Impact of Removing Race Correction in PFTs on Lung Cancer Surgery

Removal of race correction in pulmonary function tests (PFTs) is a priority of stakeholders to address inappropriate use of race within algorithms. To date, the concern with race-corrected PFTs has centered on how race-corrected PFT values underdiagnose Black patients with pulmonary conditions such as asthma or chronic obstructive pulmonary disease. However, little is known about the implication for Black patients who require surgical intervention for lung cancer.

Forced expiratory volume in 1 second (FEV₁) from preoperative PFTs is commonly used by surgeons to determine a patient’s surgical risk and provide treatment recommendations. For Black patients, the predicted FEV₁ is often adjusted for race, which can lead to an artificially elevated race-corrected percent predicted FEV₁ compared with using a race-neutral prediction technique.

According to Sidra N. Bonner, MD, PhD, and colleagues, understanding how race-corrected PFTs may impact surgical decision-making among Black patients undergoing surgery for lung cancer is critical. This led the researchers to conduct a study to identify how hospitals providing lung cancer surgery use race correction, examine the association between race correction and predicted lung function, and test the effect of de-correction on surgeons’ treatment recommendations. Findings were reported in JAMA Surgery [2023;158(10):1061-1068; doi:10.1001/jamasurg.2023.3239].

In this quality improvement study, the researchers used a multipronged approach. Initially, they established communication with hospitals participating in a statewide quality collaborative to determine the use of race corrections in PFTs. Then, for those hospitals applying race correction, percent predicted preoperative and postoperative FEV₁ was calculated for Black patients who underwent lung cancer resection between January 1, 2015, and September 31, 2022, using race-corrected and race-neutral equations.

Finally, US-based cardiothoracic surgeons were randomized 1:1:1 to receive one clinical vignette that differed only by percent predicted postoperative FEV₁ using Global Lung Function Initiative equations. Each one was tailored for (1) Black race (percent predicted postoperative FEV₁, 49%); (2) other race or multiracial (percent predicted postoperative FEV₁, 45%); and (3) race-neutral (percent predicted postoperative FEV₁, 42%). The hypothetical patient was a 71-year-old Black woman with a 3.6-cm mass confirmed to be adenocarcinoma with nodal involvement undergoing evaluation for a right upper lobectomy. The vignette included history of present illness, medical history, smoking history, vital signs, physical examination findings, percent predicted postoperative FEV₁, and diffusion capacity for carbon monoxide. It also included data on functional status, scan results (eg, chest computed tomography [CT] and CT-guided biopsy), and mediastinal staging.

Primary outcome measures included determining the number of hospitals using race correction in PFTs, evaluating changes in both the preoperative and postoperative FEV₁ estimation based on race-neutral or race-corrected equations, and evaluating surgeon treatment recommendations based on the clinical vignettes.

“To the best of our knowledge, there have been no empirical evaluations of the role race correction in PFTs plays in surgical decision-making. Our findings highlight the potential problems that may arise if race correction is removed from PFTs,” wrote the researchers.

The study included 515 Black patients (mean age, 66 years; 59.8% women). The researchers reported that 98.0% of the hospitals performed lung cancer resection for Black patients using race correction in preoperative PFTs, leading to 91.8% having race-corrected PFTs. Among these patients, if PFT values were switched from race corrected to race neutral, the predicted preoperative FEV₁ would decrease by 9.2% (P<.001) and by 7.6% (P<.001) for predicted postoperative FEV₁.

A total of 225 surgeons (87.8% men), with a mean time in practice of 11.3 years and general thoracic surgery representing a mean of 68.5% of their clinical practice, were randomized and completed the vignette items regarding risk perception and treatment outcomes (76.0% completion rate). Surgeons randomized to the vignette with Black race-corrected PFTs were more likely to recommend lobectomy (79.2%; 95% CI, 69.8-88.5) compared with surgeons randomized to the other race or multiracial-corrected (61.7%; 95% CI, 51.1-72.3; P=.02) or race-neutral (52.8%; 95% CI, 41.2-64.3; P=.001) PFTs.

“Our findings raise concern that if PFTs become race neutral, [Black] patients may be offered potentially curative lung cancer surgery less frequently if surgeons do not realize that lower predicted PFT values are a function of a change in equations and not a change in actual lung function. Surgical decision-making reflects a complex process for which PFTs help guide overall risk perception,” said the researchers.

Furthermore, the findings also have important implications given the American Thoracic Society’s recent guidelines to remove race correction from PFTs. For example, the results should not be used as a justification for the continuance of race correction in PFTs, given the false conflation of race with biology. However, the results underscore that removing race correction cannot happen in isolation and should take place alongside large-scale efforts to foster interventions to educate clinicians, improve shared decision-making with patients, and develop new preoperative diagnostic studies of lung function for lung cancer surgery.

The authors cited some limitation to the study, including that the overall recruitment rate for study participants was low, the vignettes did not allow for surgeons to ask for additional preoperative testing (eg, cardiopulmonary exercise testing), segmentectomy was excluded as a surgical option, and the actual FEV₁ value in liters was not included.

In conclusion, the researcher said, “Surgeons exposed to race-neutral PFT values were less likely to offer surgery than surgeons exposed to race-corrected PFTs. These results highlight the need to carefully consider the potential unintended consequences of removing race correction from PFTs to avoid exacerbating existing racial disparities in lung cancer surgery.”