Embracing Genetic Diversity to Improve Black Health

Germline variation contributes to false negatives in CRISPR-based experiments with varying burden across ancestries

Reducing disparities is vital for equitable access to precision treatments in cancer. Socioenvironmental factors are a major driver of disparities, but differences in genetic variation likely also contribute. The impact of genetic ancestry on prioritization of cancer targets in drug discovery pipelines has not been systematically explored due to the absence of pre-clinical data at the appropriate scale. Here, we analyze data from 611 genome-scale CRISPR/Cas9 viability experiments in human cell line models to identify ancestry-associated genetic dependencies essential for cell survival. Surprisingly, we find that most putative associations between ancestry and dependency arise from artifacts related to germline variants. Our analysis suggests that for 1.2-2.5% of guides, germline variants in sgRNA targeting sequences reduce cutting by the CRISPR/Cas9 nuclease, disproportionately affecting cell models derived from individuals of recent African descent. We propose three approaches to mitigate this experimental bias, enabling the scientific community to address these disparities.

Managing differential performance of polygenic risk scores across groups: Real-world experience of the eMERGE Network

The differential performance of polygenic risk scores (PRSs) by group is one of the major ethical barriers to their clinical use. It is also one of the main practical challenges for any implementation effort. The social repercussions of how people are grouped in PRS research must be considered in communications with research participants, including return of results. Here, we outline the decisions faced and choices made by a large multi-site clinical implementation study returning PRSs to diverse participants in handling this issue of differential performance. Our approach to managing the complexities associated with the differential performance of PRSs serves as a case study that can help future implementers of PRSs to plot an anticipatory course in response to this issue.

Aspiring toward equitable benefits from genomic advances to individuals of ancestrally diverse backgrounds

Advancements in genomic technologies have shown remarkable promise for improving health trajectories. The Human Genome Project has catalyzed the integration of genomic tools into clinical practice, such as disease risk assessment, prenatal testing and reproductive genomics, cancer diagnostics and prognostication, and therapeutic decision making. Despite the promise of genomic technologies, their full potential remains untapped without including individuals of diverse ancestries and integrating social determinants of health (SDOHs). The NHGRI launched the 2020 Strategic Vision with ten bold predictions by 2030, including "individuals from ancestrally diverse backgrounds will benefit equitably from advances in human genomics." Meeting this goal requires a holistic approach that brings together genomic advancements with careful consideration to healthcare access as well as SDOHs to ensure that translation of genetics research is inclusive, affordable, and accessible and ultimately narrows rather than widens health disparities. With this prediction in mind, this review delves into the two paramount applications of genetic testing-reproductive genomics and precision oncology. When discussing these applications of genomic advancements, we evaluate current accessibility limitations, highlight challenges in achieving representativeness, and propose paths forward to realize the ultimate goal of their equitable applications.

[Taking origins into account in medical reasoning in infectious and tropical diseases? A critical look]

Healthcare discriminations based on one's ethnic background is increasingly being studied in medicine. The scale of the Covid-19 pandemic has played an important role in bringing them to light. Data, although scarce, exist in France. These discriminations have an impact on the care pathway and contribute to the renunciation of care by the most affected populations. The issue of discrimination is particularly relevant in infectious diseases. Although the epidemiology of infectious diseases is unevenly distributed worldwide, erroneous social representations are prevalent and expose to a harmful prejudice against migrants with regard to infectious diseases. The transmissible nature of some infectious diseases reinforces their stigmatizing potential. In this context, it seems important to discuss the dimension to be given to social determinants, geographical origin, phenotype, and ethnicity in teaching and medical reasoning. The English-speaking world uses the concept of "race" in a structural way, whereas this "international standard" has not been applied in France until now. To improve the care of people from minority groups, it seems important to better document and teach a more nuanced clinical reasoning based on origin, without neglecting the importance of collecting and taking into account social determinants of health and environmental factors.

2023 lifetime achievement award: "If you want to go fast, go alone; if you want to go far, go together"

This article is based on the address given by the author at the 2023 meeting of The American Society of Human Genetics (ASHG). A video of the original address can be found at the ASHG website.

Principles and methods for transferring polygenic risk scores across global populations

Polygenic risk scores (PRSs) summarize the genetic predisposition of a complex human trait or disease and may become a valuable tool for advancing precision medicine. However, PRSs that are developed in populations of predominantly European genetic ancestries can increase health disparities due to poor predictive performance in individuals of diverse and complex genetic ancestries. We describe genetic and modifiable risk factors that limit the transferability of PRSs across populations and review the strengths and weaknesses of existing PRS construction methods for diverse ancestries. Developing PRSs that benefit global populations in research and clinical settings provides an opportunity for innovation and is essential for health equity.

Advancing Diversity in Behavior Genetics: Strategies for Incorporating Undergraduates into Student-Driven Research

Undergraduate research experiences are crucial for fostering the next generation of behavior genetics researchers. However, incorporating undergraduates into research can be challenging for faculty mentors. In this article, we provide strategies for successfully integrating undergraduates into behavior genetics research based on our experiences mentoring undergraduates in our lab. These strategies include: (1) Practicing reflexivity, specifically an ongoing self-examination and critical self-awareness of personal biases, beliefs, and practices; (2) Implementing an Inclusion, Diversity, Equity, and Access (IDEA) centered approach; (3) empowering students through clear expectations; (4) Providing focused training and mentorship; (5) Aligning research projects with student interests; (6) Assigning meaningful tasks; and (7) Facilitating professional development opportunities. By following these strategies, faculty mentors can cultivate a supportive and inclusive research environment that empowers undergraduates for successful careers in behavior genetics research.

Race, Ethnicity, and Ancestry in Clinical Pathways: A Framework for Evaluation

Clinical algorithms, or "pathways," promote the delivery of medical care that is consistent and equitable. Race, ethnicity, and/or ancestry terms are sometimes included in these types of guidelines, but it is unclear if this is appropriate for clinical decision-making. At our institution, we developed and applied a structured framework to determine whether race, ethnicity, or ancestry terms identified in our clinical pathways library should be retained, modified, or removed. First, we reviewed all text and associated reference documents for 132 institutionally-developed clinical pathways and identified 8 pathways that included race, ethnicity, or ancestry terms. Five pathways had clear evidence or a change in institutional policy that supported removal of the term. Multispecialty teams conducted additional in-depth evaluation of the 3 remaining pathways (Acute Viral Illness, Hyperbilirubinemia, and Weight Management) by applying the framework. In total, based on these reviews, race, ethnicity, or ancestry terms were removed (n = 6) or modified (n = 2) in all 8 pathways. Application of the framework established several recommended practices, including: (1) define race, ethnicity, and ancestry rigorously; (2) assess the most likely mechanisms underlying epidemiologic associations; (3) consider whether inclusion of the term is likely to mitigate or exacerbate existing inequities; and (4) exercise caution when applying population-level data to individual patient encounters. This process and framework may be useful to other institutional programs and national organizations in evaluating the inclusion of race, ethnicity, and ancestry in clinical guidelines.

