Preoperative exercise training for patients with non-small cell lung cancer

[Chinese Expert Consensus on Perioperative Pulmonary Rehabilitation Training for Lung Cancer]

Perioperative pulmonary rehabilitation may effectively reduce the incidence of postoperative pulmonary complications and improve the quality of life of lung cancer patients and its clinical application value in lung cancer patients has been widely recognized. However, there is still no international consensus or guideline for pulmonary rehabilitation regimen, lacking standardized criteria when pulmonary rehabilitation applied in perioperative clinical practice for lung cancer. The consensus provides implementation regimen and process of pulmonary rehabilitation, aiming to promote the reasonable and standardized application of perioperative pulmonary rehabilitation training in clinical practice, sequentially enable patients to maximize benefits from the rehabilitation.
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Summary of the best evidence for prehabilitation management of patients with non-small cell lung cancer

Objective

This study adopts an evidence-based methodology to establish a comprehensive theory foundation for preoperative prehabilitation management in non-small cell lung cancer (NSCLC) patients.

Methods

A systematic literature review linked to prehabilitation management for NSCLC patients was conducted, utilizing reputable databases such as UpToDate, BMJ Best Practice, UK NICE, SIGN, GIN, Joanna Briggs Institute Library, Cochrane Library, Web of Science, Embase, OVID evidence-based database, PubMed, Chinese Wanfang database, CNKI, CBM, ATS, BTS, AACVPR, and EACTS. The search encompassed articles, including clinical decision-making, guidelines, evidence summaries, expert consensuses, and systematic reviews, from the inception of databases up to March 31st, 2023. Two researchers performed quality assessment of the literature and subsequent evidence extraction.

Results

Nineteen articles were included, comprising five guidelines, three expert consensuses, seven systematic reviews, and four randomized controlled trials. A total of 41 pieces of evidence were summarized, addressing key aspects such as the multidisciplinary team, appropriate patient population, prehabilitation modes, timing of prehabilitation, prehabilitation assessment, prehabilitation content, quality control, and effectiveness evaluation.

Conclusions

The synthesis of the best evidence for prehabilitation management in NSCLC patients provides a solid evidence-based foundation for its implementation. It is recommended that healthcare professionals conduct thorough patient evaluations, optimize and integrate medical resources, and collaboratively engage in interdisciplinarity efforts to develop and implement personalized and multimodal prehabilitation plans.

Effect of exercise on postoperative recovery of patients with non-small cell lung cancer: a systematic review and meta-analysis

Patients with non-small cell lung cancer (NSCLC) in the postoperative recovery period often experience reduced exercise capacity and impaired lung function, which affects their overall quality of life. This paper investigated the effect of exercise interventions on exercise capacity, lung function, quality of life, and symptoms in these patients.

METHODS

We performed a literature search across Cochrane, Embase, PubMed, Web of Science, and EBSCO databases were comprehensively searched for randomized controlled trials (RCTs) from inception to September 2023, all English RCTs were eligible if they assessed the effects of exercise interventions on postoperative NSCLC patients.

RESULTS

Twelve articles met our inclusion criteria, evidencing that exercise interventions could significantly improve the functional capacity of NSCLC patients in postoperative recovery. Notably, Forced Expiratory Volume in 1 s (FEV1) was improved, indicating enhanced lung function. Furthermore, exercise improved the physical and mental health scores of SF-36, along with increased quadriceps strength and relieved dyspnea. However, fatigue levels were not significantly changed.

CONCLUSIONS

Exercise interventions of NSCLC patients in the postoperative recovery are associated with improved functional capacity, lung function, quality of life, and quadriceps strength, as well as alleviated symptoms of dyspnea. These findings underscore the potential benefits of incorporating exercise into postoperative care for NSCLC patients. Nonetheless, further large-scale RCTs are required to solidify the evidence base on the clinical outcomes of exercise following pneumonectomy.

Relationship between prehabilitation responsiveness and postoperative physical functional recovery in cardiovascular surgery

BACKGROUND

The purpose of this study was to examine the relationship between responsiveness to prehabilitation and postoperative recovery of physical function in cardiac surgery patients.

METHODS

Ninety-three cardiac surgery patients (mean age: 76.4 years) were included in this retrospective cohort study. Preoperative physical function was measured using the Short Physical Performance Battery (SPPB), and a prehabilitation exercise program was implemented for the SPPB domains with low scores. Among the patients, those whose SPPB score was over 11 from the start of prehabilitation and remained over 11 on the day before surgery were defined as the high-functioning group, and those whose SPPB score improved by 2 points or more from the start of prehabilitation and exceeded 11 points were defined as the responder group. Those whose SPPB score did not exceed 11 immediately before surgery were classified as non-responders. The characteristics of each group and postoperative recovery of physical function were investigated.

RESULTS

There were no serious adverse events during prehabilitation. Mean days of prehabilitation was 5.4 days. The responder group showed faster improvement in postoperative physical function and shorter time to ambulatory independence than the non-responder group. The non-responder group had lower preoperative skeletal muscle index, more severe preoperative New York Heart Association classification, and a history of musculoskeletal disease or stroke.

CONCLUSION

There were responders and non-responders to prehabilitation among cardiac surgery patients. Cardiac surgery patients who respond to prehabilitation had faster recovery of physical function. Further research is needed to determine what type of prehabilitation is more effective in postoperative recovery of physical function in cardiac surgery patients.

Multimodal prehabilitation in patients with non-small cell lung cancer: a feasibility study

Background

Anatomic pulmonary resection is the preferred curative treatment in operable non-small cell lung cancer (NSCLC) but is associated with postoperative complications and inevitable compromise in functional capacity. Preoperative enhancement of functional capacity can be achieved with prehabilitation, yet the window of opportunity in NSCLC patients is small because patients are required to undergo surgery within 3 weeks from diagnosis. The goal of this study was to assess the feasibility of a prehabilitation programme in NSCLC within a 3-week timeframe and its effect on functional capacity-although the study was not powered to confirm improvements in functional capacity.

Methods

Prehabilitation consisted of six interventions: exercise programme, nutritional support, mental support, smoking cessation, patient empowerment, and optimisation of respiratory status and was executed in two large teaching hospitals in the Netherlands. Assessments were scheduled at baseline (T0), end of program preoperatively (T1), and 6 weeks postoperatively (T2). Feasibility was defined as ≥80% of participants completing ≥80% of the programme. Functional capacity [6-minute walk test (6MWT), steep ramp test (SRT), one repetition maximum (1RM), maximal inspiratory pressure (MIP), and hand grip strength (HGS)] was evaluated on T1 and T2 compared to T0 using mixed model analyses.

Results

In total, 24 patients were included. In 95.8% of patients, the program proved feasible and preoperative functional capacity significantly improved in all pre-specified tests on T1. 1RM sustained improved at T2.

Conclusions

Multimodal prehabilitation for lung surgery is feasible within a timeframe of 3 weeks. Even though this study was not powered to confirm it, prehabilitation may improve preoperative functional capacity.

Comparison Results of Three-Port Robot-Assisted and Uniportal Video-Assisted Lobectomy for Functional Recovery Index in the Treatment of Early Stage Non-small Cell Lung Cancer: A Propensity Score-Matched Analysis

BACKGROUND

Minimally invasive lobectomy is the standard treatment for early stage non-small cell lung cancer (NSCLC). The aim of this study is to investigate postoperative recovery in a prospective trial of discharged patients with early stage non-small cell lung cancer undergoing robot-assisted thoracic surgery (RATS) versus uniportal video-assisted thoracic surgery (UVATS).

PATIENTS AND METHODS

This is a prospective and observational study. From 9 September 2022 to 1 July 2023, 178 patients diagnosed with NSCLC admitted to the Department of Thoracic Surgery of Shandong Provincial Hospital signed informed consent and underwent lobectomy by RATS and UVATS. The functional recovery index included MD Anderson Symptom Inventory, Christensen Fatigue Scale, EORTC QLQ-C30, and Leicester Cough Questionnaire.

RESULTS

After propensity score-matched analysis, each group included 42 cases. For the baseline characteristics of patients, operation time (p = 0.01) and length of stay (p = 0.04) were shorter in the RATS group. The number of lymph nodes resected in the RATS group was much more than in the UVATS group. According to our investigation, appetite loss, nausea, diarrhea, and cough severity after RATS were better than after UVATS. After the first week, pain severity degree of the RATS group was higher than UVATS, while there was no difference during the second and third week. The physical score of the RATS group was higher than the UVATS group (p = 0.04), according to the Leicester Cough Questionnaire.

CONCLUSION

RATS was associated with severe short-term postoperative pain but less postoperative complications.

Early Ambulation Following Lung Resection Surgery: Impact on Short-term Outcomes in Patients with Lung Cancer

OBJECTIVES

Previous studies indicated that early ambulation following lung resection can prevent postoperative pulmonary complications (PPCs). However, some patients fail to achieve early ambulation owing to factors such as postoperative nausea, vomiting, or pain, particularly on postoperative day 1. This study aimed to address the critical clinical question: Is ambulation for ≥10 m during initial pulmonary rehabilitation necessary after lung resection surgery?

METHODS

This retrospective observational cohort study included 407 patients who underwent lung resection surgery for lung cancer between January 2021 and December 2022. Twelve patients with a performance status of ≥2 and 21 patients lacking pulmonary rehabilitation prescriptions were excluded. Patients were categorized into the "early ambulation" group, which included individuals ambulating ≥10 m during rehabilitation on the first postoperative day, and the "delayed ambulation" group. The primary outcome was PPC incidence, with secondary outcomes encompassing pleural drain duration, hospital length of stay, and Δ6-minute walk distance (Δ6MWD: postoperative 6MWD minus preoperative 6MWD).

RESULTS

The early and delayed ambulation groups comprised 315 and 59 patients, respectively. Significant disparities were noted in the length of hospital stay (7 [6-9] days vs. 8 [6-11] days, P = 0.01), pleural drainage duration (4 [3-5] days vs. 4 [3-6] days, P = 0.02), and Δ6MWD (-70 m vs. -100 m, P = 0.04). However, no significant difference was observed in PPC incidence (20.6% vs. 32.2%, P = 0.06).

CONCLUSIONS

Ambulation for ≥10 m during initial pulmonary rehabilitation after lung resection surgery may yield short-term benefits as evidenced by improvements in various outcomes. However, it may not significantly affect the PPC incidence.

