated that to what you saw in the general population, you would theoretically start screening African Americans age 45 to get down to that 5% to 95% ratio. This also implies that the numbers I showed you from the American Cancer Society, so just the African Americans present 0 to 8 years younger with colorectal cancer than Caucasians. It implies that the precursors occur earlier, and since we do do screening, and this would be also true for other screenings, for instance liver cancer in someone who has specific types of hepatitis, there's less time from that age of 50 to the average age of colorectal cancer, meaning the window is short for screening utilization with that type of data. And this has also been held up from data from David Lieberman, who runs the CORI database, which looks at multiple practices and screening data from colonoscopies, and if you break down age intervals for every five years from just 50 on up to about 80, essentially for both females and males, at every one of those five-year intervals, blacks had a higher, except for one or two, essentially had a higher ratio for high-risk polyps compared to Caucasians. There's also data that I'm not showing you from Doug Corley, which also shows very high in Native Americans and Alaskan Natives as well. This trend has been going on for a while. You see the trends over the last 30 or 40 years for both males and females. The good news is that for all races, the incidence and mortality have gone down, largely because of screening, but some of this started dropping before we started screening, so there's not a good explanation for that. But if you look at the black line, which is the ratio, for males, the delta between blacks and whites were going up until about 2007, 2008, and it's kind of leveled off. And for females, there's a slight trend down, meaning that that gap can be closed with appropriate screening. Now if you also look at, this is a paper that's going to come out in January with Tchaik Dubany and myself, looking at socioeconomics and colorectal cancer deaths. If you look at the Mississippi Delta region, where there is a lot of colorectal cancer, this is exactly where some of the highest poverty rates in the country, and that suggests that maybe the two are equated. And so we put this graph together, it'll come out in January, looking at how things build on each other for your lifelong risk for colorectal cancer. Someone who walks in with lower socioeconomic status, lower level of education, and difficult access to healthcare, tends to reside in lower neighborhoods, have lower paying jobs, live in areas where there's grocery store deserts, tend to have higher fat, higher caloric diets, might be more likely to use tobacco and alcohol and have low physical activity, and then that subsequently has biological consequences by altering the gut microbiome, generation of pro-carcinogenic byproducts, increased inflammation, ultimately leading to different types of semantic gene mutations that drive the colorectal cancer. So we believe these things are all related. Now how can you reduce that disparity? And this is a paper with Sonia Kupfer and Rotania Carr from Chicago and University of Pennsylvania, we wrote a few years ago, suggesting some strategies to reduce that disparity. We honed in a little more on increasing the screening age by any method by 50, because the more people screen, the more you're gonna catch it. Modifying the age of screening, which that has now been recommended by the Multi-Society Task Force, as well as patient navigation. And I'll show you a little data from that as well. So this regards patient navigation. This is a fantastic result from a paper published about six years ago from the Delaware Cancer Consortium, which is funded by the state of Delaware. And if you look at the African American colorectal cancer stage at diagnosis comparing 2001, before this study started, in 2009, when they got the results, you can see that by doing patient navigated screening, you've greatly increased the finding of cancers at the local and regional levels where they're curable compared to prior to navigation-based screening. If you look at the incidence in the lower left panel here, that by the time they concluded the study, the incidence of African Americans shown in the yellow line had reached the same incidence that whites had over time. And you can see the trend was down for all races. And if you look at the mortality, they had approached the same mortality from 31.27 on the top of the yellow line down to 18.35 on the bottom of the yellow line. This is comparable to 16.9 for 100,000 for whites and the general population. The good news is that all races benefit by this patient navigated screening, but it really benefited African Americans who were much lower screening. They went from 47.8% in 2001 to 73.5%, very comparable to whites, which also went from 58% to 74% screening in 2009. So this shows you that, at least on a screening standpoint, you can equate the incidence and mortality of colorectal cancer disease, and that might apply to other populations as well. In the United States, based on the National POP study data, we start screening colorectal cancer age 50, and based on, depending on if you have a positive family history and depending on the type of relatives you have, that is recommended to start age 40. There was no consideration of race up until the Multisociety Task Force published their recommendations in July of 2017, and what they said is that screening should begin at age 50 years in average persons, except in African Americans who limited evidence support screening at age 45, based on all the data I just showed you. So that was the first time ever race was considered in National Implemented Guidelines. This has not been taken up by the U.S. Preventive Service Task Force, which really drives insurability of the screening. As you know, in the past year, the American Cancer Society came out with a qualified recommendation to put everyone at age 45, and this is because of the number of increase of all cancers below the age 50. So when Sinwidauer published his data 25, 30 years ago, you know, 50 was the age. Now for all races, and particularly for Caucasian and Hispanic, the percentage of patients getting colorectal cancer under the age of 50 is now creeping toward 10%, almost similar to what you see in African Americans now. So let me just switch gears and talk about the physician disparity. So this is data that Luke John Day, myself, and Sandra Quisada published earlier this year, data taken from the AAMC. On the left is, in panel A, you'll see the percent of underrepresented minorities in medicine. This is Hispanics or Latino, African Americans, Alaskan Native Americans, et cetera. And that percent has dropped slowly over the last 7 or 8 years from 14% to 12.1% for those applying to GI and hepatology fellowships. So that's in upper panel A. In the lower panel are the fellows enrolled in programs across this country. And you know, I've heard people say, oh, there's more coming into GI. That is absolutely not true, because here's the data. This is the data taken directly from AAMC. So you're in this data point if you're a fellow, if you're an ACGME fellow. And you can see on the lower blue is the Caucasians. It's gone from 513 to 560 or something like that. I can't see the numbers. In the red is Asians. But at the very top, you see a green band. That's African Americans or