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Internal medicine physician Earl Stewart, Jr. discusses his article “Pancreatic cancer racial disparities.” Earl examines the devastating pattern of pancreatic cancer claiming Black cultural icons like John Lewis and Aretha Franklin while the medical establishment fails to implement race-specific screening guidelines. He highlights research showing that high-risk individuals undergoing surveillance have a 50 percent five-year survival rate compared to just 9 percent for those diagnosed through usual care. The discussion challenges the current medical inertia that demands perfect data before acting and proposes a three-tier risk-stratified approach to save lives in Black communities. Listen to understand why we must stop waiting for permission to prioritize health equity.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Earl Stewart, Jr. He is an internal medicine physician. Today’s KevinMD article is “Pancreatic cancer racial disparities.” Earl, welcome back to the show.

Earl Stewart, Jr.: Oh, Kevin, thanks for having me. Good to be with you.

Kevin Pho: All right, so tell us what this latest article is about and the events that led you to write it in the first place.

Earl Stewart, Jr.: This is an article that is more of a passion project than many of the articles I have penned before in the past, even for the KevinMD blog over the years. I am a practicing physician and I serve as medical director of health equity for my health system, which is the largest non-for-profit health system in the state of Georgia.

I have been keeping a running list of celebrities and individuals of fame in the African American community who have succumbed to pancreatic cancer. That is something I started about five to six years ago at the beginning of really transitioning jobs. I started to notice a trend of these really well-known, powerful public servants, musicians, and just people of remarkable stature in the African American community, and many of them were succumbing to pancreatic cancer.

I have also had some personal connections to this topic. As I mentioned in the article, I lost one of my mom’s baby brothers to pancreatic cancer on Christmas Eve in 2013. We also had cholangiocarcinoma in the family. I have had some educators in my life, school teachers from my high school, who also passed away from pancreatic cancer. I started to notice this trend of just these very well-known individuals and some not as well-known who are succumbing to this very treacherous cancer.

All cancers are treacherous. As we know, pancreatic cancer has a really high mortality risk, and the five-year survival rate based on data from the American Cancer Society is just over 13 percent. This article was sort of written to be a clarion call to the medical community, the clinical community, to really catch up with the data. We really need guidelines that are centered on that race-specific data regarding how we are seeing more African Americans succumb to the disease.

Kevin Pho: For some context, what are some of the numbers when it comes to the racial disparities of pancreatic cancer?

Earl Stewart, Jr.: African Americans are 50 to 90 percent more likely to die from pancreatic cancer in comparison to their white counterparts. We see every year, based on data from NIH and from the gastroenterology journals, that over 62,000 individuals were diagnosed in 2023. In 2025, the data is closer to 60,000 to 65,000 individuals being diagnosed with pancreatic cancer across different racial groups.

About 50,000, or 40,000 to 50,000, pass away every year from this cancer. You can see how the data compares for those being diagnosed versus those who actually succumb to the disease.

In terms of lifetime risk based on data also from the American Cancer Society, about one in 60 women will be diagnosed. In terms of gender-related data, about one in 56 men will be diagnosed. Men are almost twice as likely to be diagnosed with pancreatic cancer than women will be. It is certainly more common in men. There has been specific data about how to protect African American men and detect it early in African American men. As we know, almost all the time, as soon as we diagnose pancreatic cancer, it has already metastasized.

The purpose of the article, given my work in health equity, was really to call our attention to something that we need to do for the future of medicine to better take care of our patients who are at higher risk of this particular cancer.

Kevin Pho: I just want to echo what you said. By the time a patient presents with the symptoms of pancreatic cancer, it is already at a relatively late stage, unfortunately.

Earl Stewart, Jr.: Yes.

Kevin Pho: Now, you mentioned that disparity of the diagnosis of pancreatic cancer, especially in Black patients. What are some of the reasons you could speculate why that is?

Earl Stewart, Jr.: We do not really know, but there is really all conjecture and speculation. Maybe there is some genetic risk there. We do know if individuals have BRCA mutations, particularly BRCA2, if they have a family history of Lynch syndrome, which we know by its scientific name is hereditary nonpolyposis colorectal cancer.

We do know also maybe smoking trends, tobacco use such as smoking cigars or cigarettes, is an independent risk factor for the development of pancreatic cancer. Also new-onset type 2 diabetes after the age of 50, as well as a history of chronic pancreatitis, which for the most part is tied to alcoholism or heavy alcohol use.