The effect of incentive spirometry in perioperative patients with lung cancer-a systematic review and meta-analysis

BACKGROUND

Incentive spirometry (IS) as a routine respiratory therapy during the perioperative period has been widely used in clinical practice. However, the impact of IS on patients with perioperative lung cancer remains controversial. This review aimed to evaluate the efficacy of IS in perioperative pulmonary rehabilitation for patients with lung cancer.

METHODS

Cochrane Library, PubMed, Web of Science, Ovid, CINAHL, Chinese National Knowledge Infrastructure, Weipu, and Wanfang Databases were searched from inception to 30 November 2023. Only randomized controlled trials were included in this systematic review. The PRISMA checklist served as the guidance for conducting this review. The quality assessment of the included studies was assessed by the Cochrane risk-of-bias tool. The meta-analysis was carried out utilizing Review Manager 5.4. Furthermore, sensitivity analysis and subgroup analysis were also performed.

RESULTS

Nine studies recruited 1209 patients met our inclusion criteria. IS combined with other respiratory therapy techniques was observed to reduce the incidence of postoperative pulmonary complications, enhance pulmonary function, curtail the length of hospital stay, and lower the Borg score. Nevertheless, no improvements were found in the six-minute walk distance or quality of life score.

CONCLUSIONS

Although IS demonstrates benefits as a component of comprehensive intervention measures for perioperative patients with lung cancer, it proves challenging to determine the precise impact of IS as a standalone component within the comprehensive intervention measures. Therefore, further researches are required to better understand the effectiveness of IS isolation and its interactions when integrated with additional respiratory therapies for these patients.

CLINICAL TRIAL REGISTRATION

PROSPERO, https://www.crd.york.ac.uk/prospero/ , registry number: CRD42022321044.

[Modern Perioperative Care Concepts in Thoracic Surgery: Enhanced Recovery After Thoracic Surgery (ERATS)]

In modern perioperative care concepts, multimodal ERAS (Enhanced Recovery After Surgery) is a multimodal perioperative treatment concept for improving postoperative recovery of surgical patients after an operation. This is managed by the so-called ERAS Society and through which hospitals can also be officially certified. The focus of the ERAS concept is on uniform patient care from admission to discharge, with the aim of improving perioperative processes by implementing evidence-based protocols involving a multidisciplinary treatment team. In 2019, ERAS guidelines were published for the first time by the European Society of Thoracic Surgery (ESTS), in cooperation with the ERAS Society, for specific lung resection procedures, and these identified a total of 45 graduated recommendations or Enhanced Recovery Pathways (ERP). The implementation of ERAS concepts in thoracic surgery (ERATS = Enhanced Recovery After Thoracic Surgery) is intended to establish standardised perioperative procedures based on study results and/or expert recommendations. These recommendations take into account organisational aspects as well as thoracic surgical and anaesthesiological procedures, with the overriding goal of creating a structured treatment plan tailored to the patient. All these measures should result in a multimodal overall concept, which should primarily lead to an improved outcome after elective thoracic surgery and secondarily to shorter hospital stays with correspondingly lower costs.This review article describes basic ERAS principles and provides a compact presentation of the most important European ERAS recommendations from the authors' point of view, together with typical obstacles to the implementation of the corresponding ERATS program in German thoracic surgery.

Development of a real-time RGB-D visual feedback-assisted pulmonary rehabilitation system

Background

Following surgery, perioperative pulmonary rehabilitation (PR) is important for patients with early-stage lung cancer. However, current inpatient programs are often limited in time and space, and outpatient settings have access barriers. Therefore, we aimed to develop a background-free, zero-contact thoracoabdominal movement-tracking model that is easily set up and incorporated into a pre-existing PR program or extended to home-based rehabilitation and remote monitoring. We validated its effectiveness in providing preclinical real-time RGB-D (colour-depth camera) visual feedback.

Methods

Twelve healthy volunteers performed deep breathing exercises following audio instruction for three cycles, followed by audio instruction and real-time visual feedback for another three cycles. In the visual feedback system, we used a RealSense™ D415 camera to capture RGB and depth images for human pose-estimation with Google MediaPipe. Target-tracking regions were defined based on the relative position of detected joints. The processed depth information of the tracking regions was visualised on a screen as a motion bar to provide real-time visual feedback of breathing intensity. Pulmonary function was simultaneously recorded using spirometric measurements, and changes in pulmonary volume were derived from respiratory airflow signals.

Results

Our movement-tracking model showed a very strong correlation (r = 0.90 ± 0.05) between thoracic motion signals and spirometric volume, and a strong correlation (r = 0.73 ± 0.22) between abdominal signals and spirometric volume. Displacement of the chest wall was enhanced by RGB-D visual feedback (23 vs 20 mm, P = 0.034), and accompanied by an increased lung volume (2.58 vs 2.30 L, P = 0.003).

Conclusion

We developed an easily implemented thoracoabdominal movement-tracking model and reported the positive impact of real-time RGB-D visual feedback on self-promoted external chest wall expansion, accompanied by increased internal lung volumes. This system can be extended to home-based PR.

A qualitative stakeholder analysis of beliefs, facilitators, and barriers for a feasible prehabilitation program before lung cancer surgery

BACKGROUND

In order to develop a feasible prehabilitation program before surgery of NSCLC, this study aimed to gain insight into beliefs, facilitators, and barriers of (1) healthcare professionals to refer patients to a prehabilitation program, (2) patients to participate in and adhere to a prehabilitation program, and (3) informal caregivers to support their loved ones.

METHODS

Semi-structured interviews were conducted with healthcare professionals, patients who underwent surgery for NSCLC, and their informal caregivers. The capability, opportunity, and motivation for behavior-model (COM-B) guided the development of the interview questions. Results were analyzed thematically.

RESULTS

The interviews were conducted with twelve healthcare professionals, seventeen patients, and sixteen informal caregivers. Four main themes were identified: (1) content of prehabilitation and referral, (2) organizational factors, (3) personal factors for participation, and (4) environmental factors. Healthcare professionals mentioned that multiple professionals should facilitate the referral of patients to prehabilitation within primary and secondary healthcare involved in prehabilitation, considering the short preoperative period. Patients did not know that a better preoperative physical fitness and nutritional status would make a difference in the risk of postoperative complications. Patients indicated that they want to receive information about the aim and possibilities of prehabilitation. Most patients preferred a group-based physical exercise training program organized in their living context in primary care. Informal caregivers could support their loved one when prehabilitation takes place by doing exercises together.

CONCLUSION

A prehabilitation program should be started as soon as possible after the diagnosis of lung cancer. Receiving information about the purpose and effects of prehabilitation in a consult with a physician seems crucial to patients and informal caregivers to be involved in prehabilitation. Support of loved ones in the patient's own living context is essential for adherence to a prehabilitation program.

Acceptability of prehabilitation for cancer surgery: a multi-perspective qualitative investigation of patient and 'clinician' experiences

BACKGROUND

'Prehabilitation' interventions aim to enhance individuals' physical fitness prior to cancer treatment, typically involve exercise training as a key component, and may continue to support physical activity, strength, and fitness during or after treatment. However, uptake of prehabilitation is variable. This study investigated how patients from diverse socio-economic status groups perceived an exemplar prehabilitation and recovery programme, aiming to understand factors impacting acceptability, engagement and referral.

METHODS

This research was conducted in the context of the Prehab4Cancer and Recovery Programme, a prehabilitation and recovery programme available across Greater Manchester, UK. Qualitative, semi-structured phone/video-call interviews were conducted with 18 adult patient participants referred to the programme (16 'engagers', 2 'non-engagers'; half the sample lived in localities with low socio-economic status scores). An online questionnaire with free-response and categorical-response questions was completed by 24 'clinician' participants involved in referral (nurses, doctors and other staff roles). An inductive, multi-perspective, thematic analysis was performed, structured using the Framework approach.

RESULTS

Discussing and referring patients to prehabilitation can be challenging due to large quantities of information for staff to cover, and for patients to absorb, around the time of diagnosis. The programme was highly valued by both participant groups; the belief that participation would improve recovery seemed a major motivator for engagement, and some 'clinicians' felt that prehabilitation should be treated as a routine part of treatment, or extended to support other patient groups. Engagers seemed to appreciate a supportive approach where they did not feel forced to do any activity and tailoring of the programme to meet individual needs and abilities was appreciated. Initial engagement could be daunting, but gaining experience with the programme seemed to increase confidence.

CONCLUSIONS

The prehabilitation programme was highly valued by engagers. Introducing prehabilitation at a challenging time means that personalised approaches might be needed to support engagement, or participation could be encouraged at a later time. Strategies to support individuals lacking in confidence, such as buddying, may be valuable.

STUDY REGISTRATION

The study protocol was uploaded onto the Open Science Framework 24 September 2020 ( https://osf.io/347qj/ ).

Multimodal prehabilitation in patients with non-small cell lung cancer undergoing anatomical resection: protocol of a non-randomised feasibility study

BACKGROUND

The preoperative period can be used to enhance a patient's functional capacity with multimodal prehabilitation and consequently improve and fasten postoperative recovery. Especially, non-small cell lung cancer (NSCLC) surgical patients may benefit from this intervention, since the affected and resected organ is an essential part of the cardiorespiratory fitness. Drafting a prehabilitation programme is challenging, since many disciplines are involved, and time between diagnosis of NSCLC and surgery is limited. We designed a multimodal prehabilitation programme prior to NSCLC surgery and aimed to conduct a study to assess feasibility and indicative evidence of efficacy of this programme. Publication of this protocol may help other healthcare facilities to implement such a programme.

METHODS

The multimodal prehabilitation programme consists of an exercise programme, nutritional support, psychological support, smoking cessation, patient empowerment and respiratory optimisation. In two Dutch teaching hospitals, 40 adult patients with proven or suspected NSCLC will be included. In a non-randomised fashion, 20 patients follow the multimodal prehabilitation programme, and 20 will be assessed in the control group, according to patient preference. Assessments will take place at four time points: baseline, the week before surgery, 6 weeks postoperatively and 3 months postoperatively. Feasibility and indicative evidence of efficacy of the prehabilitation programme will be assessed as primary outcomes.

DISCUSSION

Since the time between diagnosis of NSCLC and surgery is limited, it is a challenge to implement a prehabilitation programme. This study will assess whether this is feasible, and evidence of efficacy can be found. The non-randomised fashion of the study might result in a selection and confounding bias. However, the control group may help putting the results of the prehabilitation group in perspective. By publishing this protocol, we aim to facilitate others to evaluate and implement a multimodal prehabilitation programme for surgical NSCLC patients.