Host genetic variation at a locus near CHD1L impacts HIV sequence diversity in a South African population

IMPORTANCE

It has been previously shown that genetic variants near CHD1L on chromosome 1 are associated with reduced HIV VL in African populations. However, the impact of these variants on viral diversity and how they restrict viral replication are unknown. We report on a regional association analysis in a South African population and show evidence of selective pressure by variants near CHD1L on HIV RT and gag. Our findings provide further insight into how genetic variability at this locus contributes to host control of HIV in a South African population.

Population Pharmacogenomics for Health Equity

Health equity means the opportunity for all people and populations to attain optimal health, and it requires intentional efforts to promote fairness in patient treatments and outcomes. Pharmacogenomic variants are genetic differences associated with how patients respond to medications, and their presence can inform treatment decisions. In this perspective, we contend that the study of pharmacogenomic variation within and between human populations-population pharmacogenomics-can and should be leveraged in support of health equity. The key observation in support of this contention is that racial and ethnic groups exhibit pronounced differences in the frequencies of numerous pharmacogenomic variants, with direct implications for clinical practice. The use of race and ethnicity to stratify pharmacogenomic risk provides a means to avoid potential harm caused by biases introduced when treatment regimens do not consider genetic differences between population groups, particularly when majority group genetic profiles are assumed to hold for minority groups. We focus on the mitigation of adverse drug reactions as an area where population pharmacogenomics can have a direct and immediate impact on public health.

Rate of Pathogenic Germline Variants in Patients With Lung Cancer

PURPOSE

Germline genetic testing (GGT) is now recommended for all patients diagnosed with ovarian or pancreatic cancer and for a large proportion of patients based solely on a diagnosis of colorectal or breast cancer. However, GGT is not yet recommended for all patients diagnosed with lung cancer (LC), primarily because of a lack of evidence that supports a significant frequency of identifying pathogenic germline variants (PGVs) in these patients. This study characterizes GGT results in a cohort of patients with LC.

METHODS

We reviewed deidentified data for 7,788 patients with GGT (2015-2022). PGV frequencies were compared to a control cohort of unaffected individuals. GGT results were stratified by genomic ancestry, history of cancer, and PGV clinical actionability per current guidelines.

RESULTS

Of all patients with LC, 14.9% (1,161/7,788) had PGVs. The rate was similar when restricted to patients with no cancer family history (FH) or personal history (PH) of other cancers (14.3%). PGVs were significantly enriched in BRCA2, ATM, CHEK2, BRCA1, and mismatch repair genes compared with controls. Patients of European (EUR) genomic ancestry had the highest PGV rate (18%) and variants of uncertain significance were significantly higher in patients of non-EUR genomic ancestry. Of the PGVs identified, 61.3% were in DNA damage repair (DDR) genes and 95% were clinically actionable.

CONCLUSION

This retrospective study shows a LC diagnosis identifies patients with a significant likelihood of having a cancer-predisposing PGV across genomic ancestries. Enrichment of PGVs in DDR genes suggests that these PGVs may contribute to LC cancer predisposition. The frequency of PGVs among patients with LC did not differ significantly according to FH or PH of other cancers.

Algorithmic fairness in artificial intelligence for medicine and healthcare

In healthcare, the development and deployment of insufficiently fair systems of artificial intelligence (AI) can undermine the delivery of equitable care. Assessments of AI models stratified across subpopulations have revealed inequalities in how patients are diagnosed, treated and billed. In this Perspective, we outline fairness in machine learning through the lens of healthcare, and discuss how algorithmic biases (in data acquisition, genetic variation and intra-observer labelling variability, in particular) arise in clinical workflows and the resulting healthcare disparities. We also review emerging technology for mitigating biases via disentanglement, federated learning and model explainability, and their role in the development of AI-based software as a medical device.

Accuracy of the New Creatinine-based Equations for Estimating Glomerular Filtration Rate in Koreans

Background

New creatinine-based estimated glomerular filtration rate (eGFR) equations, including the 2021 Chronic Kidney Disease Epidemiology Collaboration (2021 CKD-EPI) and European Kidney Function Consortium (EKFC) equations, have been introduced recently. We assessed the performance of the 2021 CKD-EPI and EKFC equations in the Korean population.

Methods

We analyzed 1,654 Korean patients aged ≥18 years who underwent chromium-51-ethylenediamine tetraacetic acid GFR measurements (mGFR). Bias (eGFR-mGFR), root mean square error (RMSE), and proportion of eGFR within 30% of mGFR (P30) of the 2009 CKD-EPI, 2021 CKD-EPI, and EFKC equations were compared. The concordance rate between eGFR and mGFR categories was evaluated. Both eGFR and mGFR categories were classified into six groups: ≥90, 89-60, 59-45, 44-30, 29-15, and <15 mL/min/1.73 m².

Results

The median bias (mL/min/1.73 m²) was 1.8 for the 2009 CKD-EPI equation, 4.8 for the 2021 CKD-EPI equation, and -0.3 for the EKFC equation. The P30 and RMSE were 78.2% and 17.0 for the 2009 CKD-EPI equation, 75.6% and 17.4 for the 2021 CKD-EPI equation, and 80.0% and 16.7 for the EKFC equation, respectively. The overall GFR category concordance rate between eGFR and mGFR was 63.4% for the 2009 CKD-EPI equation, 60.5% for the 2021 CKD-EPI equation, and 61.0% for the EKFC equation.

Conclusions

Among the three eGFR equations, the EKFC equation had the smallest bias and highest P30 in Koreans. The 2009 CKD-EPI equation had a lower bias than the 2021 CKD-EPI equation.

Primary care physician use of patient race and polygenic risk scores in medical decision-making

PURPOSE

The use of patient race in medicine is controversial for its potential either to exacerbate or address health disparities. Polygenic risk scores (PRSs) have emerged as a tool for risk stratification models used in preventive medicine. We examined whether PRS results affect primary care physician (PCP) medical decision-making and whether that effect varies by patient race.

METHODS

Using an online survey with a randomized experimental design among PCPs in a national database, we ascertained decision-making around atherosclerotic cardiovascular disease prevention and prostate cancer screening for case scenario patients who were clinically identical except for randomized reported race.

