Charles Ryan: Hello, I'm Dr. Charles Ryan from the Prostate Cancer Foundation. Today I'm joined by three colleagues to discuss some recently published data that are demonstrating some concerning findings around several populations regarding prostate cancer. We are seeing for the first time a rise in the incidence of prostate cancer and a plateauing of the mortality. Of all of the populations that are affected, the most affected are Black men, and today that's going to be the focus of our conversation.

I'm happy to introduce my guests. To my left is Michael Milken, who is the founder and the chairman of the Board of the Prostate Cancer Foundation and a 30-year prostate cancer survivor. To Mike's left is Professor Isla Garraway. Professor Garraway is a urologist at the University of California Los Angeles. She is a Prostate Cancer Foundation awardee and an expert on the detection and treatment of prostate cancer. Joining us remotely is Dr. Kneeland Youngblood, who is a member of the Prostate Cancer Foundation Board of Directors. Thank you all for joining me today. We've got a really important set of topics to discuss. Mike, thank you for being with us. I'm going to start with you. The Prostate Cancer Foundation is now in its 30th year and has contributed to a number of great findings, I think, in the field around the treatment and detection of the disease. Tell us a little bit about the history of the PCF and its role in so many of these discoveries.

Michael Milken: When you consider that prostate cancer played such a large role in men's lives and so little research was going on at the time, the question was how do you jumpstart this effort? The goal of what was originally called CaP CURE, CA all cancer, P, prostate, Cure all life-threatening disease. Our mission was to increase funding for prostate cancer research tenfold, double funding for all medical research. We accomplished that over five years with the help of thousands, but also getting people talking about prostate cancer and finding solutions for prostate cancer that extended not only the length of life, but the quality of life.

Charles Ryan: As I think back on the arc of my own personal career, and I think about the role of Prostate Cancer Foundation in my own career development, I think of PCF as a place that was the convening place of the dialogue. It made prostate cancer a topic in every household and made it okay to talk about prostate cancer and made it a desirable career direction for researchers and doctors. I think Dr. Garraway and I are both examples of that, and that's really part of that rich 30-year legacy. I'm going to go to one of our awardees now and next to you and ask to comment on what we're seeing today in 2023 around some recent data. We do see some concerning factors emerge that we want to pay attention to.

Isla Garraway: Well, it's always a pleasure to be with you guys today. The data that we are focused on today was published recently, just last month in the European Urology Journal. This was a large study, contemporary study that looked at cancer registries that represent nearly 50% of American patients nationwide. What we saw from the data is that this group was able to break out populations of patients based on race, ethnicity, and look at the trends of incidence and also look at the trends in mortality from prostate cancer since approximately the year 2000.

A lot has happened in our prostate cancer world since 2000. Number one has been changes in recommendations for PSA screening. The PSA test, as you know, is that early detection blood tests that we use, because prostate cancer, if we wait for symptoms to happen, it's very, very late to be diagnosed, often times beyond the ability for us to cure. We rely on blood testing often times to detect that cancer early, and we've been successful in doing that, but what we have seen is unfortunately some changes in recommendations to who we should screen and how often we should do the PSA testing. As a result, now we're seeing alarming trends in the incidence. The incidence dropped when testing went away, but when testing started coming back, the incidence went up, but also the incidence of more advanced stage prostate cancer went up as well, so we kind of lost that window a little bit for early detection.

Michael Milken: By not screening and not identifying it earlier, all we're saying is we're going to discover it later. It's going to be more difficult. We've been well aware that there's a substantially higher incidence in the African American community and a much higher death rate, so we began to address that, as you know, at the Prostate Cancer Foundation, and a lot of this work fell on the shoulders of my young colleague over here at the VA here in Los Angeles. What we saw, and Richard Stone, who was running the VA centers throughout the country, told us the only place in America where the death rate for African American men had dropped to the level the general population was in the VA system. We have a plan, we have a strategy that we could deal with these issues, but not getting tested makes our job harder.

Charles Ryan: We're seeing the results of not getting tested now several years after the guidelines have changed. We're seeing the incidence of individuals with later stage prostate cancer being diagnosed. Isla, tell us a little bit about the VA program that you've led and what the findings are and how they can be seen as a sign of encouragement for the broader population.

Isla Garraway: Well, the VA is what's considered a relatively equal access institution, and it also serves a very diverse population. One of the factors that impacted and challenged the USPSTF, the organization that creates some of the guidelines that we follow is that a lot of the studies previously had not been done in populations that are well represented. As Mr. Milken just pointed out, African American population has such an increased risk of prostate cancer incidence across all stages and over twofold higher chance of death from prostate cancer. We can represent those populations in our studies. By doing studies in the VA population and having the longitudinal data to follow out in terms of outcomes, we can understand what the impact of screening is. Patients who are seen more frequently by their primary care and therefore have more access to screening have a lower rate of metastatic or advanced prostate cancer disease incidence. It is really an important population to take advantage of and really understand the benefits of screening so we can really affect the guidelines hopefully in a positive manner.

