Transcript slides - Minority Health Project

12th Annual Summer Public Health Research
Videoconference on Minority Health
Minority Health Conference:
Genes, Race and Medicine
Pilar N. Ossorio
University of Wisconsin-Madison
Schools of Law and Medicine
Visiting: UC Berkeley Boalt Hall School of Law
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Individualized or Race-targeted
Medicine???
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The BiDil Story
July 20, 2004
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Popular Depictions of BiDil
Current News
Racial Pill Maker’s Sales Drop in Wider-thanexpected-loss
By Diverse and news wire reports
May 31, 2006, 23:58
“…
Despite low sales affecting stock market shares of
the drug’s maker, NitroMed Inc., racially tailored drugs
might be here to stay.”
“The launch of the 10-month-old drug BiDil has been
closely watched because it is expected to help usher
in an era of “personalized” medicine, in which
treatments are increasingly tailored to individuals’
genetic make-ups.”
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Current news continued…
“‘There are genetic differences between individuals…’
says Dr. Kenneth Edelin, associate dean of students and
minority affairs at Boston University’s School of
Medicine. “Asian doctors who treated Asian patients
noticed these differences and subsequently tailored
prescription to meet their needs.”’
“Edelin says the increased use of personalized
medicine is here to stay because of how one group of
people reacts to a drug in relation to another group.
“‘The truth is we are different … and drugs can be
individually tailored due to a specific problem based on
genetic instructions.’”
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Crestor
• 04/02/06 Astra Zenica news release
on Crestor
– Data presented at the annual meeting of the
National Hispanic Medical Association
showed that, in Hispanic patients, Crestor
reduced LDL-C more than atrovastatin at
similar doses
– Who is Hispanic? How could a doc use the info
presented?
– Does this mean that the drug works better in
Hispanics than in non-Hispanic people? If not, then
why the focus on Hispanics?
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Race- & Ethnicity-targeted
“Nutriceuticals”
GenSpec Formulates the World's First Genetically
Specific Vitamins and Weight Loss Supplements
PR Newswire
NEW YORK, Feb. 7 /PRNewswire/ -- GenSpec Labs, LLC.
has announced that it has formulated the world's first
genetically specific nutraceutical product line which
effectively addresses the unique metabolic needs of
African- Americans, Hispanics, and Caucasians…”
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GenSpec continued…
“While diet, exercise and regular medical
exams can have a positive effect on an
individual's overall health, these same
studies indicate that genetics play a
major role," says Vice President of
GenSpec, Dr. Dexter Russell…
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Common Mistakes
• Health differences between
racial, ethnic, national and other groups are
treated as though they MUST be caused by
genetic difference!!!
– A genetic cause is inferred not
demonstrated.
• Mistake correlation for causation
• E.g., story on “ethnic specific” vitamins, BiDil
– Ignore non-genetic factors that affect health
or treatment responses
– Ignore inter-individual differences, and all other
differences that do not correlate with
race/ethnicity
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Common Mistakes
• Treat all people of one racial, ethnic, national
or other group as though they are all the same with
respect to all important health determinants
– Differences (genetic, cultural and otherwise)
between individuals within groups are ignored
• Who are the Hispanics?
• Who are the Asians???
– Groups are treated as distinct and mutually
exclusive (genetically, culturally, etc)
• What about people who are black Hispanic?
• What about people who are black Asian?
• What about Chicanos of Ashkenazi Jewish descent?
– Conflates ancestry, culture, socio-political categories
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Differences Treated as Genetic
Observed difference between racial/ ethnic
groups
in treatment outcome, drug response,
disease course, side-effects, etc.
is due to different frequencies of some
causal allele among the different racial
or ethnic groups
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Biological ≠ Genetic
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Biology ≠ Genes
• Not all biological variation is caused primarily
by genetic variation
• Not all genetic variation results in phenotypic variation
– Mutations in non-coding and
non-control regions of DNA
– Mutations in genes that do not
change the encoded protein
• Do not assume causal relationship between genetic
variation and between-group differences!
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Sources of Biological Variation
• Between groups
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Different diets
Differential exposures to toxins
Differential access to health care
Differential exposure to physical risk
Differential access to power and control
over one’s life
– Differential exposure to racism and other
stressors
– Different allele frequencies (~5-15%
of variable loci)
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Between-Race Differences
• Not necessarily due to genetic differences!
• Group difference (racial or otherwise)
is a difference in mean response profile
or shape of the response profile (statistical,
not categorical)
• Lack of between-race differences may obscure
important genetic risks/differences within a
group
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Sources of Biological Variation
• Inter-individual variation
– Diet
– Age
– Gender
– Co-morbidities
– Concomitant medications
– Other exposures (toxins,
stressors, dangers)
– Genetics
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Dietary Effects on Pigmentation
R. Waterland & R. Jirtle,
Molecular & Cellular Biology,
23(15): 5293-5300 (2003)
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Mistakes (reminder)
• Treat people of one racial, ethnic, national
or other group as though they are all
fundamentally the same
– Differences (genetic, cultural and otherwise)
between individuals within groups are
ignored
• “Will Tomorrow’s Medicines Work for
Everybody?”
• Absolutely not; no medicine works for everybody!
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Inter-individual Difference
in Drug Response
Marked Interindividual Variability in Response
to Selective Inhibitors of Cyclooxygenase 2
Fries et al., Gastroenterology 130: 55-64 (2006)
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Why The Mistakes Occur…
• Mistakes consistent with “folk notions”
of race as
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•
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Fixed
Natural
Essential
Distinct and distinguishable groups
Categorically different/non-overlapping
Pervasively similar within group
• “We all know that…”
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Individualized Medicine ≠
Race-based Medicine
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Individualized medicine
• Do not treat statistical differences btwn
groups as categorical differences!
• Attend to the individual patient
to identify risk
• Family and personal medical history
• Talk about personal circumstancese
– Exposures, medicines and supplements taken,
beliefs and treatment goals, etc.
• When knowledge of the relevant allele matters for
a tx decision, do a genetic test if one is available!
• Ask about ancestry
• Genes are not all!
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