RESULTS

Across 369 PCPs (email open rate = 10.8%, partial completion rate = 93.7%), recommendations varied with PRS results in expected directions (low-risk results, no available PRS results, and high-risk results). Still, physicians randomized to scenarios with Black patients were more likely to recommend statin therapy than those randomized to scenarios with White patients (odds ratio = 1.74, 95% CI = 1.16-2.59, P = .007) despite otherwise identical clinical profiles and independent of PRS results. Similarly, physicians were more likely to recommend prostate cancer screening for Black patients than for White patients (odds ratio = 1.58, 95% CI = 1.06-2.35, P = .025) despite otherwise identical clinical and genetic profiles.

CONCLUSION

Despite advances in precision risk stratification, physicians will likely continue to use patient race implicitly or explicitly in medical decision-making.

Association of Joint Genetic and Social Environmental Risks With Incident Myocardial Infarction: Results From the Health and Retirement Study

Background Myocardial infarction (MI) is a significant clinical and public health problem worldwide. However, little research has assessed the interplay between genetic susceptibility and social environment in the development of MI. Methods and Results Data were from the HRS (Health and Retirement Study). The polygenic risk score and polysocial score for MI were classified as low, intermediate, and high. Using Cox regression models, we assessed the race-specific association of polygenic score and polysocial score with MI and examined the association between polysocial score and MI in each polygenic risk score category. We also examined the joint effect of genetic (low, intermediate, and high) and social environmental risks (low/intermediate, high) on MI. A total of 612 Black and 4795 White adults aged ≥65 years initially free of MI were included. We found a risk gradient of MI across the polygenic risk score and polysocial score among White participants; no significant risk gradient across the polygenic risk score was found among Black participants. A disadvantaged social environment was associated with a higher risk of incident MI among older White adults with intermediate and high genetic risk but not those with low genetic risk. We revealed the joint effect of genetics and social environment in the development of MI among White participants. Conclusions Living in a favorable social environment is particularly important for people with intermediate and high genetic risk for MI. It is critical to developing tailored interventions to improve social environment for disease prevention, especially among adults with a relatively high genetic risk.

A Review of the Evolving Landscape of Inclusive Research and Improved Clinical Trial Access

Current clinical research does not reflect the diversity of patient populations, despite continued recommendations to increase enrollment of under-represented racial and ethnic groups. The ramifications of this lack of trial diversity are important because of potential differences between races and ethnicities in response to therapies, which have been observed for drugs across indications. Nonrepresentative research populations limit the generalizability of study results, which may lead to questions about safety and efficacy in certain subgroups of patients and hinder regulators, healthcare providers, and patients in their ability to adequately consider the benefits and risks of a therapeutic treatment across all populations. Renewed efforts to address healthcare disparities and increase diversity in clinical trials have demonstrated that inclusive trials are achievable and can provide scientifically rigorous results, and, thus, should stimulate greater action across all stakeholders. Ensuring that studies throughout the clinical development process include representative populations is a scientific imperative to advance health equity, racial justice, and trust in the safety and efficacy of medical therapies. This article reviews the long-standing lack of diversity and barriers to enrollment of diverse and representative populations in clinical trials, outlines the current evolving trial landscape and the efforts of stakeholders, and provides examples from scientifically rigorous inclusive trials. The goal is to share learnings in a wider context of opportunities to enhance diversity, equity, and inclusion in clinical development while ensuring the safety and efficacy of medical therapies in all populations of patients, and in doing so, provide wider patient access to therapeutic treatments.

A systematic review and meta-analysis of germline BRCA mutations in pancreatic cancer patients identifies global and racial disparities in access to genetic testing

BACKGROUND

Germline BRCA1 and BRCA2 mutations (gBRCAm) can inform pancreatic cancer (PC) risk and treatment but most of the available information is derived from white patients. The ethnic and geographic variability of gBRCAm prevalence and of germline BRCA (gBRCA) testing uptake in PC globally is largely unknown.

MATERIALS AND METHODS

We carried out a systematic review and prevalence meta-analysis of gBRCA testing and gBRCAm prevalence in PC patients stratified by ethnicity. The main outcome was the distribution of gBRCA testing uptake across diverse populations worldwide. Secondary outcomes included: geographic distribution of gBRCA testing uptake, temporal analysis of gBRCA testing uptake in ethnic groups, and pooled proportion of gBRCAm stratified by ethnicity. The study is listed under PROSPERO registration number #CRD42022311769.

RESULTS

A total of 51 studies with 16 621 patients were included. Twelve of the studies (23.5%) enrolled white patients only, 10 Asians only (19.6%), and 29 (56.9%) included mixed populations. The pooled prevalence of white, Asian, African American, and Hispanic patients tested per study was 88.7%, 34.8%, 3.6%, and 5.2%, respectively. The majority of included studies were from high-income countries (HICs) (64; 91.2%). Temporal analysis showed a significant increase only in white and Asians patients tested from 2000 to present (P < 0.001). The pooled prevalence of gBRCAm was: 3.3% in white, 1.7% in Asian, and negligible (<0.3%) in African American and Hispanic patients.

CONCLUSIONS

Data on gBRCA testing and gBRCAm in PC derive mostly from white patients and from HICs. This limits the interpretation of gBRCAm for treating PC across diverse populations and implies substantial global and racial disparities in access to BRCA testing in PC.

Ancestry: How researchers use it and what they mean by it

Background: Ancestry is often viewed as a more objective and less objectionable population descriptor than race or ethnicity. Perhaps reflecting this, usage of the term "ancestry" is rapidly growing in genetics research, with ancestry groups referenced in many situations. The appropriate usage of population descriptors in genetics research is an ongoing source of debate. Sound normative guidance should rest on an empirical understanding of current usage; in the case of ancestry, questions about how researchers use the concept, and what they mean by it, remain unanswered. Methods: Systematic literature analysis of 205 articles at least tangentially related to human health from diverse disciplines that use the concept of ancestry, and semi-structured interviews with 44 lead authors of some of those articles. Results: Ancestry is relied on to structure research questions and key methodological approaches. Yet researchers struggle to define it, and/or offer diverse definitions. For some ancestry is a genetic concept, but for many-including geneticists-ancestry is only tangentially related to genetics. For some interviewees, ancestry is explicitly equated to ethnicity; for others it is explicitly distanced from it. Ancestry is operationalized using multiple data types (including genetic variation and self-reported identities), though for a large fraction of articles (26%) it is impossible to tell which data types were used. Across the literature and interviews there is no consistent understanding of how ancestry relates to genetic concepts (including genetic ancestry and population structure), nor how these genetic concepts relate to each other. Beyond this conceptual confusion, practices related to summarizing patterns of genetic variation often rest on uninterrogated conventions. Continental labels are by far the most common type of label applied to ancestry groups. We observed many instances of slippage between reference to ancestry groups and racial groups. Conclusion: Ancestry is in practice a highly ambiguous concept, and far from an objective counterpart to race or ethnicity. It is not uniquely a "biological" construct, and it does not represent a "safe haven" for researchers seeking to avoid evoking race or ethnicity in their work. Distinguishing genetic ancestry from ancestry more broadly will be a necessary part of providing conceptual clarity.

