Charting a Path toward Diagnostic Excellence and Equity in Thoracic Oncology: The Critical Role of Interventional Pulmonologists and Oncopulmonologists

Diagnostic excellence is defined as “an optimal process to attain an accurate and precise explanation about a patient’s condition” (1). To achieve diagnostic excellence, six fundamental metrics of healthcare quality recommended by the Institute of Medicine in 2001 must be prioritized: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity (2). As clinicians and researchers, we have generally focused our energy on the first five metrics while perhaps unconsciously omitting equity. When seeking to diagnose lung cancer, the pursuit of diagnostic excellence begins with identifying a pulmonary nodule, which requires complex shared decision-making and, ultimately, timely diagnostic evaluation and staging using the least invasive and most streamlined approach available (Figure 1) (3, 4). Synthesizing the patient experience across multiple specialties, interventional pulmonologists and oncopulmonologists (IP-OPs) are often patients’ de facto first point of contact with this diagnostic process, shepherding them through lung cancer screening, pulmonary nodule identification and risk stratification, diagnostic evaluation, and referral for appropriate treatment (5, 6). IP-OPs comprise pulmonologists who have received subspecialty and/or dedicated training in therapeutic and advanced diagnostic bronchoscopy, among other minimally invasive thoracic procedures (7, 8), and have expertise in thoracic oncology diagnostics and treatment (5, 6). As such, IP-OPs collectively are a key cog in multidisciplinary thoracic oncology care and are uniquely positioned to lead clinical and research efforts to optimize the thoracic oncology diagnostic process and ensure equitable patient access across the care continuum.

Figure 1.

Framework for the complete and timely diagnosis of lung cancer. Adapted with permission from Reference 3.

Having a robust IP-OP program is significantly beneficial for cancer centers because of essential contributions to oncologic diagnostic care in general, but especially for thoracic oncology diagnosis and treatment (7), highlighted by paradigm-shifting endobronchial ultrasound–guided transbronchial needle biopsy for thoracic lymph node staging (9) and advances in navigational bronchoscopy for peripheral lung biopsy (10, 11). With the increased necessity of timely and accurate diagnostics, multiple research consortiums have been established to conduct high-quality, multicenter pragmatic studies to rigorously evaluate techniques for diagnostic lung biopsy and other thoracic oncology–related diagnostic and therapeutic advances. For example, the Interventional Pulmonary Outcomes Group (12) has led studies evaluating the diagnostic yield and safety of navigational bronchoscopy compared with that of transthoracic needle aspiration (13, 14) and a joint official research statement from the American Thoracic Society and the American College of Chest Physicians standardizing the definition of diagnostic yield in advanced diagnostic bronchoscopy while providing a framework for patient-centered study designs (15). These efforts and others have collectively targeted the safety and effectiveness metrics for healthcare quality and diagnostic excellence. Importantly, the Interventional Pulmonary Outcomes Group and other consortiums have laid the groundwork for efficient multicenter studies in the blossoming field of IP-OP and afforded us the ability to advance the field by making randomized controlled trials in target patient populations possible.

However, to achieve all six metrics of diagnostic excellence, as an IP-OP community, we must collectively strive to identify and address drivers of disparities in the thoracic oncology diagnostic process. Social determinants of health (SDOH) and health-related social needs (HRSNs) must be considered as part of the diagnostic algorithm because they affect all aspects of cancer management, including screening, diagnosis, treatment, survivorship, and end-of-life care (16). Progress toward equity requires investments in time, education, and resources. This begins with acknowledging disparities and identifying barriers to optimal care, which includes ensuring guideline-concordant care, such as accurate staging and upfront molecular testing that are crucial to initiate appropriate treatment, in all patient populations. One potential area of study is to discern the value of a single diagnostic and staging procedure. This streamlined approach is likely underreported and underappreciated, particularly in instances in which HRSNs such as housing, time off work, and transportation are significant barriers to receiving care. Although this seems obvious, a well-designed research project assessing this could be critical to accruing the resources necessary to help implement a more efficient and equitable journey through the lung cancer diagnostic process. We encourage further implementation research focused on system-level efforts to standardize best practices and codify requirements for diagnostic testing.

Racial disparities currently plague efforts to achieve diagnostic excellence in thoracic oncology. Black patients experience worse lung cancer outcomes across the care continuum, likely because of multifaceted SDOH factors, including differential access to high-quality care and clinical trials (17). For instance, neighborhood-level socioeconomic status may account for nearly 50% of racial disparities in lung cancer screening follow-up (18). However, it is necessary to move beyond identifying and describing disparities in thoracic oncology care and instead evaluate interventions to reduce these inequities (19). Nationally, Black Americans comprise 13% of the country’s population but only approximately 5% of cancer clinical trial enrollees (20). Historical medical exploitation and unethical abuse in the context of clinical research and ongoing systemic inequalities are known to drive Black Americans’ mistrust in the healthcare system and reduced voluntary participation in clinical trials (21). A core responsibility of clinicians and clinical researchers is to rebuild trust and ensure that studies have tangible potential benefits for members of not only Black communities, but all historically underrepresented populations. As a first step, future trials should strive to enroll a diverse patient population that reflects the communities we serve. To accomplish this task, we believe planning for race-specific sample sizes, providing materials and information about studies in understandable formats, offering interpreter services when necessary, and ensuring cultural sensitivity in trial design will be essential. Streamlined reading material, multimedia, and social media could bridge potential communication gaps. Additionally, we appeal to trial sponsors (investigator-initiated and industry-sponsored) to augment access to research personnel and services via virtual or home-based visits, flexible hours of operation, and assistance with transportation. Regarding study design, pragmatic effectiveness clinical trials should be prioritized over explanatory efficacy trials whenever feasible. This strategy will allow for real-world evaluation of interventions and more closely approximate target patient populations. Moreover, pragmatic trials more easily lend themselves to assessing novel outcomes such as equitable medical decision-making and reductions in racial disparities in patient-centered outcomes (22).

In conclusion, as an IP-OP clinical and research community, we can chart a path toward diagnostic excellence and equity in thoracic oncology care. By addressing modifiable SDOH and HRSN factors in our day-to-day clinical practice and intentionally considering these factors in our study designs, we can help shape the equitable lung cancer care of the future. Through professional societies and other multiinstitutional collaborative efforts, IP-OPs can lead the way in thoracic oncology diagnosis and health equity, ensuring that all patients receive the effective, timely, guideline-concordant, and compassionate care they deserve.