blacks. And that number is somewhere around 60 or so. If you look at the purple, which is Hispanic and Latinos, that number has grown to about maybe 80. And at the very top, where you see at zero, that's American Indians, Alaskan Natives. And if you look at the six-year absolute trend, there's really no change for any of those races. On the right is the faculty, since the faculty typically come from the fellows. You'll see the blue line, which is Caucasians at the top, somewhere between 60 and 70%. The red line is Asian faculty in GI and hepatology. And then you see all the other races stacked at the bottom. That's all less than 5%. And so without the change in the fellows, which begots medical school, which begots undergrad, which begots high school, that pipeline is still extremely flat, hasn't changed at least in the last seven or eight years. And so we still have this leaky pipeline, as depicted in the bottom right figure. So what are issues regarding the lack of diversity? Underrepresented minorities are more likely to work in underserved areas. And so the lack of that, you see deserts for those types of physicians. They can help exchange cultural customs and values, which can help inpatient adhere to treatment. There's a number of studies showing this improves the patient experience. Underrepresented minorities bring a different point of view to the workplace for their creativity and promote cross-cultural competence. And underrepresented minorities are more likely to perform research that applies to health disparities. And I can tell you about my own situation, and I didn't think about health disparities until much later in my career. And certainly they can serve as mentors to perpetuate that type of study. So I'm at the University of Michigan, and there's a faculty member named Scott Page who's written a number of things about the diversity bonus. And he's published a book, and I'm not quoting his book, I have nothing related to his book. But his findings are interesting. He states, if people think alike, no matter how smart they are, they most likely will get stuck at the same local optimal solution. Finding new and better solutions, innovating, requires thinking differently. That's why diversity powers innovation. In another quote, diverse groups of problem solvers outperform the groups of the best individuals at solving complex problems. The reason, diverse groups got stuck less often than the smart individuals who tended to think very similarly. So diversity can really enhance your innovation wherever you are. And this is a little graphic I took out from a PNAS article, really on gender diversity in this particular case. But diversity in doesn't necessarily mean diversity or creativity out. There's a lot of things that have to go on in there, diversifying knowledge outcomes, utilizing true expertise, diversifying research methods, et cetera, where the outcome could be diversity, discovery, and innovation. And I think most organizations strive to do that. I know certainly my university and most universities do. I came across this one interesting paper that showcased this. This paper was published in Nature Communications just last year. They looked at over six million scientists with 10 million published papers in multiple fields. And they looked at paper citations within five years. And they looked at the element of diversity. And diversity they looked at was ethnicity, your discipline, your gender, your affiliation, and your academic age, meaning young assistant to full professor. But you know what had the strongest correlation with citations? Was your ethnicity. That had the strongest correlation. And the ethnic diversity of the team, particularly group diversity, consistently outperformed the non-diverse. And I told this to the Association of American Physicians, where there's a lot of physician conferences, that the diversity enhances your citations of your papers. And in these graphs here, they show the real versus random. If everything was randomized, everything would look the same. But in actuality, when they analyzed these papers, the diverse was always the top line, as shown up there, irrespective of the year of publication, irrespective of the number of authors on the paper, and irrespective of the number of collaborators per author. If you had a diverse team, you had more citations of your paper. And I didn't make this up. This is published in Nature Communications. So they looked at individual diversity, as well as group ethnic diversity, and group ethnic diversity. In other words, multiple views on your team trumped individual diversity. And that resulted in 11% impact gain for your papers, and almost a 50% impact gain for scientists on your citations. Impressive. Okay? So, this is the data out there from 10 million published papers. What are some barriers to that? You know, I hear all kinds of excuses. I can't get there because there's no one in the pipeline, da-da-da. Well, there's a lot of barriers. We come from a very diverse nation. We have a lot of different issues for people to get to the level that they are. This can include cost of living, starting a family, that could be different depending on your background, exposure to science at a young age, the retention of minority fact, I can show you data on that, but I don't have time for that, restricted research directions if you're learning something from someone, the ability to secure extramural funding, there's been a number of studies on that. And finding mentors, which there's a dearth of at the level of, particularly of associate or full professors. So how can you address this? Well, be a mentor and advisor to any underrepresented minority at any stage. This goes from high school all the way up. Be a role model. Okay? Invite underrepresented minority students to be exposed or experienced so they may get interested in that. Participate in programs. I know during my career, particularly at UCSD and some at Michigan, participating in some of these funded programs that guide students. Sometimes they get a little excited and you can further that excitement. Pay attention to people on your staff so they don't quit early. That happens a lot, too. And I say this at our faculty, be mindful and make a selection of committees, because some people can get overtaxed because they're the one representative on the entire faculty and then they get committed to death. So let me just close with taking points. An example, colorectal cancer, the disparity clearly exists. It's likely multifactorial, but prevention is definitely an equalizer. The Delaware Cancer Consortium showed that, and that can eliminate barriers to screening despite the higher incidence and mortality. And in the GI hepatology physician workforce, there is certainly a pipeline issue, but there is, if we can somehow fix that, and there's a lot of ways you could try to attempt to do that, and there's probably going to be some resources and funds and money in there, but there is, once you achieve that, there's a diversity bonus if diversity is achieved. And that will include diversity bonus not for innovation and thinking, but also with patients, cross-cultural competency, studying of research and disparities, and leading to higher impact scientific publications. So I'll stop there, and thank you. Thank you.

liver meeting

colorectal cancer specialist

racial disparities

gastrointestinal cancers

early screening

physician diversity