Improvement in Hypertension Control Among Adults Seen in Federally Qualified Health Center Clinics in the Stroke Belt: Implementing a Program with a Dashboard and Process Metrics

Objective

Attain 75% hypertension (HTN) control and improve racial equity in control with the American Medical Association Measure accurately, Act rapidly, Partner with patients blood pressure (AMA MAP BP™) quality improvement program, including a monthly dashboard and practice facilitation.

Methods

Eight federally qualified health center clinics from the HopeHealth network in South Carolina participated. Clinic staff received monthly practice facilitation guided by a dashboard with process metrics (measure [repeat BP when initial systolic ≥140 or diastolic ≥90 mmHg; Act [number antihypertensive medication classes prescribed at standard dose or greater to adults with uncontrolled BP]; Partner [follow-up within 30 days of uncontrolled BP; systolic BP fall after medication added]) and outcome metric (BP <140/<90). Electronic health record data were obtained on adults ≥18 years at baseline and monthly during MAP BP. Patients with diagnosed HTN, ≥1 encounter at baseline, and ≥2 encounters during 6 months of MAP BP were included in this evaluation.

Results

Among 45,498 adults with encounters during the 1-year baseline, 20,963 (46.1%) had diagnosed HTN; 12,370 (59%) met the inclusion criteria (67% black, 29% white; mean (standard deviation) age 59.5 (12.8) years; 16.3% uninsured. HTN control improved (63.6% vs. 75.1%, p<0.0001), reflecting positive changes in Measure, Act, and Partner metrics (all p<0.001), although control remained lower in non-Hispanic black than in non-Hispanic white adults (73.8% vs. 78.4%, p<0.001).

Conclusions

With MAP BP, the HTN control goal was attained among adults eligible for analysis. Ongoing efforts aim to improve program access and racial equity in control.

Cardiologists' Perspectives on BiDil and the Use of Race in Drug Prescribing

OBJECTIVES

We explored cardiologists' attitudes and prescribing patterns specific to the use of generic isosorbide dinitrate and hydralazine hydrochloride, and the fixed-dose patented drug, BiDil.

BACKGROUND

Since the Food and Drug Administration approved BiDil in 2005 with an indication for self-identified black patients, disagreement about the appropriateness of race-based drugs has intensified and led to calls for providers and researchers to abandon race-based delimitations. This paper reports empirical evidence of cardiologists' views on BiDil's race-based indication and their ongoing inertia with respect to the debate about BiDil.

METHODS

We conducted a 2010 cross-sectional online survey of members of the Association of Black Cardiologists.

RESULTS

Fifty-nine cardiologists responded to the survey. Most participants (62.7%) prescribed BiDil to their patients. More than 40% of respondents did not prescribe BiDil to any non-African Americans. When considering whether to prescribe BiDil, a patient's race determined by physician assessment was the third most important factor considered by participants. The majority of participants (72.7%) selected symptoms as the most important factor. Most participants (59.2%) perceived race as defining biologically distinct individuals. Respondents prescribed BiDil more often to African American patients than non-African American patients. However, they prescribed the generic components that makeup BiDil to African Americans and non-African American patients similarly.

CONCLUSIONS

The survey provides useful findings that, when viewed within the context of ongoing debates about race-based medicine, show little progress toward appropriately utilizing BiDil to maximize health outcomes, yet, might inform the development of practical and effective guidelines concerning the use of race in medicine.

A scoping review of guidelines for the use of race, ethnicity, and ancestry reveals widespread consensus but also points of ongoing disagreement

The use of population descriptors such as race, ethnicity, and ancestry in science, medicine, and public health has a long, complicated, and at times dark history, particularly for genetics, given the field's perceived importance for understanding between-group differences. The historical and potential harms that come with irresponsible use of these categories suggests a clear need for definitive guidance about when and how they can be used appropriately. However, while many prior authors have provided such guidance, no established consensus exists, and the extant literature has not been examined for implied consensus and sources of disagreement. Here, we present the results of a scoping review of published normative recommendations regarding the use of population categories, particularly in genetics research. Following PRISMA guidelines, we extracted recommendations from n = 121 articles matching inclusion criteria. Articles were published consistently throughout the time period examined and in a broad range of journals, demonstrating an ongoing and interdisciplinary perceived need for guidance. Examined recommendations fall under one of eight themes identified during analysis. Seven are characterized by broad agreement across articles; one, "appropriate definitions of population categories and contexts for use," revealed substantial fundamental disagreement among articles. Additionally, while many articles focus on the inappropriate use of race, none fundamentally problematize ancestry. This work can be a resource to researchers looking for normative guidance on the use of population descriptors and can orient authors of future guidelines to this complex field, thereby contributing to the development of more effective future guidelines for genetics research.

North American genetic counselors' approach to collecting and using ancestry in clinical practice

Current guidelines from the National Society of Genetic Counselors (NSGC) recommend that patients' ancestry be obtained when taking a family history. However, no study has explored how consistently genetic counselors obtain or utilize this information. The goals of this study included assessing how genetic counselors collect their patients' ancestry, what factors influence this decision, and how they view the utility of this information. Genetic counselors working in a direct patient care setting in the US or Canada were recruited to participate in an anonymous survey via an NSGC email blast. Most participants (n = 115) obtain information about their patients' ancestry (96.5%), with the most common methods being directly asking the patient (91%) and utilizing intake forms (43.2%). Of participants who ask about ancestry directly, 50.5% always ask about the presence of Ashkenazi Jewish ancestry and 70.3% always ask about additional ancestries, suggesting that for most genetic counselors' collection of ancestry is standard practice. However, the clinical utility of ancestry information is highly variable, with the impact on genetic testing choice being particularly low. A slight majority of participants support a reevaluation of current ancestry guidelines (51.3%), with many participants suggesting that the varying utility of ancestry in different clinical indications/specialties should be incorporated into guidelines. Despite being standard practice for most genetic counselors, no unified approach or standard for how ancestral information should be used in genetic counseling practice was identified.

