Our Definition of “Lung Health” Needs to Evolve
American Lung Association
We are the leading organization working to save lives by improving lung health & preventing lung disease. lung.org
You’re either healthy or you’re not, right? Not exactly. Health and wellness are assessed on a sliding scale that’s not binary, yet somehow, we need to establish a threshold for disease.
For decades, clinicians have defined lung health as the absence of lung disease. In other words, patients are assumed to have healthy lungs up until they present with respiratory symptoms, such as shortness of breath, chronic cough, or wheezing. But, by the time their spirometry or other test results show some abnormalities, it may be too late to intervene, and they may have already developed obstructive disease or even lung cancer. By defining and diagnosing lung disease before they develop symptoms, clinicians can intervene earlier, which would lead to better outcomes. But how do we get there?
A Community Approach
In November 2021, the American Lung Association co-hosted the Prevent Cancer Foundation’s 18th Annual Quantitative Imaging Workshop, a multi-disciplinary workshop which brings together clinicians, imaging researchers, and patient advocates with the goal of integrating CT imaging with screening, detection, and management of early lung cancer and other lung diseases. Anyone interested in advancing lung health through quantitative imaging can access the free resources and videos from all of the sessions here.
One of the key sessions during this workshop addressed the evolution of thoracic disease, with presentations about redefining lung health followed by a discussion of annual thoracic screening as a tool to intercept lung disease in apparently healthy people who are former or current smokers.
Redefining Baseline Lung Health
So, how do we redefine “Lung Health?” One element is through the American Lung Association Lung Health Cohort study. Similar to the landmark Framingham studies which investigated epidemiology and risk factors for cardiovascular disease, the Lung Health Cohort study is gathering clinical data and low-dose CT images to determine how environmental exposure, behaviors, and aging affects lung health in a cohort of 4,000 volunteers aged 25-35 years old.
Tracking these volunteers over the next few years will connect the dots between any early abnormalities on lung imaging and potential lung disease later in life. While this study does not specifically focus on people who smoke, it will redefine lung health and CT lung injury on a sliding scale and not a threshold, which will better inform how to optimize thoracic screening management in apparently healthy people.
Systematic Challenges to Standardizing Thoracic Screening
One major challenge in treating pre-symptomatic pulmonary disease is the lack of standard procedures across healthcare systems, lack of sustainable reimbursement processes that meet the needs of various communities, and lack of engagement of healthcare practitioners across the U.S.
Establishing a consensus of imaging findings from the Lung Health Cohort study will standardize definitions and procedures, but clinicians must work together on a central database and develop procedures on how clinicians should intervene with behavioral and therapeutic measures. Advances in machine learning and artificial intelligence will help to reduce clinician workload and fatigue but must be implemented carefully, given their limitations. Addressing these needs would reduce time-to-action and improve clinical decision making.
Clinical Community Must Act Today
While more work is needed, there are actions that we can take today. For example, findings of pre-symptomatic emphysema on lung cancer screening CT scans can and should be reported in a consensus-defined, structured format by interpreting radiologists. This allows clinicians to implement interventions such as enhancing smoking cessation measures, encouraging physical activity, keeping updated on vaccinations (standard preventive measures for COPD), and assessing lung function when indicated.
Encouraging these discussions within the medical and scientific community, which encompasses healthcare administrators, healthcare providers, advocates and insurers allows for collaborative solutions. Community outreach helps to build trust with medically underserved individuals, improving compliance rates and ensuring access to these innovative solutions.
Final Thoughts
Thoracic CT imaging of people who smoke and used to smoke gives an early window into lung cancer, COPD, and heart disease - the top three causes of premature death in the U.S. and around the world. Better integration of screening for early lung disease starts with cohort studies which will show the progression and predisposition of lung disease in apparently healthy individuals. Then, standardizing procedures for diagnosis and reporting of these early changes, and a centralized database and referral structure will help deliver early interventions to patients.
These advances in lung disease screening can improve the interception of major smoking-related disease prior to the development of symptoms, improving patients’ daily lives and ultimately their survival.
About the author: Vincent Tedjasaputra, Ph.D. is the Director of Scientific Communications at the American Lung Association.
Medical Director, Pulmonary Service Line, Respiratory Care, and Pulmonary Nodule Program
3yThe impact of telling a patient that they have emphysema based on a screening CT cannot be understimated. Patients are often shocked. Sometimes shocked enough to quit smoking and quitting before symptoms develop is the goal. Another benefit of lung cancer screening.
Field Marketing Manager focused on providing resources for external and internal customers advancing robotics in thoracic oncology to benefit the care pathway of lung cancer patients.
3yI wonder if those exposed to smoking over a sustained time frame, like almost 18yrs living in a home with and visiting other homes of heavy smokers, has any impact on ‘healthy/non-smoking lungs’ over time.
President & CEO at American Lung Association
3yHeightening the awareness of good Lung Health practices is critical as we face increasing numbers of lung disease deaths in the United States.
Chief Marketing Officer | Brand Strategist | Digital Marketer | Board Director | AI Enthusiast | Author | Midmarket Growth Leader
3yThis view of #lunghealth is more important than ever and it is right at the center of American Lung Association’s Lung Health Cohort longitudinal study.
Program Director - AI/ Machine Learning, National Institute of Biomedical Imaging and Bioengineering (NIBIB)
3yVince Tedjasaputra, PhD, Thank you for the shout out. You are absolutely right: 'disease' is neither binary nor static. It changes with time, it is a dynamic process. On the AI perspective, there are significant efforts in place to develop trustworthy, inclusive AI, from both government and the private sector. I am significantly involved with one of them: https://www.midrc.org, focused on medical images of Covid-19, mostly lung-centric for now. There are many other efforts along the lines you describe (NIH: Bridge2AI, Aim-Ahead, as well as privately funded efforts, such as https://www.nightingalescience.org/). In my view, the hard part is something your text flies through in a couple of words: "clinicians must work together"... It is much more than clinicians: it involves physicists, engineers, ethicists, physiologists, basic scientists, data scientists, funding agencies, policy deciders, professional societies, patient advocacy groups, a new legal framework (?),... It is the multidisciplinarity and necessary integration of all stakeholders that makes things such as AI/ML development, deployment and acceptance a hard problem. Technology *alone* is not enough. It needs the human platform. And the human platform needs a significant upgrade, upgrade as in learning to communicate across disciplinary boundaries - taking the time to understand each other's language -, understand the limitations of all facets of the problem, understand implications, unintended consequences, the right incentives in place, ... The human platform needs to work TOGETHER, we need **communities** of experts coming together on specific problems. Bringing it back to your question: the importance of a "community of experts" may actually be the most important 'lesson learned' from my experience of the University of California, San Diego - School of Medicine Pulmonary Imaging Lab.