TRIAL REGISTRATION

The current study is registered as NL8080 in the Netherlands Trial Register on the 10th of October 2019, https://www.trialregister.nl/trial/8080 . Secondary identifiers: CCMO (Central Committee on Research Involving Human Subjects) number NL70578.015.19, reference number of the Medical Ethical Review Committee of Máxima MC W19.045.

A toolbox for a structured risk-based prehabilitation program in major surgical oncology

Prehabilitation is a multimodal concept to improve functional capability prior to surgery, so that the patients' resilience is strengthened to withstand any peri- and postoperative comorbidity. It covers physical activities, nutrition, and psychosocial wellbeing. The literature is heterogeneous in outcomes and definitions. In this scoping review, class 1 and 2 evidence was included to identify seven main aspects of prehabilitation for the treatment pathway: (i) risk assessment, (ii) FITT (frequency, interventions, time, type of exercise) principles of prehabilitation exercise, (iii) outcome measures, (iv) nutrition, (v) patient blood management, (vi) mental wellbeing, and (vii) economic potential. Recommendations include the risk of tumor progression due to delay of surgery. Patients undergoing prehabilitation should perceive risk assessment by structured, quantifiable, and validated tools like Risk Analysis Index, Charlson Comorbidity Index (CCI), American Society of Anesthesiology Score, or Eastern Co-operative Oncology Group scoring. Assessments should be repeated to quantify its effects. The most common types of exercise include breathing exercises and moderate- to high-intensity interval protocols. The program should have a duration of 3-6 weeks with 3-4 exercises per week that take 30-60 min. The 6-Minute Walking Testing is a valid and resource-saving tool to assess changes in aerobic capacity. Long-term assessment should include standardized outcome measurements (overall survival, 90-day survival, Dindo-Clavien/CCI®) to monitor the potential of up to 50% less morbidity. Finally, individual cost-revenue assessment can help assess health economics, confirming the hypothetic saving of $8 for treatment for $1 spent for prehabilitation. These recommendations should serve as a toolbox to generate hypotheses, discussion, and systematic approaches to develop clinical prehabilitation standards.

Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery

BACKGROUND

Surgery is the cornerstone in curative treatment of colorectal cancer. Unfortunately, surgery itself can adversely affect patient health. 'Enhanced Recovery After Surgery' programmes, which include multimodal interventions, have improved patient outcomes substantially. However, these are mainly applied peri- and postoperatively. Multimodal prehabilitation includes multiple preoperative interventions to prepare patients for surgery with the aim of increasing resilience, thereby improving postoperative outcomes.

OBJECTIVES

To determine the effects of multimodal prehabilitation programmes on functional capacity, postoperative complications, and quality of life in adult patients undergoing surgery for colorectal cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and PsycINFO in January 2021. We also searched trial registries up to March 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adult patients with non-metastatic colorectal cancer, scheduled for surgery, comparing multimodal prehabilitation programmes (defined as comprising at least two preoperative interventions) with no prehabilitation. We focused on the following outcomes: functional capacity (i.e. 6-minute walk test, VO2peak, handgrip strength), postoperative outcomes (i.e. complications, mortality, length of hospital stay, emergency department visits, re-admissions), health-related quality of life, compliance, safety of prehabilitation, and return to normal activities.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data, assessed risk of bias and used GRADE to assess the certainty of the evidence. Any disagreements were solved with discussion and consensus. We pooled data to perform meta-analyses, where possible.

MAIN RESULTS

We included three RCTs that enrolled 250 participants with non-metastatic colorectal cancer, scheduled for elective (mainly laparoscopic) surgery. Included trials were conducted in tertiary care centres and recruited patients during periods ranging from 17 months to 45 months. A total of 130 participants enrolled in a preoperative four-week trimodal prehabilitation programme consisting of exercise, nutritional intervention, and anxiety reduction techniques. Outcomes of these participants were compared to those of 120 participants who started an identical but postoperative programme. Postoperatively, prehabilitation may improve functional capacity, determined with the 6-minute walk test at four and eight weeks (mean difference (MD) 26.02, 95% confidence interval (CI) -13.81 to 65.85; 2 studies; n = 131; and MD 26.58, 95% CI -8.88 to 62.04; 2 studies; n = 140); however, the certainty of evidence is low and very low, respectively, due to serious risk of bias, imprecision, and inconsistency. After prehabilitation, the functional capacity before surgery improved, with a clinically relevant mean difference of 24.91 metres (95% CI 11.24 to 38.57; 3 studies; n = 225). The certainty of evidence was moderate due to downgrading for serious risk of bias. The effects of prehabilitation on the number of complications (RR 0.95, 95% CI 0.70 to 1.29; 3 studies; n = 250), emergency department visits (RR 0.72, 95% CI 0.39 to 1.32; 3 studies; n = 250) and re-admissions (RR 1.20, 95% CI 0.54 to 2.65; 3 studies; n = 250) were small or even trivial. The certainty of evidence was low due to downgrading for serious risk of bias and imprecision. The effects on VO2peak, handgrip strength, length of hospital stay, mortality rate, health-related quality of life, return to normal activities, safety of the programme, and compliance rate could not be analysed quantitatively due to missing or insufficient data. The included studies did not report a difference between groups for health-related quality of life and length of hospital stay. Data on remaining outcomes were not reported or were reported inadequately in the included studies.

AUTHORS' CONCLUSIONS

Prehabilitation may result in an improved functional capacity, determined with the 6-minute walk test both preoperatively and postoperatively. A solid effect on the number of omplications, postoperative emergency department visits and re-admissions could not be established. The certainty of evidence ranges from moderate to very low, due to downgrading for serious risk of bias, imprecision and inconsistency. In addition, only three heterogeneous studies were included in this review. Therefore, the findings of this review should be interpreted with caution. Numerous relevant RCTs are ongoing and will be included in a future update of this review.

Home-Based Preoperative Exercise Training for Lung Cancer Patients Undergoing Surgery: A Feasibility Trial

BACKGROUND

Clinical guidelines recommend prehabilitation with exercise training to optimize recovery after lung cancer surgery. However, the lack of access to facility-based exercise programs is a major barrier to routine participation. This study aimed to assess the feasibility of a home-based exercise intervention before lung cancer resection.

METHODS

We conducted a prospective, two-site feasibility study, including patients scheduled for lung cancer surgery. Exercise prescription involved aerobic and resistance training with telephone-based supervision. The primary endpoint was overall feasibility (recruitment rate, retention rate, intervention adherence and acceptability). Secondary endpoints included safety and effects on health-related quality of life (HRQOL) and physical performance, evaluated at baseline, after the exercise intervention and 4-5 weeks after surgery.

RESULTS

Over three months, 15 patients were eligible, and all agreed to participate (recruitment rate: 100%). A total of 14 patients completed the exercise intervention, and 12 patients were evaluated postoperatively (retention rate: 80%). The median length of the exercise intervention was 3 weeks. Patients performed an aerobic and resistance training volume higher than prescribed (median adherence rates of 104% and 111%, respectively). A total of nine adverse events occurred during the intervention (Grade 1, n = 8; Grade 2, n = 1), the most common being shoulder pain. After the exercise intervention, significant improvements were observed in the HRQOL summary score (mean difference, 2.9; 95% confidence interval [CI], from 0.9 to 4.8; p = 0.049) and the five-times sit-to-stand test score (median difference, -1.5; 95% CI, from -2.1 to -0.9; p = 0.001). After surgery, no significant effects on HRQOL and physical performance were observed.

CONCLUSION

A short-term preoperative home-based exercise intervention is feasible before lung cancer resection and may enhance accessibility to prehabilitation. Clinical effectiveness should be investigated in future studies.

The protocol for the prehabilitation for thoracic surgery study: a randomized pragmatic trial comparing a short home-based multimodal program to aerobic training in patients undergoing video-assisted thoracoscopic surgery lobectomy

BACKGROUND

Prehabilitation has been shown to have a positive effect on the postoperative recovery of functional capacity in patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy. The optimal way to implement prehabilitation programs, such as the optimal forms of prehabilitation, duration, intensity, and methods to improve compliance, remained to be studied. This Prehabilitation for Thoracic Surgery Study will compare the effectiveness of multimodal and aerobic training-only programs in patients undergoing thoracoscopic lobectomy.

METHODS

This randomized pragmatic trial will be conducted in Peking Union Medical College Hospital (PUMCH) and include 100 patients who are eligible to undergo VATS lobectomy. Patients will be randomized to a multimodal or aerobic training group. Prehabilitation training guidance will be provided by a multidisciplinary care team. The patients in the multimodal group will perform aerobic exercises, resistance exercises, breathing exercises, psychological improvement strategies, and nutritional supplementation. Meanwhile, the patients in the aerobic group will conduct only aerobic exercises. The interventions will be home-based and supervised by medical providers. The patients will be followed up until 30 days after surgery to investigate whether the multimodal prehabilitation program differs from the aerobic training program in terms of the magnitude of improvement in functional capability pre- to postoperatively. The primary outcome will be the perioperative 6-min walk distance (6MWD). The secondary outcomes will include the postoperative pulmonary functional recovery status, health-related quality of life score, incidence of postoperative complications, and clinical outcomes.

DISCUSSION

Prehabilitation remains a relatively new approach that is not widely performed by thoracic surgery patients. The existing studies mainly focus on unimodal interventions. While multimodal prehabilitation strategies have been shown to be preferable to unimodal strategies in a few studies, the evidence remains scarce for thoracic surgery patients. The results of this study will contribute to the understanding of methods for thoracoscopic lobectomy patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04049942 . Registered on August 8, 2019.

[Are we missing the first step? : An online expert survey in a mixed methods design on current state analysis of perioperative risk estimation and preoperative preparation of patients over 65 years old in Germany]

BACKGROUND

The proportion of patients over 65 years of age in surgical care is increasing in Germany. Frailty represents a relevant problem in the perioperative care of older patients and has a negative impact on the postoperative outcome. The individual degree of frailty can be influenced. Multimodal prehabilitation concepts can contribute to improving the degree of frailty in the perioperative care of affected patients. As a multidimensional syndrome, frailty is related to the aging process, affects multiple organ systems and typically leads to increased vulnerability to internal and external stressors. This is accompanied by a decrease in homeostatic reserves and resilience, which implies an increased risk of several adverse health outcomes, such as loss of physical function and quality of life. Prehabilitation is described as a multimodal concept to prepare patients preoperatively in the best possible way for elective surgical procedures, thereby minimizing postoperative complications and improving the patients' outcome.