Recommendations for Using Causal Diagrams to Study Racial Health Disparities

There have been calls for race to be denounced as a biological variable and for a greater focus on racism, instead of solely race, when studying racial health disparities in the United States. These calls are grounded in extensive scholarship and the rationale that race is not a biological variable, but instead socially constructed, and that structural/institutional racism is a root cause of race-related health disparities. However, there remains a lack of clear guidance for how best to incorporate these assertions about race and racism into tools, such as causal diagrams, that are commonly used by epidemiologists to study population health. We provide clear recommendations for using causal diagrams to study racial health disparities that were informed by these calls. These recommendations consider a health disparity to be a difference in a health outcome that is related to social, environmental, or economic disadvantage. We present simplified causal diagrams to illustrate how to implement our recommendations. These diagrams can be modified based on the health outcome and hypotheses, or for other group-based differences in health also rooted in disadvantage (e.g., gender). Implementing our recommendations may lead to the publication of more rigorous and informative studies of racial health disparities.

Race-based medicine in the point-of-care clinical resource UpToDate: A systematic content analysis

BACKGROUND

Race-based practices in medical education and clinical care may exacerbate health inequities. Misguided use of race in popular point-of-care clinical decision-making tools like UpToDate® may promote harmful practices of race-based medicine. This article investigates the nature of mentions of Black/African American race in UpToDate®.

METHODS

We conducted a systematic content analysis of UpToDate® articles mentioning Black or African American race to assess for biological interpretations of racial categories. Following a simple text search for the terms "Black" and "African American" in UpToDate® on January 24 and March 19, 2020, respectively, removal of duplicates yielded an analytical sample of 208 documents. We adopted a deductive coding approach and systematically applied 16 a priori codes to all documents, refining the codebook to achieve a final inter-rater reliability of 0.91. We then developed these codes into two themes: (1) biologization of race and (2) racialized research and practice.

FINDINGS

Biologization of race occurred nearly universally across all documents (93.3%), with discussions of inherent physiological differences between racial groups and presentation of epidemiologic disparities without context emerging most frequently. Sixty-eight documents (32.7%) included codes related to racialized biomedical research and clinical practice, including references to racialized patterns of behavior and cultural practices, insufficient data on Black populations, research limiting study to a specific racial group, and race-based clinical practices guidelines.

INTERPRETATION

Our findings suggest that UpToDate® articles often inappropriately link Black race to genetics or clinical phenotype-without considering socio-structural variables or the health effects of structural racism-thus perpetuating a false narrative that race is inherently biological. UpToDate® articles may also promote unequal treatment by recommending race-based clinical practices. Such racial essentialism risks exacerbating racialized health inequities.

FUNDING

The study is supported by the Health Policy Research Scholars Program, Robert Wood Johnson Foundation, Medical Scientist Training Program, National Institutes of Health, the National Science Foundation, the JPB Foundation, the Minnesota Population, the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD), and the Center for Antiracism Research for Health Equity at the University of Minnesota.

Enrollment of Individuals From Racial and Ethnic Minority Groups in Gynecologic Cancer Precision Oncology Trials

OBJECTIVE

To characterize whether enrollment patterns in precision oncology clinical trials for gynecologic cancers reflect the racial and ethnic diversity of patients with gynecologic cancers in the United States.

METHODS

ClinicalTrials.gov was queried to perform this cross-sectional review. We included precision oncology trials -defined as trials using molecular profiling of a tumor or the patient genome to identify targetable alterations to guide treatment-of ovarian, uterine, cervical, and vulvar cancers in the United States. National Cancer Institute Surveillance, Epidemiology, and End Results and United States Census Bureau data were used to estimate cancer burden and the expected number of trial participants by race and ethnicity for each gynecologic cancer. The ratio of actual-to-expected participants was calculated. A ratio greater than 1 signified overenrollment. A random effects meta-analysis was performed to assess the relative weights of individual trials.

RESULTS

We identified 493 trials, 61 of which met inclusion criteria. There were 2,573 patients enrolled in ovarian cancer trials, 1,197 in uterine cancer trials and 162 in cervical cancer trials. Non-Hispanic White women were overrepresented overall (enrollment ratio 1.26, 95% CI 1.20-1.32) and across all cancer types on subgroup analysis. Asian women, non-Hispanic Black women, and Hispanic women were underrepresented overall (enrollment ratios 0.63, 95% CI 0.41-0.86; 0.51, 95% CI 0.36-0.66 and 0.30, 95% CI 0.23-0.36, respectively). In subgroup analyses, Asian women and non-Hispanic Black women were underrepresented in ovarian and uterine cancer trials and Hispanic women were underrepresented across all cancer types.

CONCLUSION

Non-Hispanic Black women, Asian women, and Hispanic women with gynecologic cancers are underrepresented in precision oncology trials. Few U.S.-based precision oncology trials exist for uterine and cervical cancers, which have a high burden of morbidity and mortality among racial and ethnic minority groups. Failure to equitably enroll patients who belong to racial and ethnic minority groups may perpetuate existing disparities in gynecologic cancer outcomes.

Effects of genetic ancestry and socioeconomic deprivation on ethnic differences in serum creatinine

The inclusion of ethnicity in equations for estimating the glomerular filtration rate (eGFR) from serum creatinine levels has been challenged since ethnicity is socially defined and therefore a poor proxy for biological differences. We hypothesized that genetic ancestry (GA) would be more strongly associated with creatinine levels among healthy individuals than self-identified ethnicity. We studied a diverse cohort of 35,590 participants characterized as part of the UK Biobank, grouped by self-reported ethnicity: Black, East Asian, Mixed, Other, South Asian, and White. We used multivariable modeling to test for associations between ethnicity, GA, socioeconomic deprivation, and serum creatinine levels, including covariates for age, sex, height, and body mass index. Model fit comparisons and relative importance analysis were used to compare the effects of ethnicity and GA on creatinine levels. Black ethnicity shows a positive effect on participant serum creatinine levels (β = 9.36 ± 0.38), whereas East Asian (β = -1.80 ± 0.66) and South Asian (β = -0.28 ± 0.36) ethnicity show negative effects on creatinine. Male sex (β = 17.69 ± 0.34) and height (β = 0.13 ± 0.02) also show high positive associations with creatinine levels, while socioeconomic deprivation (β = -0.04 ± 0.04) shows no significant association. African ancestry has the highest association (β = 13.81 ± 0.52) with creatinine levels. Overall, GA (9.06%) explains significantly more of the variation in creatinine levels than ethnicity (4.96%), with African ancestry (6.36%) alone explaining more of the variation than ethnicity. We found that GA explains more of the variation in serum creatinine levels than socioeconomic deprivation, suggesting the possibility that ethnic differences in creatinine are shaped by genetic rather than social factors.