Charles Ryan: In a way, what you're saying is that if everybody had the same system of care, we would see a lot of these disparities narrow and some of them go away completely, which is another way of saying that the disparities are a product of the systems of care and the implementations.

Isla Garraway: Partially, but unfortunately access doesn't explain everything. In the VA, we still see the same higher incidence of prostate cancer across all stages, so there is more to it than just the access to care.

Charles Ryan: I'm going to turn to Dr. Youngblood now and ask his thoughts on this. Kneeland, thank you so much for joining us. I am very blessed at the Prostate Cancer Foundation to have a board of directors and a chairman of the board who are thoughtful and forward looking. As we begin to look forward and think about what it is that we can do as a foundation that can help the world correct this problem, what comes to mind for you?

Kneeland Youngblood: Fortunately, the PCF, Prostate Cancer Foundation, is taking a multi-pronged approach to this. First and foremost, we're in the business of research that is in terms of really trying to find the best treatments available and prospectively that are going to be available to not only treat the illness, but hopefully cure the illness. That's number one. Number two, it's also educating physicians and clinicians around the world about what are the optimal treatments relative to the stages of care. The other component of this is diagnostics. In one particular case, we have the award from Robert Smith where we are looking at a specific diagnostic test focused on Black men to identify those that are most at risk for the disease. Mike has been prolific in terms of promoting awareness and education through the Home Run Challenge, which in partnership with Major League Baseball. We also have an initiative now with the National Basketball Association and other entities, so it's creating awareness, it's creating education, and then convening a place where the best and brightest minds in the world can come to share their ideas and advance treatment for the illness.

Charles Ryan: You bring up a lot of really important points, and I want to dive a little bit deeper on this idea that you brought up of the polygenic risk score or other diagnostics. We talk about screening as if it's only a PSA test, but we can go beyond this. The polygenic risk score is something that looks across multiple genes to identify a higher score for an individual. It's science like that and research like that that the Prostate Cancer Foundation has been promoting and has been funding over the years.

The other key point that Dr. Youngblood raises is our notion of the Prostate Cancer Foundation as the public square of prostate cancer; where we convene people, we convene ideas, we educate, and we communicate, and we're in a particularly good position around this issue given our work with the VA, given your 30 years of hard work on this issue. Mike, to be the leaders in the dialogue moving forward on how we address these emerging and still existent, I should say, disparities. I'm proud to announce that the Prostate Cancer Foundation will be launching the first ever screening guidelines panel specifically directed for black men. This panel of experts will review the data, will integrate it, and will issue written guidelines that are specifically targeting screening, diagnosis and treatment for Black men around prostate cancer in the United States.

Michael Milken: Chuck, as you know, the goal at the beginning is how do we get men to be involved? We started this keep dad in the game theme by going to baseball parks throughout the country, and this will be our 27th year. By going on and reminding them to get tested and having baseball players, Hall of Famers, managers, announcers drive that home, this was for many people the first encouragement which they received to get tested.

Isla Garraway: One more thing I wanted to emphasize that Mr. Milken just pointed out is the PSA test has to be requested. It has to be something you ask your doctor for. It's not going to be automatically drawn. Because of the recommendations that require shared decision-making with the doctor, you have to in indicate your interest in being tested. I think that's another thing that maybe we don't all realize as men who are in the age range that need to be tested and as the wives and the daughters and the sisters who support them, is that it is something that you have to ask for and request. It's so important to make sure that you ask for that test and ask to be screened.

Charles Ryan: That's a great point. You have to ask for it, request it, and you have to be in a place that knows what to do with the result. I'm very optimistic that we at the PCF and we as a society are going to make progress, that we're going to slow this rate of rise of the incidence of late stage prostate cancer. We're going to continue to make great strides on reducing the mortality by helping people live longer and better after a diagnosis of prostate cancer, but hopefully we will lead to more cures and more people who can move on to a life after prostate cancer.

Michael Milken: I think also, Chuck, that the investment we've made throughout the country and trying to understand why African American men have a higher incidence and a higher death rate, and how much it's related to genetics, how much related to the microbiome, and those investments will not only help African American men, but as we better understand, will help all men throughout the world.

Charles Ryan: I want to thank you, all three of you, for joining us today as we embark on this next phase of our work for this important risk population. Again, Michael Milken, founder and chairman of the Board of the Prostate Cancer Foundation, thank you. Professor Isla Garraway from UCLA and the West LA VA, and Dr. Kneeland Youngblood joining us remotely. Thank you all for your thoughtful insights into these important data and the plans that we have at the Prostate Cancer Foundation for moving forward.