METHOD

Current state analysis of perioperative care of patients over the age of 65 years in relation to frailty assessment and the use of prehabilitation concepts. Conducting a multicenter online survey of anesthesiology experts (n = 189) in German anesthesiology departments. Survey of the preoperative preparation and assessment routine in patients aged 65 years and over using a mixed methods design questionnaire.

OBJECTIVE

The aim of this study was to demonstrate the applied assessments and measures taken for specific perioperative risk assessment and preoperative preparation of patients aged 65 years and over.

RESULTS

Specific risk assessments or additional preoperative preparation of patients older than 65 years are currently not carried out routinely. The preoperative risk assessment and preparation usually focus on ascertaining the patient's previous illnesses or diseases. Assessment instruments for assessing frailty and multimodal prehabilitation concepts are not used in clinical practice in a noteworthy quantity.

CONCLUSION

In German clinical practice frailty assessment and structured prehabilitation approaches in perioperative care of older patients are not broadly known or established. Multimodal prehabilitation concepts can positively influence the outcome of older patients. To this end, it should be considered good clinical practice to assess and address frailty in older patients and to establish multimodal prehabilitation approaches tailored to this patient group.

Prähabilitation bei elektiver Lungen-Teilresektion (PRELS)

Hintergrund Lungenkrebs weist die höchste krebsbedingte Sterblichkeitsrate auf. Die chirurgische Resektion bei nicht kleinzelligem Lungenkrebs im Frühstadium bildet den Grundstein der Behandlung. Thoraxchirurgische Eingriffe sind mit einer erhöhten Rate an postoperativen Komplikationen verbunden, insbesondere bei verminderter präoperativer Leistungsfähigkeit. Das Enhanced Recovery Protocol stellt einen evidenzbasierten Ansatz für die Versorgung von Patient*innen dar, wobei ein wachsendes Interesse am Wert der Prähabilitation besteht. Prähabilitationsprotokolle, die auf eine Verbesserung der postoperativen Genesung abzielen, wurden als eine Intervention zur Verringerung der post-chirurgischen Beschwerden vorgeschlagen. Bis heute gibt es in der Schweiz keine etablierten Protokolle für ein präoperatives, körperliches Training.

Ziel Untersuchung der Machbarkeit eines präoperativen Trainingsprogramms für Patient*innen mit geplanter Lungenteilresektion.

Methoden Im Rahmen einer multizentrischen Machbarkeitsstudie wurden an 4 Schweizer Kliniken je 1 Person in ein präoperatives Training aufgenommen. Die Intervention bestand aus einem ambulanten Übungsprogramm mit Krafttraining und High-Intensity Intervall-Ausdauertraining für mindestens 1 Woche vor dem chirurgischen Eingriff. Die Endpunkte der Studie waren die Durchführbarkeit der präoperativen Rehabilitation und der Assessments sowie eine erste Abschätzung der Effekte.

Ergebnisse 4 Patient*innen wurden eingeschlossen. In allen Kliniken begannen die Patient*innen 21,5 ± 3 Tage vor der Operation mit dem Training, es gab keine Trainingsunterbrechungen. Es wurden keine unerwünschten Ereignisse beobachtet, was darauf hinweist, dass das präoperative Bewegungstraining sicher ist. Das vorgesehene Studiendesign konnte eingehalten werden. Die ausgewählten funktionellen Assessments sind durchführbar, sicher und die Ergebnisse sind für die Studie geeignet. Die Rekrutierung erwies sich jedoch als große Herausforderung.

Diskussion Die Ergebnisse zeigen, dass ein präoperatives Training durchführbar ist. Um das Rekrutierungspotenzial voll auszuschöpfen, ist es notwendig, die Risikostratifizierung, die organisatorischen Abläufe der beteiligten Kliniken zu spezifizieren und eine hohe Kooperationsbereitschaft aller beteiligten Disziplinen sicherzustellen bzw. zu definieren.

Schlussfolgerung Ein präoperatives, intensives Training vor einer geplanten Lungenteilresektion in 4 großen Spitälern der Schweiz war machbar. Es zeigten sich positive Effekte bezüglich Kraft und Ausdauer, zudem fühlten sich die Patient*innen in dieser Phase gut betreut. Ängste und Bedenken konnten frühzeitig adressiert und besprochen werden. Die Machbarkeitsstudie lieferte wertvolle Erkenntnisse für das Protokoll einer nachfolgenden Effektivitätsstudie.

Functional and postoperative outcomes after high-intensity interval training in lung cancer patients: A systematic review and meta-analysis

Objective

The study evaluated the effects of high-intensity interval training (HIIT) on postoperative complications and lung function in patients with lung cancer compared to usual care.

Methods

We searched electronic databases in April 2022, including PubMed, Embase, the Cochrane Library, Web of Science, and the China National Knowledge Infrastructure (CNKI). Two authors independently applied the Cochrane Risk of Bias tool to assess the quality of RCTs. The postoperative complications, length of hospitalization, and cardiopulmonary functions from the studies were pooled for statistical analysis.

Results

A total of 12 randomized controlled trials were eligible for inclusion and were conducted in the meta-analysis. HIIT significantly increased VO_2peak (MD = 2.65; 95% CI = 1.70 to 3.60; I² = 40%; P <0.001) and FEV1 (MD = 0.12; 95% CI = 0.04 to 0.20; I² = 51%; P = 0.003) compared with usual care. A subgroup analysis of studies that applied HIIT perioperatively showed significant improvement of HIIT on FEV1 (MD = 0.14; 95% CI = 0.08 to 0.20; I² = 36%; P <0.0001). HIIT significantly reduced the incidence of postoperative atelectasis in lung cancer patients compared with usual care (RD = -0.16; 95% CI = -0.24 to -0.08; I² = 24%; P <0.0001). There was no statistically significant effect of HIIT on postoperative arrhythmias (RD = -0.05; 95% CI = -0.13 to 0.03; I² = 40%; P = 0.22), length of hospitalization (MD = -1.64; 95% CI = -3.29 to 0.01; P = 0.05), and the six-minute walk test (MD = 19.77; 95% CI = -15.25 to 54.80; P = 0.27) compared to usual care.

Conclusion

HIIT may enhance VO_2peak and FEV1 in lung cancer patients and reduce the incidence of postoperative atelectasis. However, HIIT may not reduce the incidence of postoperative arrhythmia, shorten the length of hospitalization, or improve the exercise performance of patients with lung cancer.

Systematic review registration

PROSPERO, CRD42022335441.

Preoperative respiratory therapy in patients undergoing surgery for lung cancer: A randomized controlled trial

BACKGROUND

A preoperative respiratory therapy treatment was performed to analyze the effectiveness, with respect to postoperative air leak and pain, in patients undergoing surgery for lung cancer.

OBJECTIVES

To analyze air leakage and postoperative pain.

MATERIAL AND METHODS

Seventy one patients were studied, with a mean age of 62.58 years. Descriptive variables of gender, carcinogenic pathology, type of surgical incision and lung resection, use of glue and endostapler, and presence of adhesions were analyzed. Likewise, analysis of the quantitative variables of age, body mass index and forced expiratory volume in 1 s Two homogeneous groups resulted. Differentiated, experimental group (EG) that performed preoperative respiratory therapy and control group (CG).

RESULTS

There were statistically significant differences in favor of the EG with respect to postoperative air leak on days 1-2 during the performance of physiotherapy techniques, the food and during the performance of the exercises autonomously. Furthermore, differences in air leakage were observed on days 2-4 during gait. The number of patients decreased to a greater extent in the EG. Regarding pain, there were statistically significant differences in the sample on days 1-4, with greater intensity of pain in the CG and after doing physiotherapy every day except the second.

CONCLUSIONS

Preoperative respiratory therapy in patients undergoing surgery for lung cancer was effective in reducing the number of patients who presented postoperative air leak and reducing pain in the EG.

[KINE PREOP pilot study: Prehabilitation in fast-track thoracic surgery protocol]

INTRODUCTION

Prehabilitation preceding oncological thoracic surgery according to a fast-track enhanced recovery after surgery (ERAS) protocol is in full expansion. Many recent studies have demonstrated the benefits of preoperative pulmonary rehabilitation as a means of reducing postoperative pulmonary complications. Unfortunately, it is rarely carried out by independent physiotherapists, and questions arise: is it feasible in private practice? Can it yield results similar to those achieved in institutional settings?

DESIGN

The study was non-interventional. The patients included had to be able to practice physical activities according to a standard ERAS approach. The endpoints were: postoperative pulmonary complications, physical condition (VO2max), and impact on the quality of life (SF-36 questionnaire). A statistical study was conducted to analyze the results with parametric and non-parametric tests.

RESULTS

Between June 2018 and January 2019, nine patients were included. From two to fifteen pulmonary rehabilitation sessions were carried out by six volunteering independent physiotherapists. Only two minor postoperative complications ensued. VO2max post rehabilitation increased on average by 2.4mL.kg -1.min-1. The SF-36 physical score increased significantly (+17.9%). The physical functioning (PF) (+28.9), physical restrictions (PR) (+11.1) and vitality (VT) (+16.7) sub-scores likewise improved.

CONCLUSION

Based on a literature review and on comparisons, our results seem promising. While further investigations are needed, it would seem that prehabilitation by independent physiotherapists leads to results similar to those achieved in inpatient prehabilitation.

Impact of Preoperative Patient Education on Postoperative Recovery in Abdominal Surgery: A Systematic Review

BACKGROUND

Patient education is recommended as an essential component of Enhanced Recovery after Surgery (ERAS) protocols. However, there are many uncertainties regarding content and methodological criteria, which may have a significant impact on the effectiveness of the intervention. The aim of this review is to assess the effect of preoperative patient education on postoperative recovery in abdominal surgery and to examine different patient education strategies for their effectiveness.

METHODS

We performed a systematic review according to the PRISMA guidelines. PubMed, CINAHL, and Cochrane were searched from 2011 to 2022. All studies investigating the effect of preoperative patient education on postoperative recovery in abdominal surgery were included. A critical quality assessment of all included studies was performed.

RESULTS

We identified 826 potentially suitable articles via a database search and included 12 studies in this review. The majority of the included studies reported a reduction in the length of hospital stay (LOS) and even a reduction in postoperative complications and adverse events. Patients with preoperative education seemed to have lower psychological stress and experience less anxiety. However, the contents, delivery, and general conditions were implemented differently, making comparison difficult. Moreover, the majority of the included studies were weak in quality.

