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What:

Are marginalized groups slipping through the cracks when it comes to lung cancer prevention? Pulmonologists looked into this question and will present their conclusions and recommendations in a live-stream Q&A direct from the annual meeting of the American Thoracic Society.

There is rising concern that the use of race/ethnicity in Pulmonary Function Test (PFT) interpretation contributes to a false view of fixed differences between races and may mask the effects of differential exposures. This use of race/ethnicity may contribute to health disparities by norming differences in pulmonary function. The ATS convened a diverse group of clinicians and investigators for a workshop in 2021 to evaluate the use of race/ethnicity in PFT interpretation. The outcome of most research will be presented, leading to recommendations for PFT interpretation.

Who:

• Dr. Kevin Wilson, MD - Pulmonary/Critical Care Physician and Professor of Medicine at Boston University Medical Center
• Dr. Nirav Bhakta, MD, Ph.D. - Director of Education and Associate Director in the Adult Pulmonary Function Laboratory at the University of California, San Francisco
• Dr. Katrina Steiling, MD, MSc - Assistant Professor of Medicine at Boston University

When: 

May 22, 2023, at 11:15 AM EDT

Where:

News Live event space on Zoom -

Thom Canalichio: Hello and welcome everyone to this Â鶹´«Ã½ live expert panel. We're joining live from the annual meeting of the American Thoracic Society. Today's discussion is about lung cancer screenings for marginalized groups and the need for more priority in research, clinical interventions, and recognizing these disparities. I'd like to introduce our panelists. Dr. Kevin Wilson, he's MD, pulmonary critical care physician, and professor of medicine at Boston University Medical Center. We also have Dr. Nirav Bhakta, MD, PhD, Director of Education, and Associate Director in the adult pulmonary function laboratory at the University of California, San Francisco, and Dr. Katrina Steiling, MD, MSc, Assistant Professor of Medicine at Boston University. Dr. Steiling, if you could start for us by giving us an overview of the problem here with lung nodules and how much it is to potentially miss the early signs of lung cancer and especially in these marginalized groups.

Dr. Katrina Steiling: Yes, thank you. Lung nodules are an incredibly common finding on CT scans of the chest. About one in 20 people that have a lung nodule will ultimately be diagnosed with lung cancer. And this is important because lung cancer remains the leading cause of death in the United States and worldwide. And so this means that early and timely management of these lung nodules is one of the keys to detecting lung cancer at an early stage when it's curable. The problem is that certain patient groups experienced delays in their care related to pulmonary nodules. This includes people that are plaque, patients with lower income, patients with substance use disorders, and individuals with lower levels of income. There are knowledge gaps related to the interventions that would be most optimal to addressing these disparities among nodule management. Our committee focused on setting research priorities in order to address those knowledge gaps. It's our hope that this work can help set a national research agenda for prioritizing high quality, high tech research, for identifying the optimal strategies for addressing disparities in lung nodule management.

Thom Canalichio: Dr. Bhakta, could you tell us what was the reasoning for these race-based adjustments when they’re originally created and what has been the result of using them?

Dr. Nirav Bhakta: The reason extends that far into United States history in particular, and at that time, they reflected views that these racial ethnic categories reflected in the beautiful characteristics of people. Along the line many decades later, it was thought that this was the right thing to do, that it was better than all of us. Even sitting here at this table, we’re trained in that way and to operate that way without question. On the backdrop of increasing attention on health equity, its concern is that such an approach would have different standards for different groups of people could lead to inequitable outcomes. And with the challenges of race and concerns of racism in our society, we wanted to take this opportunity to get together the expertise of many ATS members, and really use the platform of ATS to be able to critically examine this issue and to make a broad statement to the public to guide its next steps.

Thom Canalichio: Dr. Wilson, can you tell us why it's important for lung cancer specialists and pulmonologists, especially, to work on changing these policies that perpetuate the racial disparities?

Dr. Kevin Wilson: We have 17,000 members and we feel like we can really have an impact on systemic change that ultimately down the road benefits our patients. And so Dr. Steiling and Dr. Bhakta really taking on this project on behalf not only the ATS, but all of its members as well, in the name of science and in the name of public health and our patients.

Thom Canalichio: So Dr. Steiling, tell us what's the increased risk for these marginalized groups? How much worse are the outcomes likely to be if the screening procedures do not get improved?

Dr. Katrina Steiling: That's an excellent question. This is one of the areas that our committee identified as needing additional research studies. And so there's a limited number of studies examining disparities specifically related to lung nodules, who we know that there is extensive literature describing disparities in lung cancer care, in lung cancer survival and in lung cancer screening. So we think that similar differences also exist in the evaluation of pulmonary nodules, but more studies are needed to determine the extent of the disparities that exist.

Thom Canalichio: Dr. Bhakta, if race-based adjustments were created on a misunderstanding of the data in the first place, what would be more appropriate comparisons to judge normal ranges or pulmonary function and especially in these marginalized groups?

Dr. Nirav Bhakta: One thing that the evidence is pointing to right now is that when using the reference equation to judge whether somebody is normal, that using a single average reference equation, you ended up recommending the GLI Global, leads to an equal assessment of risk of a bad outcome in populations and an equal assessment of how impacted patients are with respiratory disease through respiratory symptoms and their ability to walk. And so about our recommendation is to use a single average.

