Physical behavior and associations with health outcomes in operable NSCLC patients: A prospective study

Exploring factors associated with postoperative physical activity and sedentary behavior in newly diagnosed lung cancer patients: a cross-sectional study

PURPOSE

To comprehensively analyze the factors associated with different intensities of physical activity and sedentary behavior in newly diagnosed lung cancer patients in the early postoperative period, providing a basis for clinically tailored personalized intervention measures.

METHODS

A cross-sectional study design was employed, and 915 patients newly diagnosed with lung cancer completed a questionnaire survey on demographics, disease, health-related fitness, and psychosocial factors. Physical activity levels and sedentary behaviors were assessed using the International Physical Activity Questionnaire. Data were analyzed using SPSS 25.0.

RESULTS

The physical activity level of walking amounted to 1265.4 ± 1025.8 MET-min/week, potentially influenced by factors such as region, depression, health behavior capacity, and lactate dehydrogenase. The moderate-intensity physical activity level stood at 529.8 ± 976.5 MET-min/week, subject to influences like regional lymph node staging, body mass index, and albumin levels, among other factors. The high-intensity physical activity level was 111.1 ± 731.0 MET-min/week, potentially affected by region, grip strength, health behavior capacity, and other factors. Sedentary time averaged 5 ± 3 h/day, potentially influenced by work conditions, red blood cell values, and other factors.

CONCLUSION

In patients newly diagnosed with lung cancer, early postoperative walking activities predominate, with less engagement in high-intensity physical activity and prolonged sedentary time. Physical activity and sedentary behavior may be influenced by various factors such as geography, physiology, psychology, and health-related fitness. To enhance the quality of life of patients with lung cancer in the early postoperative period, tailored intervention measures should be devised based on the circumstances of the individual patients.

Effectiveness of Non-pharmacologic Interventions on Device-measured Physical Activity in Adults With Cancer, and Methodology Used for Assessment: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the effectiveness of different types of interventions aimed at enhancing device-measured physical activity (PA) and summarize the devices and methodologies used to measure PA in adults with cancer.

DATA SOURCES

A systematic review was prospectively registered on PROSPERO (CRD42020199466). The search was conducted in PubMed, The Cochrane Library, EMBASE (via Ovid), and PEDro from 2005 onward.

STUDY SELECTION

Prospective interventional studies (randomized controlled trials [RCTs], non-randomized controlled trials, and single-group trials), that included adults within 12 months from cancer diagnosis, and device-measured PA before and after commencement of an intervention were included. Studies were excluded if PA was measured at a single time point. Two independent reviewers screened 3033 records and 30 articles met the inclusion criteria.

DATA EXTRACTION

Two reviewers independently extracted the data. PEDro scale and GRADE approach were used to assess methodological quality of RCTs and overall quality of evidence, respectively. A meta-analysis of relevant RCTs was conducted.

DATA SYNTHESIS

Thirty studies were identified, mainly including adults with multiple cancer types. Interventions were behavior change interventions (n=15), exercise training (n=13), neuromuscular electrostimulation (n=1), or a nutritional program (n=1). The meta-analysis showed improvements on moderate-to-vigorous intensity PA (MVPA) in the experimental group (8 studies; standardized mean difference (SMD)=0.23; 95% CI 0.06-0.39); with subgroup analysis showing that findings were mainly driven by behavior change interventions (5 studies; SMD=0.23, 95% CI 0.05-0.41). An uncertain effect on sedentary behavior, daily steps, and light intensity PA was found. PA was measured with medical devices and commercial wearables, quality of the methodology was variable.

CONCLUSIONS

Behavior change interventions increased device-derived MVPA in adult cancer patients who underwent the intervention within 12 months of the cancer diagnosis. Various devices and methodologies were used to assess PA, which limits comparisons across the studies.