Some of the data suggest that African Americans may have a higher preponderance of those risk factors and they would be more likely to develop pancreatic cancer as a result of that. But also we know BMI is a big component as well and can be considered itself an independent risk factor for the development of pancreatic cancer.

Kevin Pho: As you know, the U.S. Preventive Services Task Force gives pancreatic cancer screening a D rating, meaning that it does not recommend screening for pancreatic cancer. So what is your reaction to the guideline and what would you like to see done?

Earl Stewart, Jr.: As medicine becomes increasingly individualized, we take a more individualistic approach. There are some recommendations out there for individuals who have more genetic risk factors like BRCA and Lynch syndrome. We do know that those exist and there are some surveillance programs. We even have one here in Atlanta with the Piedmont Health System that I have started referring patients to in order to screen individuals who are higher risk and who need additional surveillance.

But I think the guidelines really miss where we are in terms of the data. We have the data. We know the data. Why aren’t the guidelines following it? I am not knocking our very reputable guideline-making bodies, but this is where the discrepancy exists between what we see clinically, what we see experientially, what we see even in our own families and our own communities. As a Black man, my family has been touched by pancreatic cancer disproportionately as well.

When are we going to catch up to what we are seeing in the community? It is not lung cancer, it is not breast cancer, it is not colon cancer. Those are certainly more prevalent and certainly more incident. But we do know it is the third most common cause of cancer-related death in the United States, and it still impacts people significantly.

As I mentioned in the article that you accepted in October, I think we really fall behind. There are so many different people who would benefit from early detection, additional surveillance, and research endeavors to help us get to the point where we can develop more specific guidelines that include the race-specific data. That is where we are. I think the current USPSTF guidelines sort of fall short.

Kevin Pho: So tell us about what you do in your own practice in terms of the patients that you select for screening, as well as the different tests that you would order for those who would have a higher than normal risk of pancreatic cancer.

Earl Stewart, Jr.: That is absolutely correct. We are very fortunate in our health system, the Wellstar Health System, and other large comprehensive health systems to have specialists, even academic medical centers. They have specialists who can do EUS, endoscopic ultrasound, which is one of the reputable safe ways of carrying out screening and early detection for this particular type of cancer. We can order abdominal MRIs.

I remember as a resident at Brown, we had some discussions on rounds once about a patient whose wife was just remarkably persistent. He had some symptoms. I believe he had painless jaundice, which is a common symptom of pancreatic cancer, particularly adenocarcinoma in the head of the pancreas. We got a CAT scan, and it didn’t show anything. We got some additional imaging with IV contrast, and it really didn’t show anything. But his wife was persistent about getting an abdominal MRI, and we got the abdominal MRI. Sure enough, it showed a very, very small head-of-pancreas mass, which turned out after biopsy to be pancreatic cancer.

He was diagnosed fortunately at stage I, which is where we want to diagnose people with this cancer. Since that time, those are two of the modalities that I find to be extremely important and useful for patients for whom this is apropos. Individuals with painless jaundice, individuals with acholic stools, individuals with abdominal pain, and individuals with these risk factors that we have already previously discussed are candidates.

Primary care internal medicine is a puzzle. When we put all these pieces together and many of these boxes are checked, it is important for us to act. It is important for us to not just say there is no national guideline for this from the American College of Gastroenterology and no national guideline for this from USPSTF. We treat the patients; we do not treat the guidelines.

The guidelines are helpful in situations where we need clinical decision-making help and expertise, but they are not the be-all and end-all, especially in situations like this where we do not have national guidelines to screen the majority of the population. As I say in the article, I am not calling for all Black people to get CT scans at a certain age. But we need to single out the fact that Black people, Black Americans, and African Americans are more likely just based on that race-specific data to be encumbered by this cancer than other racial groups and ethnicities. From that specific population, let’s talk about how we can single out those at highest risk with these risk factors. That is what we are calling for and that is what I look for in my practice.

Kevin Pho: From the perspective of the guideline makers, why has it taken them so long to make any changes when it comes to individualizing pancreatic cancer screening? I was just looking at the U.S. Preventive Services Task Force. It hasn’t been revisited since 2019. So what do you think some of their arguments are and how would you rebut those arguments?