CONCLUSION

With this review, we report potential effects, current implementations, and frameworks of patient education. However, the results must be interpreted with caution and are not directly transferable to clinical practice. Further studies in this field are necessary to make concrete recommendations for clinical practice.

Preoperative exercise training for people with non-small cell lung cancer

BACKGROUND

Surgical resection for early-stage non-small cell lung cancer (NSCLC) offers the best chance of cure, but it is associated with a risk of postoperative pulmonary complications. It is unclear if preoperative exercise training, and the potential resultant improvement in exercise capacity, may improve postoperative outcomes. This review updates our initial 2017 systematic review.

OBJECTIVES

1. To evaluate the benefits and harm of preoperative exercise training on postoperative outcomes, such as the risk of developing a postoperative pulmonary complication and the postoperative duration of intercostal catheter, in adults scheduled to undergo lung resection for NSCLC. 2. To determine the effect on length of hospital stay (and costs associated with postoperative hospital stay), fatigue, dyspnoea, exercise capacity, lung function and postoperative mortality.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was from 28 November 2016 to 23 November 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which study participants who were scheduled to undergo lung resection for NSCLC were allocated to receive either preoperative exercise training or no exercise training.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. risk of developing a postoperative pulmonary complication; 2. postoperative duration of intercostal catheter and 3.

SAFETY

Our secondary outcomes were 1. postoperative length of hospital stay; 2. postintervention fatigue; 3. postintervention dyspnoea; 4. postintervention and postoperative exercise capacity; 5. postintervention lung function and 6. postoperative mortality. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

Along with the five RCTs included in the original version, we identified an additional five RCTs, resulting in 10 RCTs involving 636 participants. Preoperative exercise training results in a large reduction in the risk of developing a postoperative pulmonary complication compared to no preoperative exercise training (risk ratio (RR) 0.45, 95% CI 0.33 to 0.61; I2 = 0%; 9 studies, 573 participants; high-certainty evidence). The evidence is very uncertain about its effect on postoperative intercostal catheter duration (MD -2.07 days, 95% CI -4.64 to 0.49; I2 = 77%, 3 studies, 111 participants; very low-certainty evidence). Preoperative exercise training is likely safe as studies reported no adverse events. Preoperative exercise training likely results in a reduction in postoperative length of hospital stay (MD -2.24 days, 95% CI -3.64 to -0.85; I2 = 85%; 9 studies, 573 participants; moderate-certainty evidence). Preoperative exercise training likely increases postintervention exercise capacity measured by peak oxygen consumption (MD 3.36 mL/kg/minute, 95% CI 2.70 to 4.02; I2 = 0%; 2 studies, 191 participants; moderate-certainty evidence); but the evidence is very uncertain about its effect on postintervention exercise capacity measured by the 6-minute walk distance (MD 29.55 m, 95% CI 12.05 to 47.04; I2 = 90%; 6 studies, 474 participants; very low-certainty evidence). Preoperative exercise training may result in little to no effect on postintervention lung function (forced expiratory volume in one second: MD 5.87% predicted, 95% CI 4.46 to 7.28; I2 = 0%; 4 studies, 197 participants; low-certainty evidence).  AUTHORS' CONCLUSIONS: Preoperative exercise training results in a large reduction in the risk of developing a postoperative pulmonary complication compared to no preoperative exercise training for people with NSCLC. It may also reduce postoperative length of hospital stay, and improve exercise capacity and lung function in people undergoing lung resection for NSCLC. The findings of this review should be interpreted with caution due to risk of bias. Research investigating the cost-effectiveness and long-term outcomes associated with preoperative exercise training in NSCLC is warranted.

Systematic assessment of microRNAs associated with lung cancer and physical exercise

It has long been evident that physical exercise reduces the risk of cancer and improves treatment efficacy in tumor patients, particularly in lung cancer (LC). Several molecular mechanisms have been reported, but the mechanisms related to microRNAs (miRNAs) are not well understood. MiRNAs modulated various basic biological processes by negatively regulating gene expression and can be transmitted between cells as signaling molecules. Recent studies have shown that miRNAs are actively released into the circulation during exercise, and are deeply involved in cancer pathology. Hence, the role of exercise intervention in LC treatment may be further understood by identifying miRNAs associated with LC and physical activity. Here, miRNAs expression datasets related to LC and exercise were collected to screen altered miRNAs. Further bioinformatic approaches were performed to analyze the value of the selected miRNAs. The results identified 42 marker miRNAs in LC, of which three core-miRNAs (has-miR-195, has-miR-26b, and has-miR-126) were co-regulated by exercise and cancer, mainly involved in cell cycle and immunity. Our study supports the idea that using exercise intervention as adjuvant therapy for LC patients. These core-miRNAs, which are down-regulated in cancer but elevated by exercise, may act as suppressors in LC and serve as non-invasive biomarkers for cancer prevention.

The effect of prehabilitation on the postoperative outcomes of patients undergoing colorectal surgery: A systematic review and meta-analysis

Study objective

Prehabilitation is analogous to marathon training and includes preoperative preparation for exercise, as well as nutrition and psychology. However, evidence-based recommendations to guide prehabilitation before colorectal surgery are limited. We aimed to evaluate the effect of prehabilitation on the postoperative outcomes of patients undergoing colorectal surgery.

Design

This study is a systematic review and meta-analysis.

Methods

The PubMed, Embase, and Cochrane databases were searched for studies reporting the effect of prehabilitation strategies versus standard care or rehabilitation in patients undergoing colorectal surgery. The primary outcomes were overall postoperative complications and length of hospital stay (LOS), and the secondary outcome was functional capacity (measured using the 6-min walk test [6MWT]) at 4 and 8 weeks after surgery.

Main results

Fifteen studies with 1,306 participants were included in this meta-analysis. The results showed no significant reduction in the number of overall postoperative complications (risk ratio = 1.02; 95% confidence interval [CI] = 0.79-1.31; p = 0.878) or LOS (standardized mean difference = 0.04; 95% CI = -0.11 to 0.20; p = 0.589) in patients who underwent colorectal surgery with or without prehabilitation strategy. Additionally, there were no significant differences in the functional capacity estimated using the 6MWT at 4 and 8 weeks postoperatively.

Conclusions

Prehabilitation did not significantly affect the number of postoperative complications, LOS, or functional capacity of patients undergoing colorectal surgery. Whether prehabilitation should be recommended deserves further consideration.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=290108, identifier CRD42021290108.

Recovery of respiratory muscle strength, physical function, and dyspnoea after lobectomy in lung cancer patients undergoing pulmonary rehabilitation: A retrospective study

OBJECTIVE

To characterise changes in respiratory muscle strength, physical function, and dyspnoea in patients who underwent pre- and post-operative exercise intervention following lobectomy for non-small-cell lung cancer (NSCLC).

METHODS

This retrospective study included NSCLC patients who underwent lobectomy via video-assisted thoracoscopic surgery (VATS) or posterolateral thoracotomy (PLT) and pre- and post-operative exercise intervention consisting of breathing, flexibility, resistance, aerobic exercises, coughing/huffing techniques, and early mobilisation. Maximum mouth inspiratory (Pimax) and expiratory pressures (Pemax), 6-min walk distance (6MWD), quadriceps force (QF), and modified Medical Research Council (mMRC) dyspnoea scale were evaluated preoperatively, at hospital discharge, and post-lobectomy 1 and 3 months.

RESULTS

Data from 41 patients were analysed. At hospital discharge, the Pimax, Pemax, 6MWD, and mMRC dyspnoea scores were lower than pre-operatively; QF remained unchanged; Pimax and 6MWD recovered to pre-operative values at post-lobectomy 1 month; and Pemax and mMRC dyspnoea scores recovered at 3 months. During sub-analysis, Pimax and mMRC dyspnoea scores in the VATS (n = 24) and PLT groups (n = 17) recovered to pre-operative values at post-lobectomy 1 and 3 months.

CONCLUSION

After lobectomy, respiratory muscle strength, physical function, and dyspnoea in patients who underwent exercise intervention returned to pre-operative values at post-lobectomy 3 months.

Physical activity interventions in older people with cancer: A review of systematic reviews

INTRODUCTION

Whilst there has been a wealth of research on benefits of physical activity (PA) in people with cancer, with three published reviews of reviews, no review of reviews has focused on older adults (65 years or older) who may have unique biological characteristics and barriers. We summarised PA effectiveness from reviews where majority of study participants were 65 years or older.

METHODS

Six databases were searched for systematic reviews of randomised controlled studies (RCTs)/quasi-RCTs examining any type of PA in reviews where majority of study participants were aged 65 years or older. Two reviewers conducted the search and analysis according to PRISMA and JBI guidelines.

RESULTS

Fifteen reviews involving 76 different primary studies (5404 participants) were included. The majority (3827; 71%) had prostate cancer. PA was associated with benefits across multiple physical outcomes (muscle mass, functional performance, strength), improved fatigue and health service outcomes. In contrast to younger adults, there was no improvement in anxiety and mixed findings for quality of life and depression.

CONCLUSION

PA is associated with multiple benefits in older adults with cancer, with some differences compared to younger individuals which may reflect biological or behavioural determinants. Future research should focus on mechanisms underlying PA effectiveness and underrepresented populations.

Effectiveness of Perioperative Cardiopulmonary Rehabilitation in Patients With Lung Cancer Undergoing Video-Assisted Thoracic Surgery

Objectives

Patients with lung cancer pose a high risk of morbidity and mortality after lung resection. Those who receive perioperative cardiopulmonary rehabilitation (PRCR) have better prognosis. Peak oxygen consumption (peak VO₂), VO₂ at the ventilatory threshold (VO₂ at VT), and slope of minute ventilation to carbon dioxide production (V_E/V_CO2 slope) measured during pre-surgical cardiopulmonary exercise testing (CPET) have prognostic values after lung resection. We aimed to investigate the influence of individualized PRCR on postoperative complications in patients undergoing video-assisted thoracic surgery (VATS) for lung cancer with different pre-surgical risks.

Methods

This was a retrospective study. We recruited 125 patients who underwent VATS for lung cancer between 2017 and 2021. CPET was administered before surgery to evaluate the risk level and PRCR was performed based on the individual risk level defined by peak VO2, VO2 at VT, and VE/VCO2 slope, respectively. The primary outcomes were intensive care unit (ICU) and hospital lengths of stay, endotracheal intubation time (ETT), and chest tube insertion time (CTT). The secondary outcomes were postoperative complications (PPCs), including subcutaneous emphysema, pneumothorax, pleural effusion, atelectasis, infection, and empyema.