Evaluation of race and ethnicity disparities in outcome studies of CYP2C19 genotype-guided antiplatelet therapy

Dual antiplatelet therapy with a P2Y₁₂ inhibitor (clopidogrel, prasugrel, or ticagrelor) and aspirin remains the standard of care for all patients undergoing percutaneous coronary intervention (PCI). It is well-established that patients carrying CYP2C19 no function alleles have impaired capacity to convert clopidogrel into its active metabolite and thus, are at higher risk of major adverse cardiovascular events (MACE). The metabolism and clinical effectiveness of prasugrel and ticagrelor are not affected by CYP2C19 genotype, and accumulating evidence from multiple randomized and observational studies demonstrates that CYP2C19 genotype-guided antiplatelet therapy following PCI improves clinical outcomes. However, most antiplatelet pharmacogenomic outcome studies to date have lacked racial and ethnic diversity. In this review, we will (1) summarize current guideline recommendations and clinical outcome evidence related to CYP2C19 genotype-guided antiplatelet therapy, (2) evaluate the presence of potential racial and ethnic disparities in the major outcome studies supporting current genotype-guided antiplatelet therapy recommendations, and (3) identify remaining knowledge gaps and future research directions necessary to advance implementation of this precision medicine strategy for dual antiplatelet therapy in diverse, real-world clinical settings.

Race and prostate cancer: genomic landscape

In the past 20 years, new insights into the genomic pathogenesis of prostate cancer have been provided. Large-scale integrative genomics approaches enabled researchers to characterize the genetic and epigenetic landscape of prostate cancer and to define different molecular subclasses based on the combination of genetic alterations, gene expression patterns and methylation profiles. Several molecular drivers of prostate cancer have been identified, some of which are different in men of different races. However, the extent to which genomics can explain racial disparities in prostate cancer outcomes is unclear. Future collaborative genomic studies overcoming the underrepresentation of non-white patients and other minority populations are essential.

Effect Modification by Social Determinants of Pharmacogenetic Medication Interactions on 90-Day Hospital Readmissions within an Integrated U.S. Healthcare System

The present study builds on our prior work that demonstrated an association between pharmacogenetic interactions and 90-day readmission. In a substantially larger, more diverse study population of 19,999 adults tracked from 2010 through 2020 who underwent testing with a 13-gene pharmacogenetic panel, we included additional covariates to evaluate aggregate contribution of social determinants and medical comorbidity with the presence of identified gene-x-drug interactions to moderate 90-day hospital readmission (primary outcome). Univariate logistic regression analyses demonstrated that strongest associations with 90 day hospital readmissions were the number of medications prescribed within 30 days of a first hospital admission that had Clinical Pharmacogenomics Implementation Consortium (CPIC) guidance (CPIC medications) (5+ CPIC medications, odds ratio (OR) = 7.66, 95% confidence interval 5.45−10.77) (p < 0.0001), major comorbidities (5+ comorbidities, OR 3.36, 2.61−4.32) (p < 0.0001), age (65 + years, OR = 2.35, 1.77−3.12) (p < 0.0001), unemployment (OR = 2.19, 1.88−2.64) (p < 0.0001), Black/African-American race (OR 2.12, 1.47−3.07) (p < 0.0001), median household income (OR = 1.63, 1.03−2.58) (p = 0.035), male gender (OR = 1.47, 1.21−1.80) (p = 0.0001), and one or more gene-x-drug interaction (defined as a prescribed CPIC medication for a patient with a corresponding actionable pharmacogenetic variant) (OR = 1.41, 1.18−1.70). Health insurance was not associated with risk of 90-day readmission. Race, income, employment status, and gene-x-drug interactions were robust in a multivariable logistic regression model. The odds of 90-day readmission for patients with one or more identified gene-x-drug interactions after adjustment for these covariates was attenuated by 10% (OR = 1.31, 1.08−1.59) (p = 0.006). Although the interaction between race and gene-x-drug interactions was not statistically significant, White patients were more likely to have a gene-x-drug interaction (35.2%) than Black/African-American patients (25.9%) who were not readmitted (p < 0.0001). These results highlight the major contribution of social determinants and medical complexity to risk for hospital readmission, and that these determinants may modify the effect of gene-x-drug interactions on rehospitalization risk.

Developmental behavioral genetics research on school achievement is missing vulnerable children, to our detriment

Gene-environment processes tell us how genetic predispositions and environments work together to influence children in schools. One type of gene-environment process that has been extensively studied using behavioral genetics methods is a gene-by-environment interaction. A gene-by-environment interaction shows us when the effect of your context on a phenotype differs depending on your genetic predispositions, or vice versa, when the effect of your genetic predispositions on a phenotype differs depending on your context. Developmental behavioral geneticists interested in children's school achievement have examined many different contexts within the gene-by-environment interaction model, including contexts measured from within children's home and school environments. However, this work has been overwhelmingly focused on WEIRD samples children, leaving us with non-inclusive scientific evidence. This can lead to detrimental outcomes when we overgeneralize this non-inclusive scientific evidence to racialized groups. We conclude with a call to include racialized children in more research samples.

Genetics in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Numerous genes for monogenic kidney diseases with classical patterns of inheritance, as well as genes for complex kidney diseases that manifest in combination with environmental factors, have been discovered. Genetic findings are increasingly used to inform clinical management of nephropathies, and have led to improved diagnostics, disease surveillance, choice of therapy, and family counseling. All of these steps rely on accurate interpretation of genetic data, which can be outpaced by current rates of data collection. In March of 2021, Kidney Diseases: Improving Global Outcomes (KDIGO) held a Controversies Conference on "Genetics in Chronic Kidney Disease (CKD)" to review the current state of understanding of monogenic and complex (polygenic) kidney diseases, processes for applying genetic findings in clinical medicine, and use of genomics for defining and stratifying CKD. Given the important contribution of genetic variants to CKD, practitioners with CKD patients are advised to "think genetic," which specifically involves obtaining a family history, collecting detailed information on age of CKD onset, performing clinical examination for extrarenal symptoms, and considering genetic testing. To improve the use of genetics in nephrology, meeting participants advised developing an advanced training or subspecialty track for nephrologists, crafting guidelines for testing and treatment, and educating patients, students, and practitioners. Key areas of future research, including clinical interpretation of genome variation, electronic phenotyping, global representation, kidney-specific molecular data, polygenic scores, translational epidemiology, and open data resources, were also identified.