Thom Canalichio: So what kind of new research is part of this effort? What new research can fill those knowledge gaps about these issues?

Dr. Nirav Bhakta: Yeah, I think going off with Dr. Steiling said, you're asking, there are many gaps that still remain. We don't know to what extent the race specific approach has contributed to disparities. There are already existing disparities in COPD care and outcomes, and in many other conditions, including lung nodules and management of lung cancer. And the use of pulmonary function is one part of a long chain of clinical decisions that can contribute to those disparities. And we encourage people and be aware of groups, including ATS members that are engaged in that research looking at datasets to examine what the impact is.

Thom Canalichio: Dr. Wilson, how does the diversity and representation in this research have an impact on solving these disparities? And why is that important to the organization?

Dr. Kevin Wilson: Both Dr. Steiling and Dr. Bhakta identified knowledge gaps that need to be filled. They looked at the evidence that's out there, they looked at what knowledge exists, and they identified the areas that need to be filled in order to care for it. And notice areas can only really be filled with research.

Thom Canalichio: Part of the research statement also addresses clinical interventions. Dr. Steiling or Dr. Bhakta have any comments about those clinical interventions and what's needed at that local level.

Dr. Katrina Steiling: So, from the perspective of disparities in lung nodule management, our committee focused on four key focus areas. We looked at gaps in knowledge and research methodology, in addition to looking at interventions that need to be investigated that act at the patient level, interventions that act clinician level, and research studies examining interventions that occur at this level of the health system.

Dr. Kevin Wilson: We think that it does take a multiple approach, including engagement of all the parties that are involved, going from manufacturers that make the primary function test equipment and software, and the extent to how feasible it is for individual laboratories to make these changes, how they report data, data goes into clinician facing and patient facing using electronic health record, and educational materials to help clinicians and laboratories not to talk to patients, not talk to their colleagues about why the change is recommended and what the impact is and what the knowledge of ATS is working on who said multiple manufacturers in making educational materials to help clinicians.

Thom Canalichio: Dr. Wilson, what should be the national agenda addressing these questions and how ATS in this research statement factor into that?

Dr. Kevin Wilson: So I think really the priority should be filling these knowledge gaps and ATS is actually sort of the ideal vehicle to do this for a couple of reasons. Dr. Steiling and Dr. Bhakta are up here because they were leads of their project but they were one of many that participate in these projects. So for example, Dr. Steiling’s research, all the gaps that need to be filled, that's an enormous undertaking. Research is not easy. It takes time. It takes a lot of people and ATS will allow her to interact with people who have similar interests and can get the research done and move towards similarly. Dr. Bhakta’s on leads are pulmonary function testing committee. So he's engaged on a day to day basis with people who share his interest and facilitates collaboration. And you really in this day and age, you can't do the research alone, you need collaborations to move forward and in a timely fashion. And so that's ATS role, I think. ATS sees itself as a Research Society and therefore facilitating the dissemination of research, the collaboration, and allowing the research to move forward to better life for patients is the ultimate goal.

Thom Canalichio: For any media on the call, if you have questions, please chat them to me, I'll ask the panel. I'd love to ask each of you to respond. This is a step in the right direction, it's clearly not a conclusion. It's not a done job. What do you see as next steps in that direction?

Dr. Katrina Steiling: Thank you. I think the next step for addressing disparities of lung nodule evaluation are carefully designing research studies that address these gaps in our knowledge related to research methodology and the specific interventions outlined in a menu script for interventions targeted at the patient level, at the clinician level, such as patient-clinician communication, and at the health systems level, such as the utility of interventions such as patient navigators and multidisciplinary teams.

Thom Canalichio: Dr. Wilson, anything you add about those next steps?

Dr. Kevin Wilson: I think Dr. Steiling is right. I think that the way forward is not a touchdown pass, it's a series of blocks and small runs. It's small, incremental steps that build and complement each other. And knowledge for some of the research endeavors will work, some will not and overall will generate an evidence-based that will benefit the society.

Dr. Nirav Bhakta: Yeah, we envision the recommendation, not as a final stop, but as you know, one step on the journey. And so we in the statement and continue to encourage work to fill the gaps, including new ways of interpreting pulmonary function tests that we asked about reference equations. And we are aware of people that, while they are, we’ll connect at ways of interpreting pulmonary function tests without reference equations. And we examine the ways that we use them to make clinical decisions.

Dr. Kevin Wilson: Just that some metrics are coming out just recently that suggests that these two documents have already been highly downloaded. And so the word is getting out there. So even people that maybe haven't been to the conference or haven't had the chance to interact with Dr. Steiling, Dr. Bhakta or see them talk, the word is spreading, the message is out there.

Thom Canalichio: Great. Thank you. I think that's all the questions we have today. I'd like to thank Dr. Kevin Wilson, Dr. Katrina Steiling, and Dr. Nirav Bhakta here at the American Thoracic Society 2023 annual meeting. With that, we’ll conclude. Thank you all very much and have a great day.