The efficacy of a blended intervention to improve physical activity and protein intake for optimal physical recovery after oncological gastrointestinal and lung cancer surgery, the Optimal Physical Recovery After Hospitalization (OPRAH) trial: study protocol for a randomized controlled multicenter trial

BACKGROUND

Improving physical activity, especially in combination with optimizing protein intake, after surgery has a potential positive effect on recovery of physical functioning in patients after gastrointestinal and lung cancer surgery. The aim of this randomized controlled trial is to evaluate the efficacy of a blended intervention to improve physical activity and protein intake after hospital discharge on recovery of physical functioning in these patients.

METHODS

In this multicenter single-blinded randomized controlled trial, 161 adult patients scheduled for elective gastrointestinal or lung cancer surgery will be randomly assigned to the intervention or control group. The purpose of the Optimal Physical Recovery After Hospitalization (OPRAH) intervention is to encourage self-management of patients in their functional recovery, by using a smartphone application and corresponding accelerometer in combination with coaching by a physiotherapist and dietician during three months after hospital discharge. Study outcomes will be measured prior to surgery (baseline) and one, four, eight, and twelve weeks and six months after hospital discharge. The primary outcome is recovery in physical functioning six months after surgery, and the most important secondary outcome is physical activity. Other outcomes include lean body mass, muscle mass, protein intake, symptoms, physical performance, self-reported limitations in activities and participation, self-efficacy, hospital readmissions and adverse events.

DISCUSSION

The results of this study will demonstrate whether a blended intervention to support patients increasing their level of physical activity and protein intake after hospital discharge improves recovery in physical functioning in patients after gastrointestinal and lung cancer surgery.

TRIAL REGISTRATION

The trial has been registered at the International Clinical Trials Registry Platform at 14-10-2021 with registration number NL9793. Trial registration data are presented in Table 1.

Factors associated with failure of cardiopulmonary function recovery after lung cancer surgery

BACKGROUND AND OBJECTIVE

This study aimed to evaluate the longitudinal changes in cardiopulmonary function (CPF) and identify predictors of cardiopulmonary recovery failure after lung cancer surgery.

METHODS

Data was obtained from a prospective CATCH-LUNG cohort study, where patients were divided into two groups based on 6-min walk distance (6MWD) at baseline and 6 months after surgery. CPF recovery failure was defined as a participant whose 6MWD dropped over 50 m from baseline to 6 months after surgery. Patients with a baseline 6MWD less than 400 m were excluded. The analysis was investigated using mixed effects models, and the relative estimates for the predictors were expressed relative risk (RR) and 95% CI using a Poisson regression.

RESULTS

Among 419 patients, 24.1% and 17.7% showed failure of CPF recovery at 6 months and 1 year after surgery, respectively. In the multivariable analysis, baseline step count [RR per 1000 steps lower = 1.05 (95% CI, 1.01-1.09)], baseline dyspnoea [RR per 10 points higher = 1.15(1.07-1.23)], decreased FEV1 % predicted from baseline to 2 weeks after surgery [RR per 10% lower = 1.30(1.10-1.53)] and decreased moderate-to-vigorous physical activity (MVPA) from baseline to 2 weeks [RR = 1.95(1.22, 3.11)] or persistent low MVPA at baseline and 2 weeks after surgery [RR = 1.63(1.04, 2.54)] were significant factors for loss of CPF.

CONCLUSION

The inability to recover CPF at 6 months after surgery was linked to reduction of lung function and MVPA from baseline to 2 weeks as well as baseline physical activity (PA) and dyspnoea. These results imply that engagement of perioperative PA is necessary to facilitate recovery of CPF after lung cancer surgery.

The effectiveness of an accelerometer-based physical activity enhancement intervention for patients undergoing lung resection - A pilot randomized controlled trial

OBJECTIVES

Increasing physical activity after lung resection is important for maintaining quality of life. It is unclear whether accelerometer-based exercise instruction contributes to increasing daily physical activity after lung resection. We examine whether accelerometer-based exercise instruction will lead to increased physical activity in patients undergoing lung resection.