Results

Three intergroup comparisons based on the risk level by peak VO2 (3 groups), VO2 at VT (2 groups), and VE/VCO2 slope (3 groups) were done. All of the comparisons showed no significant differences in both the primary and secondary outcomes (p = 0.061–0.910).

Conclusion

Patients with different risk levels showed comparable prognosis and PPCs after undergoing CPET-guided PRCR. PRCR should be encouraged in patients undergoing VATS for lung cancer.

Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery

BACKGROUND

Surgery is the cornerstone in curative treatment of colorectal cancer. Unfortunately, surgery itself can adversely affect patient health. 'Enhanced Recovery After Surgery' programmes, which include multimodal interventions, have improved patient outcomes substantially. However, these are mainly applied peri- and postoperatively. Multimodal prehabilitation includes multiple preoperative interventions to prepare patients for surgery with the aim of increasing resilience, thereby improving postoperative outcomes.

OBJECTIVES

To determine the effects of multimodal prehabilitation programmes on functional capacity, postoperative complications, and quality of life in adult patients undergoing surgery for colorectal cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and PsycINFO in January 2021. We also searched trial registries up to March 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adult patients with non-metastatic colorectal cancer, scheduled for surgery, comparing multimodal prehabilitation programmes (defined as comprising at least two preoperative interventions) with no prehabilitation. We focused on the following outcomes: functional capacity (i.e. 6-minute walk test, VO2peak, handgrip strength), postoperative outcomes (i.e. complications, mortality, length of hospital stay, emergency department visits, re-admissions), health-related quality of life, compliance, safety of prehabilitation, and return to normal activities.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data, assessed risk of bias and used GRADE to assess the certainty of the evidence. Any disagreements were solved with discussion and consensus. We pooled data to perform meta-analyses, where possible.

MAIN RESULTS

We included three RCTs that enrolled 250 participants with non-metastatic colorectal cancer, scheduled for elective (mainly laparoscopic) surgery. Included trials were conducted in tertiary care centres and recruited patients during periods ranging from 17 months to 45 months. A total of 130 participants enrolled in a preoperative four-week trimodal prehabilitation programme consisting of exercise, nutritional intervention, and anxiety reduction techniques. Outcomes of these participants were compared to those of 120 participants who started an identical but postoperative programme. Postoperatively, prehabilitation may improve functional capacity, determined with the 6-minute walk test at four and eight weeks (mean difference (MD) 26.02, 95% confidence interval (CI) -13.81 to 65.85; 2 studies; n = 131; and MD 26.58, 95% CI -8.88 to 62.04; 2 studies; n = 140); however, the certainty of evidence is low and very low, respectively, due to serious risk of bias, imprecision, and inconsistency. After prehabilitation, the functional capacity before surgery improved, with a clinically relevant mean difference of 24.91 metres (95% CI 11.24 to 38.57; 3 studies; n = 225). The certainty of evidence was moderate due to downgrading for serious risk of bias. Prehabilitation may also result in fewer complications (RR 0.95, 95% CI 0.70 to 1.29; 3 studies; n = 250) and fewer emergency department visits (RR 0.72, 95% CI 0.39 to 1.32; 3 studies; n = 250). The certainty of evidence was low due to downgrading for serious risk of bias and imprecision. On the other hand, prehabilitation may also result in a higher re-admission rate (RR 1.20, 95% CI 0.54 to 2.65; 3 studies; n = 250). The certainty of evidence was again low due to downgrading for risk of bias and imprecision. The effect on VO2peak, handgrip strength, length of hospital stay, mortality rate, health-related quality of life, return to normal activities, safety of the programme, and compliance rate could not be analysed quantitatively due to missing or insufficient data. The included studies did not report a difference between groups for health-related quality of life and length of hospital stay. Data on remaining outcomes were not reported or were reported inadequately in the included studies.

AUTHORS' CONCLUSIONS

Prehabilitation may result in an improved functional capacity, determined with the 6-minute walk test both preoperatively and postoperatively. Complication rates and the number of emergency department visits postoperatively may also diminish due to a prehabilitation programme, while the number of re-admissions may be higher in the prehabilitation group. The certainty of evidence ranges from moderate to very low, due to downgrading for serious risk of bias, imprecision and inconsistency. In addition, only three heterogeneous studies were included in this review. Therefore, the findings of this review should be interpreted with caution. Numerous relevant RCTs are ongoing and will be included in a future update of this review.

Unmet needs in the management of unresectable stage III non-small cell lung cancer: a review after the 'Radio Talk' webinars

INTRODUCTION

Stage III non-small cell lung cancer (NSCLC) is a variable entity, encompassing bulky primary tumors, nodal involvement or both. Multidisciplinary evaluation is essential to discuss multiple treatment options, to outline optimal management and to examine the main debated topics and critical issues not addressed by current trials and guidelines that influence daily clinical practice.

AREAS COVERED

From March to May 2021, 5 meetings were scheduled in a webinar format titled 'Radio Talk' due to the COVID-19 pandemic; the faculty was composed of 6 radiation oncologists from 6 different Institutions of Italy, all of them were the referring radiation oncologist for lung cancer treatment at their respective departments and were or had been members of AIRO (Italian Association of Radiation Oncology) Thoracic Oncology Study Group. The topics covered included: pulmonary toxicity, cardiac toxicity, radiotherapy dose, fractionation and volumes, unfit/elderly patients, multidisciplinary management.

EXPERT OPINION

The debate was focused on the unmet needs triggered by case reports, personal experiences and questions; the answers were often not univocal, however, the exchange of opinion and the contribution of different centers confirmed the role of multidisciplinary management and the necessity that the most critical issues should be investigated in clinical trials.

Physical activity in surgical lung cancer patients: a systematic review

PURPOSE

Perioperative exercise could improve health outcomes of surgical lung cancer patients, but less is known about their natural physical activity (PA) behavior before exercise interventions. This review aimed to synthesize evidence on PA, regarding the following: (1) proportion of patients meeting PA guidelines, (2) amount of PA, (3) PA trajectory following surgery, and (4) correlates of PA before or after surgery.

METHODS

We conducted a systematic review using PubMed, CINHAL, Scopus, and SPORTDiscus (July 2021). Observational or experimental studies that measure PA of lung cancer patients before/after surgery were included. We assessed methodological quality using the NIH Quality Assessment Tools and extracted data using a standardized form.

RESULTS

Seventeen studies (25 articles, N = 1737 participants) published between 2009 and 2021 were included. Fourteen studies had sample sizes less than 100. Thirteen studies were of fair quality and four studies were of good quality. Only 23-28% of patients met PA guideline (150 min/week moderate-vigorous PA) at 6 months-6 years after surgery. Patients took an average of 3822-10,603 daily steps before surgery and 3934-8863 steps at 1-3 months after surgery. Physical activity was lower at 1 day-3 months after surgery, compared with preoperative levels. Perioperative PA was positively associated with exercise capacity, quality of life and reduced postoperative complications.

CONCLUSION

This review suggests that PA is low among surgical lung cancer patients, and it may not recover within 3 months following surgery. Physical activity has the potential to improve postoperative outcomes. However, the existing evidence is weak, and future larger longitudinal studies are needed.

Preoperative Three-Dimensional Lung Simulation Before Thoracoscopic Anatomical Segmentectomy for Lung Cancer: A Systematic Review and Meta-Analysis

Background

Whether the utilization of preoperative three-dimensional (3D) lung simulation can improve the outcomes of segmentectomy for lung cancer (LC) is still controversial. Our meta-analysis was performed to compare preoperative 3D lung simulation with non-3D procedures in terms of perioperative outcomes.

Methods

Seven databases (Embase, Ovid Medline, ScienceDirect, PubMed, Web of Science, Cochrane Library, and Scopus) were searched for eligible articles. Intraoperative outcomes (conversion, operative time, etc.), postoperative indicators (postoperative hospital stay, total number of complications, etc.) and postoperative complications were endpoints.

Results

After applying predefined inclusion criteria, we included 8 studies and 989 patients (3D group: 552 patients; non-3D group: 437 patients) in our meta-analysis. The results of the meta-analysis showed that preoperative 3D lung simulation could significantly decrease the blood loss (mean difference [MD]: -16.21 [-24.95 to -7.47]ml, p = 0.0003), operative time (MD: -13.03 [-25.56 to -0.50]ml, p = 0.04), conversion rate (conversion from segmentectomy to thoracotomy or lobectomy) (MD: 0.12 [0.03-0.48], p = 0.003), postoperative hospital stay (MD: -0.25 [-0.46 to 0.04]days, p = 0.02) and total number of complications (MD: 0.59 [0.43-0.82], p = 0.001) compared with non-3D procedures. The number of resected lymph nodes (LNs), postoperative drainage time, postoperative forced expiratory volume in the first second (postoperative FEV1) and postoperative drainage volume were similar in the two groups. Arrhythmia (5.30%), pulmonary air leakage (2.72%), atrial fibrillation (2.20%), pulmonary infection (2.04%), and pneumonia (1.73%) were the top 5 postoperative complications in the 3D group.

Conclusions

Preoperative 3D lung simulation was better than non-3D procedures in segmentectomy for LC, with better intraoperative and postoperative outcomes. However, our results should be confirmed in larger prospective randomized controlled trials.

Systematic Review Registration

PROSPERO, identifier: CRD42021275020.

Circadian rhythms and cancers: the intrinsic links and therapeutic potentials

The circadian rhythm is an evolutionarily conserved time-keeping system that comprises a wide variety of processes including sleep-wake cycles, eating-fasting cycles, and activity-rest cycles, coordinating the behavior and physiology of all organs for whole-body homeostasis. Acute disruption of circadian rhythm may lead to transient discomfort, whereas long-term irregular circadian rhythm will result in the dysfunction of the organism, therefore increasing the risks of numerous diseases especially cancers. Indeed, both epidemiological and experimental evidence has demonstrated the intrinsic link between dysregulated circadian rhythm and cancer. Accordingly, a rapidly increasing understanding of the molecular mechanisms of circadian rhythms is opening new options for cancer therapy, possibly by modulating the circadian clock. In this review, we first describe the general regulators of circadian rhythms and their functions on cancer. In addition, we provide insights into the mechanisms underlying how several types of disruption of the circadian rhythm (including sleep-wake, eating-fasting, and activity-rest) can drive cancer progression, which may expand our understanding of cancer development from the clock perspective. Moreover, we also summarize the potential applications of modulating circadian rhythms for cancer treatment, which may provide an optional therapeutic strategy for cancer patients.

