Removing Race-Corrected Pulmonary Function Tests May Alter Lung Cancer Care

Removing race correction in pulmonary function tests (PFTs) appeared to affect surgeons’ recommendations for treatment among African-American patients undergoing lung cancer surgery, a quality improvement study showed.

Of the surgeons who were randomized to a vignette with African-American race-corrected PFTs, 79.2% recommended lobectomy compared with 61.7% of those randomized to the other race or multiracial-corrected equation (P=0.02) and 52.8% of those randomized to the race-neutral equation (P=0.001), reported Sidra N. Bonner, MD, MPH, MSc, of the University of Michigan in Ann Arbor, and co-authors.

Furthermore, among the 91.8% of patients who had race-corrected PFTs, the percent predicted preoperative forced expiratory volume in 1 second (FEV₁) and postoperative FEV₁ would have decreased by 9.2% (P<0.001) and 7.6% (P<0.001), respectively, if race-neutral equations had been used, they noted in JAMA Surgery.

Surgeons randomized to the race-neutral PFT group were more likely to recommend wedge resection compared with those using African-American race-corrected PFTs (19.4% vs 5.6%, P=0.01).

FEV₁ from preoperative PFTs are commonly used to determine surgical risk and to recommend treatment, and are often race-corrected for African-American patients. “As a result, the race-corrected percent predicted FEV₁ is artificially higher than if a race-neutral (i.e., without race correction) predicted FEV₁ were used,” the authors noted.

In an invited commentary, Araiye Medlock, BA, and David T. Cooke, MD, both of the University of California Davis Health in Sacramento, pointed out that the use of this practice perpetuates centuries-old racism.

“Race correction of PFTs is rooted in the myth created by slaveholders Thomas Jefferson and Samuel Cartwright that enslaved Black people had a ‘deficiency’ of lung capacity, with the goal of justifying the practice of slavery,” they wrote. “The racist pseudoscience serves as the foundation and legitimation for race correction in current clinical practices, inevitably preserving this use of structural racism in healthcare.”

Bonner and colleagues noted that their findings indicated that the path to eliminating race-corrected PFTs, while crucial, will be challenging in practice.

“On one hand, this artificial inflation in percent predicted FEV₁ values may result in African American patients having lung function values that appear too good to receive diagnoses for chronic lung conditions,” they wrote. “On the other hand, removing race correction (decorrection) may more accurately reflect true lung function but will also lower the percent predicted FEV₁, which may lead surgeons to perceive African American individuals as having worse lung function and a higher risk from surgical treatment.”

Medlock and Cooke also encouraged providers to utilize multiple assessments to ensure accurate treatment for their patients.

“It will be imperative to holistically review patients using multiprong race-neutral assessments, such as the 6-minute walk test, ventilation/perfusion scans, cardiopulmonary exercise testing to calculate maximum oxygen consumption when able, and patient-reported outcomes measures,” they concluded. “This is how we move forward in a way that is best for our patients. All of them.”

For this study, data were taken from the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative General Thoracic Surgery database for African-American patients who underwent lung cancer surgery from January 2015 through September 2022.

A total of 16 hospitals and 515 African-American patients (mean age 66.2, 59.8% women) were included. Nearly 94% of the hospitals reported using race correction, which corresponded to 473 African-American patients having race-corrected PFTs.

The study randomized 225 surgeons (87.8% men) to complete the vignette items regarding risk perception and treatment outcomes (76% completion rate). They had spent a mean 19.4 years in practice with general thoracic surgery.

The most common operations performed included lobectomy (67.1%), followed by wedge resection (15.6%) and “other surgeries” (9.3%).

Although surgeons randomized to the African-American race-corrected equation recommended stereotactic body radiation therapy less commonly than those randomized to the other race or multiracial group and the race-neutral group (15.3% vs 24.7% and 27.8%), there was no significant difference among the groups.

Limitations to the study included low enrollment, exclusion of segmentectomy as a surgical option, exclusion of actual FEV₁ values in liters, and an inability to allow for surgeons to provide additional preoperative testing.