Immune mechanisms behind prostate cancer in men of African ancestry: A review

BACKGROUND

Men of African ancestry (AA) with prostate cancer suffer from worse outcomes. However, a recent analysis of patients treated with the dendritic cell vaccine sipuleucel-T for prostate cancer suggested that AA patients could have improved outcomes relative to whites.

METHODS

We conducted a focused literature review of Medline-indexed articles and clinical trials listed on clinicaltrials.gov.

RESULTS

We identify several studies pointing to enrichment of inflammatory cellular infiltrates and cytokine signaling among AA patients with prostate cancer. We outline potential genomic and transcriptomic alterations that may contribute to immunogenicity. Last, we investigate differences in host immunity and vaccine responsiveness that may be enhanced in AA patients.

CONCLUSIONS

AA patients with prostate cancer may be enriched for an immunogenic phenotype. Dedicated studies are needed to better understand the immune mechanisms that contribute to existing cancer disparities and test immune-based therapies in this population.

Genomic supremacy: the harm of conflating genetic ancestry and race

BACKGROUND

Recent studies have reignited the tinderbox of debate surrounding the use of race and ancestry in medicine. These controversial studies have argued for a strong correlation between genetic ancestry and race, justifying continued use of genetic ancestry measures in studies of disease. These studies contend that increased use of continental ancestry estimates can inform clinical risk assessments and management. Further, recent studies of racial corrections used in clinical algorithms, such as those used to estimate 'normal' lung function, also advocate for use of genetic ancestry in place of race for refining risk algorithms.

MAIN BODY

These positions are misleading, harmful, and reflect superficial interpretations of population genetics. In this Perspective, we argue that continental genetic ancestry, often proxied by race, serves as a poor indicator of disease risk, and reinforces racialized inequities.

CONCLUSION

Instead, we endorse that racial disparities in disease should be investigated by rigorous measures of structural racism alongside careful measures of genetic factors in relevant disease pathways, rather than relying on genetic ancestry or race as a crude proxy for disease-causing alleles.

Ethnic Diversity and Warfarin Pharmacogenomics

Warfarin has remained the most commonly prescribed vitamin K oral anticoagulant worldwide since its approval in 1954. Dosing challenges including having a narrow therapeutic window and a wide interpatient variability in dosing requirements have contributed to making it the most studied drug in terms of genotype-phenotype relationships. However, most of these studies have been conducted in Whites or Asians which means the current pharmacogenomics evidence-base does not reflect ethnic diversity. Due to differences in minor allele frequencies of key genetic variants, studies conducted in Whites/Asians may not be applicable to underrepresented populations such as Blacks, Hispanics/Latinos, American Indians/Alaska Natives and Native Hawaiians/other Pacific Islanders. This may exacerbate health inequalities when Whites/Asians have better anticoagulation profiles due to the existence of validated pharmacogenomic dosing algorithms which fail to perform similarly in the underrepresented populations. To examine the extent to which individual races/ethnicities are represented in the existing body of pharmacogenomic evidence, we review evidence pertaining to published pharmacogenomic dosing algorithms, including clinical utility studies, cost-effectiveness studies and clinical implementation guidelines that have been published in the warfarin field.

Getting genetic ancestry right for science and society

We must embrace a multidimensional, continuous view of ancestry and move away from continental ancestry categories.

Pharmacogenomics and clinical cultural competency: pathway to overcome the limitations of race

Global migration trends are accelerating population admixture. Increasing population diversity met with minority health disparities necessitates thoughtful training of health professional students. Health professional accreditation standards emphasize pharmacogenomics and clinical cultural competency (CCC); however, published studies focus on students’ knowledge in pharmacogenomics alone. This report reviews considerations for integrating CCC into required pharmacogenomic education in pharmacy and other health disciplines. By coupling both topics during didactic training and active learning exercises repeated throughout the existing curriculum, students can become adept at these individualized patient care skills and retain their knowledge into their careers. Moving beyond race as a proxy for healthcare decision-making, the CCC of clinicians coupled with patients’ genetic test results could empower clinicians to address health disparities and facilitate discussions about the role of race in clinical practice. Ultimately, an integrated approach of teaching pharmacogenomics and CCC could dismantle race-norming or race-based clinical practices.

Systemic lupus erythematosus as a genetic disease

Systemic lupus erythematosus is the prototypical systemic autoimmune disease, as it is characterized both by protean multi-organ system manifestations and by the uniform presence of pathogenic autoantibodies directed against components of the nucleus. Prior to the modern genetic era, the diverse clinical manifestations of SLE suggested to many that SLE patients were unlikely to share a common genetic risk basis. However, modern genetic studies have revealed that SLE usually arises when an environmental exposure occurs in an individual with a collection of genetic risk variants passing a liability threshold. Here, we summarize the current state of the field aimed at: (1) understanding the genetic architecture of this complex disease, (2) synthesizing how this genetic risk architecture impacts cellular and molecular disease pathophysiology, (3) providing illustrative examples that highlight the rich complexity of the pathobiology of this prototypical autoimmune disease and (4) communicating this complex etiopathogenesis to patients.

Differences in Prostate Cancer Genomes by Self-reported Race: Contributions of Genetic Ancestry, Modifiable Cancer Risk Factors, and Clinical Factors

PURPOSE

Black men die from prostate cancer twice as often as White men, a disparity likely due to inherited genetics, modifiable cancer risk factors, and healthcare access. It is incompletely understood how and why tumor genomes differ by self-reported race and genetic ancestry.

EXPERIMENTAL DESIGN

Among 2,069 men with prostate cancer (1,841 self-reported White, 63 Asian, 165 Black) with access to clinical-grade sequencing at the same cancer center, prevalence of tumor and germline alterations was assessed in cancer driver genes reported to have different alteration prevalence by race.

RESULTS

Clinical characteristics such as prostate-specific antigen and age at diagnosis as well as cancer stage at sample procurement differed by self-reported race. However, most genomic differences persisted when adjusting for clinical characteristics. Tumors from Black men harbored fewer PTEN mutations and more AR alterations than those from White men. Tumors from Asian men had more FOXA1 mutations and more ZFHX3 alterations than White men. Despite fewer TP53 mutations, tumors from Black men had more aneuploidy, particularly chromosome arm 8q gains, an adverse prognostic factor. Genetic ancestry was associated with similar tumor alterations as self-reported race, but also with modifiable cancer risk factors. Community-level average income was associated with chr8q gains after adjusting for race and ancestry.

CONCLUSIONS

Tumor genomics differed by race even after accounting for clinical characteristics. Equalizing access to care may not fully eliminate such differences. Therapies for alterations more common in racial minorities are needed. Tumor genomic differences should not be assumed to be entirely due to germline genetics.