MATERIALS AND METHODS

Forty-six patients undergoing lung resection were randomly assigned to either the intervention group (n = 22) or the control group (n = 24). Twelve participants dropped out. Ultimately, 16 participants in the intervention group and 18 participants in the control group were eligible for analysis. Each group allocation was only known to the person in charge of allocation. The physiotherapists and assessors were not blinded in this study. The intervention group participated in a postoperative rehabilitation program and received physical activity instruction preoperatively and at discharge. The control group participated in a postoperative rehabilitation program only. The primary outcomes was physical activity such as the number of daily steps, light intensity physical activity (LPA) and moderate-vigorous intensity physical activity (MVPA) at the two month postoperative follow-up.

RESULTS

Thirty-four participants were enrolled in this study. Sixteen participants in the intervention group and 18 participants in the control group were included for analysis. Although there was no significant difference in physical activity at baseline, the number of daily steps in the intervention group at the two month postoperative follow-up was significantly higher than that in the control group (8039.2 ± 3480.8 vs. 4887.0 ± 2376.5 steps/day, p = 0.004). Compared to the control group, the intervention group also had greater increases in LPA (63.8 ± 25.1 vs. 44.5 ± 24.5 min/day, p = 0.030) and MVPA (20.2 ± 19.6 vs. 9.6 ± 8.6 min/day, p = 0.022).

CONCLUSIONS

This study showed that accelerometer-based exercise instruction led to an increase in physical activity after lung resection in an unsupervised setting.

CLINICAL TRIAL REGISTRATION

The University Hospital Medical Information Network (UMIN) Clinical Trials Registry (UMIN trial No. UMIN000039369).

Data-Driven Personalized Care in Lung Cancer: Scoping Review and Clinical Recommendations on Performance Status and Activity Level of Patients With Lung Cancer Using Wearable Devices

PURPOSE

Performance status (PS) is a crucial assessment for research and clinical practice in lung cancer (LC), including its usage for the assessment of the suitability and toxicity of treatment or eligibility for clinical trials of patients with LC. These PS assessments are subjective and lead to substantial discrepancies between observers. To improve the objectivity of PS assessments, Electronic Activity Monitoring devices (EAMs) are increasingly used in oncology, but how these devices are used for PS assessments in LC is an issue that remains unclear. The goal of this study is to address the challenges and opportunities of the use of digital tools to support PS assessments in patients with LC.

METHODS

The literature review followed PRISMA-ScR methodology. Searches were performed in the ScienceDirect, PsycInfo, ACM, IEEE Xplore, and PubMed databases. Furthermore, a panel discussion was performed to address the clinical use cases.

RESULTS

Thirty-two publications were found. Most of the studies used wrist accelerometry-based wearables (59%) and monitored sleep activity (SA; 28%) or physical activity (PA; 72%). Critical findings include positive usefulness of the use of wearables to categorize moderate-to-vigorous/light PA, which was associated with better sleep and health. In addition, steps and time awake immobile were found to be associated with risk of hospitalization and survival. Use cases identified included the health assessment of patients and clinical research.

CONCLUSION

There are positive experiences in the use of EAM to complement PS assessment in LC. However, there is a need for adapting thresholds to the particularities of patients with LC, for example, differentiating moderate-to-vigorous and light. Moreover, developing methodologies combining PS assessments and the use of EAM adapted to clinical and research practice is needed.

Measuring What Is Meaningful in Cancer Cachexia Clinical Trials: A Path Forward With Digital Measures of Real-World Physical Behavior

PURPOSE

The burden of cancer cachexia on patients' health-related quality of life, specifically their physical functioning, is well documented, but clinical trials thus far have failed to show meaningful improvement in physical functioning. The purpose of this review is to summarize existing methods of assessing physical function in cancer cachexia, outline a path forward for measuring what is meaningful to patients using digital measures derived from digital health technologies (DHTs), and discuss the current landscape of digital measures from the clinical and regulatory standpoint.

DESIGN

For this narrative review, peer-reviewed articles were searched on PubMed, clinical trials records were searched on clinicaltrials.gov, and records of digital measures submitted for regulatory qualification were searched on the US Food and Drug Administration's Drug Development Tool Qualification Program database.