Earl Stewart, Jr.: I think definitely around the argument of being race-specific. We have seen some of that happen and be operationalized as it pertains to prostate cancer. We have seen some of that being operationalized as it pertains to even colon cancer. Before USPSTF updated the guidelines to screen all adults a few years ago at 45 instead of 50, the ACG, the American College of Gastroenterology, really led the way in terms of starting African Americans at 45 who were average risk in comparison to other ethnic groups and their white counterparts.

I do think USPSTF has a long painstaking process, but I think what is going to really get them to that point is seeing other guideline-making bodies like major specialty societies in gastroenterology and oncology leading the way in terms of giving us a national guideline for this specific ethnicity or race of individuals. Then perhaps they will be able to follow along because the data are there.

I think we cannot ignore the fact that we are seeing time and time again that disparities exist. There was a large review article published in 2023 in *Gastroenterology* that I consulted for the purposes of writing the article. It pretty much called out these disparities that exist in pancreatic cancer screening, diagnosis, and early detection.

I just think USPSTF needs to follow suit. They need to look at updated data. They need to consult experts. They need to follow what we are seeing in clinical medicine. I know it is not always easy. It takes resources. This current geopolitical climate is really impacting our ability to be more individualized in terms of race-specific issues and ethnicity-specific issues. But we still have to go and grow in terms of practicing medicine and take care of our patients as best as we can.

Kevin Pho: How about patients who may be listening to you now? What kind of things in their history, what kind of symptoms should they have in order to perhaps ask their clinician whether they would be a candidate for pancreatic cancer screening?

Earl Stewart, Jr.: That is a great question. I do think most of these conversations take place in the confines of an annual physical or preventive visit. I would call on patients to know their family history. I would call on them to be reminded of the risk factors that we have already discussed earlier in today’s interchange. Do not be shy to approach these discussions with your primary care physician. Do not be shy in terms of discussing risk factors in family history even among yourselves and your own families and in your own communities.

Ask these questions: What is my risk of pancreatic cancer? Is there a way because I have a strong family history of pancreatic cancer that I can be tested for Lynch syndrome and genetic mutations associated with it? Or can I be tested with the BRCA? We order BRCA testing all the time in my office. A lot of times patients will come in and request it, especially if there is some family history of breast cancer in a first-degree relative. We always ask the question if we know if this is a hereditary type of breast cancer your mom had, or was this just acquired or due to environmental exposures?

That is where the conversation starts. I call for patient empowerment in these discussions as well because as physicians, we are going to always strive to do our best by our patients, but we need the input of patients in that patient-physician relationship. It is a 50/50 relationship, not 100/0. That is the way I have always looked at it. I love when patients are educated and empowered so it doesn’t hurt for them to come in with their list and ask these appropriate questions at the types of visits where it is necessary. These are the conversations that we are having at annual physicals. I know there has been a lot of vitriol written about whether or not the annual physical is still necessary, but we get a lot of good information from those visits. As a practicing physician, I still appreciate them.

Kevin Pho: We are on to Earl Stewart, internal medicine physician. Today’s KevinMD article is “Pancreatic cancer racial disparities.” Earl, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Earl Stewart, Jr.: Yes. Thank you, Kevin. Pancreatic cancer disproportionately impacts Black Americans. We need guideline-making bodies from the American College of Gastroenterology to the AGA, CDC, NIH, and the American College of Physicians, my own professional home, to lean strongly into the data that exists and really take a race-based approach to help stem this tide that we have been seeing for several years personally, clinically, professionally, and really throughout the African American populace here in the United States.

I call on patients to ask the question, to know their family history, to have these discussions, and to be empowered enough when they present to their physicians to have these discussions. I ask them to listen to today’s podcast and to know that there are those of us out there who are seeing these trends and we are paying attention to it. We are writing about it and we are speaking about it publicly.

We need to understand that these inequities still exist. Unfortunately, with what we see geopolitically, we have to take alternative approaches to getting the word out where so much has happened from a policy standpoint and in terms of stifling these conversations around race-specific health issues.

I do think it is important for us to tell the patient that we understand what they are going through. While there is no national guideline to screen for pancreatic cancer yet, we are calling on important bodies that make these decisions that help physicians help you to act. We have to do what we have to do and advocate. This is all about advocacy. The whole article is really about advocacy for the marginalized and the people who would benefit from these actions the most.

Kevin Pho: Earl, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Earl Stewart, Jr.: Good to be with you, Kevin. Thank you. Happy New Year.

Kevin Pho: Happy New Year.