From Genotype to Phenotype: Polygenic Prediction of Complex Human Traits

Decoding the genome confers the capability to predict characteristics of the organism (phenotype) from DNA (genotype). We describe the present status and future prospects of genomic prediction of complex traits in humans. Some highly heritable complex phenotypes such as height and other quantitative traits can already be predicted with reasonable accuracy from DNA alone. For many diseases, including important common conditions such as coronary artery disease, breast cancer, type I and II diabetes, individuals with outlier polygenic scores (e.g., top few percent) have been shown to have 5 or even 10 times higher risk than average. Several psychiatric conditions such as schizophrenia and autism also fall into this category. We discuss related topics such as the genetic architecture of complex traits, sibling validation of polygenic scores, and applications to adult health, in vitro fertilization (embryo selection), and genetic engineering.

Self-Reported Antihypertensive Medication Class and Temporal Relationship to Treatment Guidelines

The greater antihypertensive responses to initial therapy with calcium channel blockers (CCBs) or thiazide-type diuretics than renin-angiotensin system blockers as initial therapy in non-Hispanic Black (NHB) adults was recognized in the US High BP guidelines from 1988 to 2003. The 2014 Report from Panel Members Appointed to the Eighth Joint National Committee (2014 aJNC8 Report) and the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline were the first to recommend CCBs or thiazide-type diuretics rather than renin-angiotensin system blockers as initial therapy in NHB. We assessed the temporal relationship of these recommendations on self-reported CCB or thiazide-type diuretics monotherapy by NHB and NHW adults with hypertension absent compelling indications for β-blockers or renin-angiotensin system blockers in National Health and Nutrition Examination Surveys 2015 to 2018 versus 2007 to 2012 (after versus before 2014 aJNC8 Report). CCB or thiazide-type diuretics monotherapy was unchanged in NHW adults (17.1% versus 18.1%, P=0.711) and insignificantly higher after 2014 among NHB adults (43.7% versus 38.2%, P=0.204), although CCB monotherapy increased (29.5% versus 21.0%, P=0.021) and renin-angiotensin system blocker monotherapy fell (44.5% versus 31.0%, P=0.008). Although evidence-based CCB monotherapy increased among NHB adults in 2015 to 2018, hypertension control declined as untreated hypertension and monotherapy increased. While a gap between recommended and actual monotherapy persists, evidence-based monotherapy appears insufficient to improve hypertension control in NHB adults, especially given evidence for worsening therapeutic inertia. Initiating treatment with single-pill combinations and timely therapeutic intensification when required to control hypertension are evidence-based, race-neutral options for improving hypertension control among NHB adults.

Racial and Ethnic Disparities Among Participants in Precision Oncology Clinical Studies

IMPORTANCE

Precision oncology is revolutionizing cancer care, allowing for personalized treatments to improve outcomes. Cancer research has benefitted from well-designed studies incorporating precision medicine objectives, but it is unclear if these studies are representative of the diverse cancer population.

OBJECTIVE

To evaluate racial and ethnic representation in breast, prostate, lung, and colorectal cancer studies incorporating precision oncology objectives in the Clinicaltrials.gov registry and compare with the incidence of these cancer types in racial and ethnic minority groups in the US population.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study identified US-based breast, prostate, lung, and colorectal cancer studies incorporating precision oncology objectives for reporting of race and ethnicity. The Surveillance, Epidemiology, and End Results and US Census databases were used to determine cancer incidence by race and ethnicity, linked with cancer type and median year of enrollment for each trial. Data were collected and analyzed between December 2020 and April 2021.

MAIN OUTCOMES AND MEASURES

The expected number of participants per study by each racial and ethnic group was calculated based on the corresponding US-based proportion. Under- and overrepresentation was defined as the ratio of the actual number of enrolled cases to the expected number of cases for each trial by cancer type. Ratios above 1 indicated overrepresentation while a ratio below 1 indicated underrepresentation. Random-effects meta-analysis of representation ratios of individual trials was performed to weigh each individual study.

RESULTS

Of 93 studies encompassing 5867 enrollees with race and ethnicity data; 4826 participants (82.3%) were non-Hispanic White, 587 (10.0%) were Black, and 238 (4.1%) were Asian. Per observed-to-expected ratios, White participants were overrepresented in all studies, with a ratio of 1.35 (95% CI, 1.30-1.37), as well as Asian participants, with a ratio of 1.46 (95% CI, 1.28-1.66), while Black participants (ratio, 0.49; 95% CI, 0.45-0.54), Hispanic participants (ratio, 0.24; 95% CI, 0.20-0.28), and American Indian and Alaskan Native participants (ratio, 0.43; 95% CI, 0.24-0.78) were underrepresented. By individual cancer site, White participants were consistently overrepresented in all studies, while Black and Hispanic participants were underrepresented.

CONCLUSIONS AND RELEVANCE

This analysis found that precision oncology studies for breast, lung, prostate, and colorectal cancers vastly underrepresent racial and ethnic minority populations relative to their cancer incidence in the US population. It is imperative to increase diversity among enrollees so that all individuals may benefit from cancer research breakthroughs and personalized treatments.

The limits of personalization in precision medicine: Polygenic risk scores and racial categorization in a precision breast cancer screening trial

Population-based genomic screening is at the forefront of a new approach to disease prevention. Yet the lack of diversity in genome wide association studies and ongoing debates about the appropriate use of racial and ethnic categories in genomics raise key questions about the translation of genomic knowledge into clinical practice. This article reports on an ethnographic study of a large pragmatic clinical trial of breast cancer screening called WISDOM (Women Informed to Screen Depending On Measures of Risk). Our ethnography illuminates the challenges of using race or ethnicity as a risk factor in the implementation of precision breast cancer risk assessment. Our analysis provides critical insights into how categories of race, ethnicity and ancestry are being deployed in the production of genomic knowledge and medical practice, and key challenges in the development and implementation of novel Polygenic Risk Scores in the research and clinical applications of this emerging science. Specifically, we show how the conflation of social and biological categories of difference can influence risk prediction for individuals who exist at the boundaries of these categories, affecting the perceptions and practices of scientists, clinicians, and research participants themselves. Our research highlights the potential harms of practicing genomic medicine using under-theorized and ambiguous categories of race, ethnicity, and ancestry, particularly in an adaptive, pragmatic trial where research findings are applied in the clinic as they emerge. We contribute to the expanding literature on categories of difference in post-genomic science by closely examining the implementation of a large breast cancer screening study that aims to personalize breast cancer risk using both common and rare genomic markers.