RESULTS

There are gaps in assessing aspects of physical function that matter to patients. Existing assessment methods such as patient-reported outcomes and objective performance outcomes have limitations, including their episodic nature and burden to patients. DHTs such as wearable sensors can capture real-world physical behavior continuously, passively, and remotely, and may provide a more comprehensive picture of patients' everyday functioning. Recent regulatory submissions showcase potential clinical implementation of digital measures in various therapeutic areas.

CONCLUSION

Digital measures of real-world physical behavior present an opportunity to detect and demonstrate improvements in physical functioning in cancer cachexia, but evidence-based development is critical. For their use in clinical and regulatory decision making, studies demonstrating meaningfulness to patients as well as feasibility and validation are necessary.

Self-monitoring of Physical Activity After Hospital Discharge in Patients Who Have Undergone Gastrointestinal or Lung Cancer Surgery: Mixed Methods Feasibility Study

Background

Self-monitoring of physical activity (PA) using an accelerometer is a promising intervention to stimulate PA after hospital discharge.

Objective

This study aimed to evaluate the feasibility of PA self-monitoring after discharge in patients who have undergone gastrointestinal or lung cancer surgery.

Methods

A mixed methods study was conducted in which 41 patients with cancer scheduled for lobectomy, esophageal resection, or hyperthermic intraperitoneal chemotherapy were included. Preoperatively, patients received an ankle-worn accelerometer and the corresponding mobile health app to familiarize themselves with its use. The use was continued for up to 6 weeks after surgery. Feasibility criteria related to the study procedures, the System Usability Scale, and user experiences were established. In addition, 6 patients were selected to participate in semistructured interviews.

Results

The percentage of patients willing to participate in the study (68/90, 76%) and the final participation rate (57/90, 63%) were considered good. The retention rate was acceptable (41/57, 72%), whereas the rate of missing accelerometer data was relatively high (31%). The mean System Usability Scale score was good (77.3). Interviewed patients mentioned that the accelerometer and app were easy to use, motivated them to be more physically active, and provided postdischarge support. The technical shortcomings and comfort of the ankle straps should be improved.

Conclusions

Self-monitoring of PA after discharge appears to be feasible based on good system usability and predominantly positive user experiences in patients with cancer after lobectomy, esophageal resection, or hyperthermic intraperitoneal chemotherapy. Solving technical problems and improving the comfort of the ankle strap may reduce the number of dropouts and missing data in clinical use and follow-up studies.

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.

Functional recovery after discharge in enhanced recovery video-assisted thoracoscopic lobectomy: a pilot prospective cohort study

Little is known about functional recovery following patient discharge in an established enhanced recovery programme after video-assisted thoracoscopic lobectomy. We conducted a single-centre pilot prospective observational cohort study. We hypothesised that patients achieved early functional recovery after discharge. A total of 32 patients aged ≥ 18 years were enrolled. A digital device was used for objective activity measurements, and patient-reported outcomes were collected as subjective measurements. Primary outcomes were the difference in physical activity; sleep duration; pain; fatigue; and average quality of life scores between pre-operative baseline and 7 days following discharge. The secondary outcome was the reason for reduced daily activity during the first 7 days after discharge. Median (IQR [range]) length of stay was 3 (2-5 [1-13]) days. Up to post-discharge day 7, total, lower intensity and moderate-to-vigorous activities were lower than pre-operative activity (p < 0.001; p = 0.005 and p = 0.027, respectively). Numerical rating scale (0-10) pain scores increased postoperatively at rest (mean difference 1.2, p < 0.001) and during walking (mean difference 1.4, p < 0.001). Fatigue assessed by the Christensen Fatigue Scale (1-10) was also increased postoperatively (mean difference 1.7, p = 0.001). There was a reduction in quality of life scores, while sedentary activity and sleep duration were unchanged postoperatively. Dominant reasons for not recovering daily activity included fatigue in 43% and pain in 33% of patients. Despite compliance with an enhanced recovery programme with a median length of hospital stay of 3 days after video-assisted thoracoscopic lobectomy, functional recovery was not achieved within 7 days after hospital discharge. Reduction in postoperative pain and fatigue are important factors to enhance functional recovery.