Population-Based Analysis of Sex-Dependent Risk Factors for Mortality in Thoracic Surgery for Lung Cancer

<b><i>Objective:</i></b> Sex is an important predictor for lung cancer survival and a favorable prognostic indicator for women compared to men. Specific surgery-related sex differences of patients with lung cancer remain unclear. The aim of this study is to analyze sex-specific differences after lung cancer resections to identify factors for an unfavorable prognosis. <b><i>Methods:</i></b> This is a retrospective analysis of a German nationwide discharge register of every adult inpatient undergoing pulmonary resection for lung cancer from 2014 until 2017. DRG data and OPS procedures were analyzed with the help of the Federal Statistical Office using remote controlled data. A multivariable regression model was established in a stepwise process to evaluate the effect of sex on inpatient mortality. <b><i>Results:</i></b> A total of 38,806 patients underwent surgical resection for lung cancer between January 2014 and December 2017 in Germany. Women were significantly younger at admission than men (mean 64.7 years [SD 10.1] vs. 66.6 years [SD 9.5]; <i>p</i> &#x3c; 0.0001). They had fewer unreferred admissions (risk ratio 0.83 [0.77, 0.90], <i>p</i> &#x3c; 0.0001) and were significantly less likely to have recorded comorbidities. Raw in-hospital mortality was 1.8% for women and 4.1% for men. In the multivariable analysis of in-hospital mortality, the likelihood of death for women compared to men was 21% reduced (OR 0.79 [CI: 0.66, 0.93, <i>p</i> = 0.005]). The risk of postoperative complications such as ventilation &#x3e;48 h, ARDS, tracheotomy, or pneumonia was significantly lower for women. <b><i>Conclusions:</i></b> Women undergoing lung cancer surgery were younger and had less comorbidities than men in Germany. Female sex was associated with lower mortality and less postoperative complications.

A national survey of oncology physiotherapy services for cancer survivors in Australia

BACKGROUND

Cancer is a leading cause of illness globally. Advancements in screening and treatment have led to improved survivorship. Physiotherapy is integral in improving survivorship for people with cancer, with strong evidence supporting the use of various physiotherapy services. However, the scope and extent of these services within clinical practice in Australia is unknown.

AIM

Identify and describe physiotherapy service provision for cancer survivors in Australia and describe the scope of physiotherapy services provided to cancer survivors.

METHODS

This cross-sectional study recruited physiotherapists and their respective managers involved in cancer service/s provision across Australia. Physiotherapy departments of tertiary hospitals and known oncology rehabilitation programs were contacted through a government directory and snowball sampling. The online survey included questions related to the extent and scope of service provision of physiotherapy for cancer survivors. Quantitative data were descriptively analyzed whereas open-ended responses were analyzed and presented narratively.

RESULTS

Seventy-nine physiotherapy services were identified from 159 hospitals and/or health networks. Of the 55 (70%) responses received, 87% were from metropolitan areas, whereas 13% were regionally/rurally based services. Prehabilitation services mostly offered individual programs whereas rehabilitation programs had a mix of individual and group-based programs. The service content between prehabilitation and rehabilitation were similar, comprising primarily exercise-based interventions, followed by education and impairment-based therapies.

CONCLUSION

Few designated physiotherapy services for cancer survivors exist in Australia. There is also disparity between service provision between metropolitan and regional/rural areas highlighting a need for clinicians, managers, and policy makers to invest more resources in establishing oncology physiotherapy services.

Preoperative Physical Inactivity Affects the Postoperative Course of Surgical Patients with Lung Cancer

OBJECTIVE

Preoperative performance status is an important factor in thoracic surgery, but little is known about the effect of preoperative physical activity (PA) on the postoperative course. This study investigated the associations between preoperative PA and postoperative complications and clinical outcomes of lung cancer surgery.

METHODS

This prospective observational study included patients who underwent surgery for lung cancer at a single institution. PA was measured before hospitalization for 5 consecutive days and then after surgery until hospital discharge. The daily step count and time spent performing moderate intensity activity (> 3 metabolic equivalents) were measured with an accelerometer. We examined the correlations between PA and preoperative pulmonary function and physical fitness, and examined the relationship between postoperative complication and PA. Finally, a multivariate analysis was performed with pre-hospital PA as the dependent variable.

RESULTS

Forty-two patients were analyzed. Univariate analysis found no correlation between pre-hospital PA and preoperative pulmonary function, but found significant positive correlations between pre-hospital PA and time spent performing moderate intensity activity, in-hospital PA, preoperative 6-minute walk distance, and maximum gait speed (r > 0.5, p < 0.01). The nine patients who developed postoperative complications had significantly lower pre-hospital and postoperative step count than the patients with no complication (p = 0.04). Multiple regression analysis showed that pre-hospital PA was significantly associated with time spent performing moderate intensity activity, maximum gait speed, and postoperative complication.

CONCLUSIONS

Evaluation of pre-hospital PA is useful in predicting the postoperative course after lung cancer surgery.

The Effect of Pre-operative Exercise Intervention on Patient Outcomes Following Bariatric Surgery: a Systematic Review and Meta-analysis

This systematic review aimed to assess the effect of a pre-operative exercise intervention on short- and long-term health and clinical outcomes for adult patients undergoing bariatric surgery (BS). We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), SPORTDiscus and reference lists of relevant papers, through March 2021. Five randomised controlled trials were included (n = 199 patients). Modest increases in cardiorespiratory fitness (VO2max) were found at both pre-operative (0.73 mL kg-1 min-1, P ≤ 0.001) and maximum follow-up time points (0.98 mL kg-1 min-1, P ≤ 0.04). There was no significant effect of an exercise intervention on percentage total weight loss (%TWL). Pre-operative exercise can induce significant short- and long-term improvements in fitness in individuals with obesity. There is insufficient evidence to determine whether pre-operative training impacts other post-operative clinical outcomes.

[Pulmonary function testing and prehabilitation in thoracic surgery]

Preoperative assessment should include spirometry and analysis of the diffusing capacity for carbon monoxide. If necessary, exercise tests can be performed. High risk patients can be revealed considering these data. These patients need for prehabilitation, i.e. preoperative measures increasing functional capacity. This review is devoted to preoperative assessment, principles of prehabilitation and perioperative nutritional support.

Home-based pulmonary rehabilitation in patients undergoing (chemo)radiation therapy for unresectable lung cancer: a prospective explorative study

AIMS

The prevention of pulmonary toxicity is an important goal for patient candidate to radiation therapy for lung cancer. There is a lack of evidence on the role of exercise training for patients with unresectable stage III lung cancer candidated to radical treatment. The aim of this study was to evaluate the feasibility of a home-based pulmonary rehabilitation (PR) program and to identify reliable tools in terms of respiratory function, exercise capacity and quality of life.

METHODS

Patients' recruitment lasted from April 2020 till February 2022. The PR program was proposed concomitantly to radiation therapy to the first 20 patients (interventional group, IG), and the other 20 patients were identified as an observational group (OG). All patients were assessed at baseline (T0) and after 8 weeks (T2) with 6 minute walking test (6MWT), modified Borg Scale (mBORG), SF-36 questionnaire (SF-36) and pulmonary function test (PFT); after 4 weeks (T1), only SF-36 was administered.

RESULTS

A decrease of 13.8 m in the walked-distance was registered in the OG between T0 and T2 (p = 0.083). Instead, an increase of 56.6 m in the distance walked was recorded in the IG between T0 and T2 (p ≤ 0.001). In the OG, the mBORG scores showed a negative trend. On the contrary, in the IG, these scores showed a slight improvement. In the OG, all the items of SF-36 scores decreased between T0 and T1. In the IG, an increased trend from T0 to T2 was observed for all the items of SF-36. No clinically significant variations were detected from baseline to T2 in both groups regarding PFT.

CONCLUSION

The 6MWT, mBORG and SF-36 resulted as useful tools to assess the role of a PR program. A significant gain in functional exercise capacity and a prevention of the physiological impairment of QoL during radio(chemo)therapy was registered.

Effects of Prehabilitation on Functional Capacity in Aged Patients Undergoing Cardiothoracic Surgeries: A Systematic Review

Background: an increasing number of advanced age patients are considered for cardiothoracic surgeries. Prehabilitation optimizes the patients’ functional capacity and physiological reserve. However, the effectiveness of prehabilitation on physical functioning and postoperative recovery in the scope of cardiothoracic surgery is still uncertain. Objective: to assess the effectiveness of prehabilitation on pre- and/or postoperative functional capacity and physiological reserve in aged patients that are considered for cardiothoracic surgeries. Methods: this systematic review was registered in PROSPERO (CRD42021247117). The searches were conducted in PubMed, Web of Science, Scopus, and Cochrane CENTRAL until 18 April 2021. Randomized clinical trials that compared different prehabilitation strategies with usual care on the pre- and-postoperative results in aged patients undergoing cardiothoracic surgeries were included. Methodological quality was assessed by means of the Jadad scale, and the effectiveness of the interventions according to the Consensus on Therapeutic Exercise Training. Results: nine studies with 876 participants aged from 64 to 71.5 years old were included. Risk of bias was moderate due to the absence of double-blinding. The content of the interventions (multimodal prehabilitation n = 3; based on physical exercises n = 6) and the result measures presented wide variation, which hindered comparison across the studies. In general, the trials with better therapeutic quality (n = 6) reported more significant improvements in physical functioning, cardiorespiratory capacity, and in the postoperative results in the participants under-going prehabilitation. Conclusions: prehabilitation seems to improve functional capacity and postoperative recovery in aged patients undergoing cardiothoracic surgeries. However, due to the significant heterogeneity and questionable quality of the trials, both the effectiveness of prehabilitation and the optimum content are still to be determined.

Physical Function and Health-Related Quality of Life after Surgery for Nontuberculous Mycobacterium Pulmonary Disease: A Prospective Cohort Study

Purpose: To investigate the exercise capacity and health-related quality of life (HRQOL) of surgical patients with nontuberculous mycobacterial pulmonary disease (NTM-PD) preoperatively versus 6 months postoperatively.

Methods: This prospective observational study included patients with NTM-PD and was conducted at a single center. The intervention was surgical resection plus perioperative and post-discharge physical therapy. The physical function was assessed preoperatively and 6 months postoperatively using the 6-minute walk test (6MWT). HRQOL was assessed preoperatively and 6 months postoperatively using the Short-Form 36 (SF-36) health survey questionnaire and St. George’s Respiratory Questionnaire. The postoperative HRQOL was compared between patients with and without preoperative clinical symptoms.

