Elimination of PFTs Might Worsen Disparities for African American Patients With Lung Cancer

Surgeons should be aware of changes in pulmonary function tests (PFT) because elimination of race correction PFTs might have an impact on surgeons’ treatment decisions and might worsen present disparities in the receival of lung cancer surgery among African American patients, according to JAMA Surgery.

Elimination of race correction in PFTs is a priority for the United States government, health care systems, and practitioners to tackle inappropriate use of race in clinical algorithms, since race correction inappropriately blends the social construct of race with biological differences and falsely presumes worse lung function in African American vs White individuals, the study authors noted. However, the impact of decorrecting PFTs for African American patients with lung cancer is not known.

X-ray of lungs

The researchers aimed to recognize how many hospitals providing lung cancer surgery use race correction, evaluate the link of race correction with predicted lung function, and test the influence of decorrection on surgeons’ treatment recommendations.

First, they undertook a quality improvement study where hospitals participating in a statewide quality collaborative were contacted to define use of race correction in PFTs. Percent predicted preoperative and postoperative forced expiratory volume in 1 second (FEV1) was calculated for African American patients who underwent lung cancer resection between January 1, 2015, and September 31, 2022, for hospitals performing race correction by using race-corrected and race-neutral equations.

The primary outcomes consisted of number of hospitals using race correction in PFTs, change in preoperative and postoperative FEV1 predictions based on race-neutral or race-corrected equations, and surgeon treatment recommendations for clinical vignettes.

A total of 515 African American patients (308 [59.8%] female; mean [SD] age, 66.2 [9.4] years) comprised the study cohort. Out of the 16 hospitals, 15 that performed lung cancer resection for African American patients during the study period reported using race correction, which corresponds to 473 African American patients having race-corrected PFTs.


The percent predicted preoperative FEV1 and postoperative FEV1 among these patients would have decreased by 9.2% (95% CI, −9.0% to −9.5%; P < .001) and 7.6% (95% CI, −7.3% to −7.9%; P < .001), respectively, if race-neutral equations had been used. A total of 225 surgeons (194 male [87.8%]; mean time in practice, 19.4 [11.3] years) were effectively randomized and completed the vignette items regarding risk perception and treatment outcomes, with a 76% completion rate. Surgeons randomized to the vignette with African American 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.

These findings emphasize the possible problems that might come up if race correction is removed from PFTs. Applying race-neutral testing was linked with a nearly 10-percentage-point absolute reduction in percent predicted FEV1 and postoperative percent predicted FEV1 among African American patients in the study. This decrease happened even though there was no actual change in a patient’s FEV1 and is only because of the switch from using race-corrected to race-neutral prediction equations.

The drop in estimated lung function has vital implications for treatment recommendations, operative risk, and postoperative patient-reported outcomes, like physical function or dyspnea.

Study investigators also found surgeons to be less likely to offer lobectomy and more likely to perform wedge resection when they used race-neutral PFTs compared with when African American race-corrected PFT values were used, which happened despite change in actual risk or lung function.

The researchers emphasize that “our findings highlight that removing race correction cannot happen in isolation and must occur alongside large-scale efforts to develop interventions to educate clinicians, improve shared decision-making with patients, and create new guidelines and preoperative diagnostic studies of lung function for lung cancer surgery.”

To the best of the researchers’ knowledge, there have been no empirical assessments of the role race correction PFTs plays in surgical decision-making.

This study had some limitations. First, the overall recruitment rate for participation was low, but the internal validity was maintained. Additionally, the study vignettes did not permit surgeons to ask for additional preoperative testing, like cardiopulmonary exercise testing.

In reference to the study results, the researchers concluded, “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,” they concluded.


Bonner SN, Lagisetty K, Reddy RM, Engeda Y, Griggs JJ, Valley TS. Clinical implications of removing race-corrected pulmonary function tests for Black patients requiring surgery for lung cancer. JAMA Surg. Published online August 16, 2023. doi:10.1001/jamasurg.2023.3239

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