Rebranding COPD Care and Research in the 21st Century

By quoting the anonymous 'Believing is the first step to doing', could we dream of a paradigm shift for chronic obstructive pulmonary disease (COPD)? There has been a steady stream of new evidence and breakthroughs in COPD pathophysiology and treatment over the past two decades. Yet the prediction made in 2001 at the onset of the first GOLD guidance [1], that a common, preventable, and treatable disease, which ranked as the fifth leading cause of death would rise to third place by 2020, has unfortunately come true [2]. Tragically, we have been unable to change this trajectory for the better, and we must all share responsibility. COPD remains largely unrecognised, underdiagnosed and undertreated [3]. Outdated perceptions of COPD as a "self-inflicted" disease remain in patients, relatives and even in many practitioners. The public recognises HIV/AIDS, Alzheimer's, ALS and most cancers, but they struggle to identify what COPD means and what are its causes. Why? With an estimated prevalence of 215 million (uncertainty interval 194 up to 232) cases in 2023 [4], we must urgently examine the reasons. With a projection in the global cases of COPD of up to 600 million in 2050 and abysmal costs of up to 4 trillion USD in 2020–2050 [5, 6], can we really delay action? Rebranding is a term developed in marketing strategy, in which a concept is re-created for an established brand, with the intention of developing a new, differentiated identity in the minds of consumers, investors, inventors, competitors, and other stakeholders such as the financial and political systems; overall, it aims to modify the perception of the product by the public. Rebranding in marketing and advertising typically aims to reposition the brand or company, to refresh its image, with distance from historic associations. The ultimate aim is communicating a new message. Beyond the nihilism in respiratory medicine, and particularly in COPD, we could help to design new ways of thinking in lung health [7-9]. Take the ambition at the Ciba Guest Symposium [10], which aimed to define and classify emphysema and related conditions nearly seven decades ago. We remain entangled in a myriad of endless discussions and heated controversies on COPD. No matter how we define it, COPD has an image problem and it is time to rebrand it for the benefit of all our communities, clinicians, our patients and their carers. Take cardiovascular disease and cancer. There has been an exponential progression in modifying natural history, and even cure; yet COPD management is still barely managing symptom control and petite exacerbation reductions. Accordingly, large research budgets go to HIV/AIDS, dementia and mental health, cancer or cardiovascular disease; meanwhile, COPD remains grossly underfunded [11]. Whilst we are not seeking to highlight one disease is more important than another in global perspectives, there is an urgent need to modernise the concept and the care of COPD, in order to achieve the key goals of earlier diagnosis and earlier treatment. This entails a bold re-fashioning of care pathways, creating and testing new models of care and adapting old ones to meet patients' needs in spite of the cost and service delivery constraints imposed by healthcare systems worldwide [12]. New models of care involve collaborative teams of health professionals, shared care, and shared decision making [13]. As new therapies become available [14], a patient-centred, precision medicine-based approach will refine the broad-brush approach of one-size-fits-all, and also accelerate community awareness of better outcomes for people with COPD focused on their personal, phenotypic features. This is no longer just a theoretical possibility and should engender optimism and support to reverse the nihilism that has afflicted COPD care for all. Emerging evidence on COPD heterogeneity, the life-long contributors to COPD and the potential for prevention and early disease interventions opens up a whole new world for reducing the prevalence and the burden of COPD globally [15]. In the context of this new understanding of COPD, it is vital that we seize the chance to re-imagine COPD. Some opportunities for interventions to rebrand COPD are listed in the Table 1. Within the causal pathway, and beyond cigarettes and all new nicotine delivery systems, plus the many determinants already associated with COPD incidence, either directly or indirectly [16], a holistic approach is essential. Recently, a new COPD diagnostic schema integrating respiratory symptoms, respiratory quality of life, spirometry, and imaging was suggested [17]. 1. Rethinking COPD Nomenclature and Stigma 1.1. Moving beyond "Chronic Obstructive Pulmonary Disease" or "Acute Exacerbations of COPD" to more inclusive terms. 1.2. Mixed-methods research to identify nomenclature that resonates, is understandable across languages and cultures, and is applicable to multiple stake-holders. 1.3. Addressing stigma linked to smoking, occupational and environmental exposures, articulating the diverse contributors to COPD with a focus on the objectives of curing and managing a preventable and treatable disease. 1.4. Raising awareness of prevention and risk minimisation, and the goal of life long lung health. 2. Personalised and Early Diagnosis Strategies 2.1. Role of biomarkers (e.g., blood eosinophils, proteomics, genomics, and else) and derivation of underlying mechanisms. 2.2. Integration of artificial intelligence (AI) and digital health in early detection and diagnosis, aiming to improve the yield of forced spirometry. 2.3. Develop and understand novel techniques and indices of airflow limitation and small airway disease (FEV3/FEV6, parameter D, mucus plugging). 2.4. Expanding screening beyond high-risk smokers to never-smokers, women, and occupational exposure groups. 2.5. Consider lung function testing to all screening programmes as part of lung health awareness public policy (consider starting with breast and prostate cancer). 3. Precision Medicine Management 3.1. Stratifying treatment by endotypes, including generation of new knowledge. 3.2. Tailored non-pharmacological interventions, to suit the needs of the individual. 4. Beyond Inhalers: Redefining Care Pathways 4.1. Integrating digital health tools with a proactive management approach including large-scale early intervention models. 5. Rethinking Clinical Trials and Research Priorities 5.1. Aims should address changing disease trajectory, modulation of molecular, cellular and immunological pathogenesis and the influence of sex and ethnicity in treatment. 5.2. Implementation research to eventually reduce epidemiological indicators of incidence and mortality of COPD. 6. Addressing Global and Environmental Challenges 6.1. The impact of air pollution, climate change, global warming, and occupational exposures, with a reframing as a global health priority with and beyond tobacco smoking. 6.2. Immediate and widespread standardised policy interventions such as (indoor and outdoor) air quality, and urban planning. Overall, collaborative efforts are most needed among researchers, clinicians, policymakers, and patient organisations. A central role of nurses in COPD care and specifically in tobacco control, treatment adherence, inhaler use, and pulmonary rehabilitation is essential. This is no longer just a theoretical possibility. The newly available COPD index, comparing countries' performance by weighing indicators on policy, access, and care coverage, health system, disease burden, and tobacco and environmental factors, identifies great variability among the 34 countries assessed to date [18] (Figure 1). Whilst regions may note that their scores are better than others, this does not necessarily reflect improved outcomes. Addressing this gap continues to be an urgent aim. (Source: COPD Index Companion Report, 18 September 2024. Respiratory Health Initiative, Copenhagen Institute for Futures Studies, https://respiratoryhealth.org/copd) To conclude, a vision for the 21st century COPD care must be of early, personalised, and stigma-free care, and focused on lung health [19]. There is urgency to redefine research priorities to dramatically improve patient outcomes beyond current treatment goals. To do this, we must not only rebrand COPD but also shift our approach to COPD from being reactive to proactive, and re-imagine and re-fashion the outcomes of care. Open access publishing facilitated by University of New South Wales, as part of the Wiley - University of New South Wales agreement via the Council of Australian University Librarians. M.B. is funded by the National Institute of Health and Care Research (NIHR) as Research Professor (NIHR304263). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.