Results: In total, 35 patients were analyzed. The preoperatively symptomatic group had significantly lower preoperative HRQOL than the preoperatively asymptomatic group (p <0.05). Compared with preoperatively, there were significant improvements at 6 months postoperatively in the 6MWT (p <0.01) and HRQOL, mainly in the SF-36 mental component summary (p <0.01). The SF-36 mental component summary in the preoperatively symptomatic group was very significantly improved from preoperatively to 6 months postoperatively (p <0.05).

Conclusion: The combination of surgical treatment and physical therapy for NTM-PD contributes to improvements in physical function and HRQOL.

Attitudes and Perceptions to Prehabilitation in Lung Cancer

Background: Prehabilitation to maximize exercise capacity before lung cancer surgery has the potential to improve operative tolerability and patient outcomes. However, translation of this evidence into clinical practice is limited. Aims: To determine the acceptability and perceived benefit of prehabilitation in lung cancer among thoracic surgeons. Procedure: 198 cardiothoracic surgeons within Australia and New Zealand were surveyed to evaluate their attitudes and perceived benefits of prehabilitation in lung cancer. Results: Response rate was 14%. A moderate proportion of respondents reported that there is a need to refer lung resection patients to preoperative physiotherapy/prehabilitation, particularly high-risk patients or those with borderline fitness for surgery. 91% of surgeons were willing to delay surgery (as indicated by cancer stage/type) to optimize patients via prehabilitation. The main barriers to prehabilitation reported were patient comorbidities and access to allied health professionals, with 33% stating that they were unsure who to refer to for prehabilitation in thoracic surgery. This is despite 60% of the cohort reporting that pulmonary rehabilitation is available as a preoperative resource. 92% of respondents believe that further research into prehabilitation in lung cancer is warranted. Conclusion: The benefits of prehabilitation for the oncology population have been well documented in the literature over recent years and this is reflected in the perceptions surgeons had on the benefits of prehabilitation for their patients. This survey demonstrates an interest among cardiothoracic surgeons in favor of prehabilitation, and therefore further research and demonstration of its benefit is needed in lung cancer to facilitate implementation into practice.

Effects of multimodal prehabilitation on muscle size, myosteatosis, and dietary intake of surgical patients with lung cancer - a randomized feasibility study

Many patients with lung cancer undergo surgery, which can increase the risk for muscle loss, leading to worsened outcomes. A multimodal prehabilitation intervention integrating dietary and muscle assessment may help clinicians better understand changes in these outcomes. This pilot assessed feasibility of multimodal prehabilitation in early-stage surgical lung cancer patients and explored relationships between body composition, muscle characteristics and dietary intake, as well as muscle changes due to prehabilitation. Patients were randomized to one of two groups: multimodal prehabilitation including nutritional supplements (fish oil with vitamin D3 + whey protein with leucine), exercise and relaxation, or standard of care. Physical function, dietary intake and muscle were evaluated at 0 and 4 weeks pre-operatively. Of 87 patients assessed for eligibility, 34 (39%) were randomized and 3 (9%) were lost to follow-up. Median age was 69 years and baseline protein intake was 1.0 g/kg/d. Adherence to exercise (86%) and supplements was high (93%); 3 patients (16%) reported side effects. Supplements significantly increased protein, omega-3 fatty acid, leucine and vitamin D intake. There were no significant changes in muscle characteristics. Multimodal prehabilitation with dietary and muscle analyses proved to be feasible. An adequately powered randomized controlled trial is warranted. ClinicalTrials.gov registration no: NCT04610606. Novelty: • Multimodal prehabilitation incorporating dietary assessment and muscle analysis is feasible for early-stage surgical lung cancer patients. • An adequately powered randomized controlled trial is warranted to further explore functional and post-operative outcomes.

Five-in-one nursing management promotes rapid recovery of patients after thoracic surgery

OBJECTIVE

To explore the application effect of five-in-one nursing management in the rapid recovery of patients undergoing thoracic surgery.

METHODS

This prospective study included 45 patients admitted to thoracic surgery before the implementation of five-in-one nursing as the control group and 40 patients admitted during the implementation as the test group. The patients in the control group were nursed by conventional nursing plan, whole those in the test group received the five-in-one nursing management. The perioperative indicators, mental state, postoperative rehabilitation, surgical complications, and nursing satisfaction were compared between the two groups.

RESULTS

Compared with the control group, the time of extubation, the time of getting out of bed for the first time, the recovery time of bowel sounds, the time of the first defecation, and the length of hospital stay in the experimental group were significantly shortened (P<0.05). At 24 h after surgery, MTL and GAS levels of patients in the test group were significantly higher than those of the control group (P<0.001). Moreover, the test group had lower visual analogue score (VAS) at different times after the operation, as well as lower the Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD) scores after nursing than the control group (P<0.001). The total incidence of postoperative complications in the experimental group was significantly reduced, while nursing satisfaction was significantly increased (P<0.001) when compared with the control group.

CONCLUSION

The five-in-one nursing management effectively promoted the rapid recovery of patients after thoracic surgery, shortened the length of hospital stay, and improved nursing satisfaction.

Potential effectiveness of a surgeon-delivered exercise prescription and an activity tracker on pre-operative exercise adherence and aerobic capacity of lung cancer patients

OBJECTIVES

Pre-operative exercise may improve functional outcomes for lung cancer patients, but barriers associated with cost, resources, and burden make it challenging to deliver pre-operative exercise programs. The goal of this proof-of-concept study was to determine level of moderate-vigorous physical activity (MVPA) and change in aerobic capacity after participation in a home-based pre-operative exercise intervention.

MATERIALS AND METHODS

Eighteen patients scheduled for surgery for suspected stage I-III lung cancer received an exercise prescription from their surgeon and wore a commercially-available device that tracked their daily MVPA throughout the pre-operative period. Descriptive statistics were used to calculate adherence to the exercise prescription. A one-sample t-test was used to explore change in aerobic capacity from baseline to the day of surgery.

RESULTS

Participants exhibited a mean of 20.4 (sd = 46.2) minutes of MVPA per day during the pre-operative period. On average, the sample met the goal of 30 min of MVPA on 16.4% of the days during the pre-operative period. The mean distance achieved at baseline for the 6-min walk test was 456.7 m (sd = 72.9), which increased to 471.1 m (sd = 88.4) on the day of surgery. This equates to a mean improvement of 13.8 m (sd = 37.0), but this difference was not statistically different from zero (p = 0.14). Eight of the 17 participants (47%) demonstrated a clinically significant improvement of 14 m or more.

CONCLUSION

A surgeon-delivered exercise prescription plus an activity tracker may promote clinically significant improvement in aerobic capacity and MVPA engagement among patients with lung cancer during the pre-operative period, but may need to be augmented with more contact with and support from practitioners over time to maximize benefits.

TRIAL REGISTRATION

The study protocol was registered with ClinicalTrials.gov prior to initiating participant recruitment (NCT03162718).

Rehabilitation for lung cancer patients undergoing surgery: results of the PUREAIR randomized trial

BACKGROUND

Surgery for Non Small Cell Lung Cancer is proven to be the most effective treatment in early stages, although concerns exist on its negative impact on patients' overall fitness.

AIM

To establish whether intensive pulmonary rehabilitation, preoperative and postoperative, improves exercise capacity in patients undergoing lung resection.

DESIGN

Single centre, unblinded, designed for superiority, 1:1 randomised controlled trial with two parallel arms.

SETTING

S.Maria Nuova Hospital of Reggio Emilia (Italy).

POPULATION

Patients referred from local lung cancer multi-disciplinary team for lung resection.

METHODS

Patients were randomised to either standard of care (SC) or SC + intensive perioperative pulmonary rehabilitation (SC+PR). The primary aim was to investigate the effectiveness of pulmonary rehabilitation in improving exercise capacity six months after surgery. Additionally, we wanted to investigate the same effect shortly after surgery (at one month), as well as the overall impact of rehabilitation on lung function, postoperative complications and length of stay, Quality of Life, mood disturbances and pain. Sample was sized based on the primary outcome assuming a minimal clinically significant difference of 25 metres in exercise tolerance, measured with 6 minutes walking test.

RESULTS

The exercise tolerance at 6 months after surgery was significantly higher in patients undertaking PR compared to SC (+48.9 metres vs -7.5 metres respectively, difference: +56.4 metres, 95% CI: 29.6 - 83.0, p<0.001) and it showed significantly lower impairment at 1 month after surgery in the intervention group (-3.0 metres vs -30.1 metres difference: +27.1 metres, 95% CI: 3.4 - 50.8, p=0.025). No other significant differences between groups were found.

CONCLUSIONS

Comparison between groups showed that pulmonary rehabilitation, administered pre and postoperatively, significantly improved exercise capacity at 6 months in patients undergoing lung resection; it also significantly reduced the decrease in exercise tolerance observed 1 month after surgery.

CLINICAL REHABILITATION IMPACT

The PUREAIR trial highlights the importance of combined pre-operative and post-operative rehabilitation in reducing physical deconditioning in lung cancer patients undergoing surgery. Comprehensive pulmonary rehabilitation improves exercise capacity at 1 and 6 months after surgery. The PUREAIR trial results increase knowledge on comprehensive rehabilitation's outcomes in the first six months after surgery.

Effect of Exercise Interventions on Quality of Life in Patients With Lung Cancer: A Systematic Review of Randomized Controlled Trials

PROBLEM IDENTIFICATION

Improving quality of life (QOL) is a key issue for patients with lung cancer. Exercise interventions could positively affect patients' QOL; however, there is no clear-cut understanding of the role of exercise in improving QOL in patients with lung cancer.

LITERATURE SEARCH

The PubMed®, Embase®, Cochrane Library, and Web of Science electronic databases were searched from inception to September 6, 2019.

DATA EVALUATION

16 randomized controlled trials met the inclusion criteria. A qualitative synthesis method was used to identify the effect of exercise interventions on QOL in patients with lung cancer.

SYNTHESIS

This review indicates that exercise interventions may have beneficial effects on the QOL of patients with lung cancer. The effectiveness seems to be affected by the duration of the intervention, as well as exercise frequency, intensity, and adherence.

IMPLICATIONS FOR PRACTICE

Exercise interventions can be integrated into management plans for patients with lung cancer to improve their QOL. Healthcare providers should consider developing optimal exercise prescriptions to maximize the results for this population.