Preoperative paraspinous muscle sarcopenia and physical performance as prognostic indicators in non-small-cell lung cancer

BACKGROUND

Despite the associations of both preoperative sarcopenia and physical performance with post-operative mortality in non-small-cell lung cancer (NSCLC), there have been no comprehensive studies of the impact of physical status on prognosis. This study was performed to investigate the prognostic significance of preoperative sarcopenia and physical performance in NSCLC.

METHODS

This retrospective cohort study was performed in NSCLS patients undergoing curative lung resection at a university hospital between January 2014 and December 2017. The patients were divided into four groups according to the skeletal muscle index [sarcopenia (lowest sex-specific tertile) and non-sarcopenia] and 6 min walking distance (6MWD) [short distance (<400 m) and long distance (≥400 m)]. Sarcopenia was assessed by preoperative cross-sectional areas of right and left paraspinous muscles at the level of the 12th thoracic vertebra from computed tomography images, and physical performance was determined by preoperative 6MWD. The primary and secondary endpoints were post-operative overall survival (OS) and disease-free survival (DFS).

RESULTS

The 587 patients [mean age: 68.5 ± 8.8 years, 399 men (68%)] included in the study were divided into the non-sarcopenia/long-distance group (58%), sarcopenia/long-distance group (26%), non-sarcopenia/short-distance group (9%), and sarcopenia/short-distance group (7%). A total of 109 (18.6%) deaths and 209 (35.6%) combined endpoints were observed over a mean follow-up of 3.1 ± 1.3 years. After adjusting for other covariates, the sarcopenia/short-distance group showed significant associations with shorter OS (hazard ratio, 3.38; 95% confidence interval, 1.79-6.37; P < 0.001) and DFS (hazard ratio, 2.11; 95% confidence, 1.27-3.51; P = 0.004) compared with the non-sarcopenia/long-distance group on multivariate analyses. Although not significant, adding skeletal muscle index and 6MWD to the pre-existing risk model increased the area under the curve on time-dependent receiver operating characteristic curve analysis for OS and DFS, except within 2 years of surgery.

CONCLUSIONS

The presence of both preoperative paraspinous muscle sarcopenia and short distance in 6MWD had an adverse effect on post-operative prognosis in patients with NSCLC, suggesting that preoperative assessment of thoracic sarcopenia and physical performance may be useful for risk stratification of surgical candidates with potential for targeted interventions.

Physical Activity Levels Are Low in Inoperable Lung Cancer: Exploratory Analyses from a Randomised Controlled Trial

Background: In inoperable lung cancer, evidence is limited regarding physical activity (PA) and associations with other outcomes. Aims: in the usual care (UC) group of an RCT to (1) explore whether baseline PA was associated with improved follow-up outcomes, (2) identify baseline variables associated with higher follow-up PA and in all RCT participants, to (3) analyse patterns of objectively measured PA, and (4) report on characteristics of those who were able to maintain or increase PA levels. Methods: exploratory analyses of an assessor-blinded RCT. Outcomes, assessed at baseline, nine weeks and six months, included PA (seven-days of accelerometry), six-minute walk distance (6MWD), muscle strength, symptoms, mood and health-related quality of life (HRQoL). Results: 92 participants were randomised, 80 completed baseline accelerometry (39 intervention group (IG), 41 UC), characteristics: mean (SD) age 63.0 (12.3) years, 56% male, 51% stage IV disease. Baseline PA: median (IQR) steps/day 2859.6 (2034.0–3849.2) IG versus 3195.2 (2161.2–4839.0) UC. Associations between baseline PA and six-month outcomes were significant for HRQoL and 6MWD. PA at six months was significantly associated with baseline age, 6MWD and quadriceps strength. Between-group change score (steps/day) mean differences (95% CI) at nine weeks (174.5 (−1504.7 to 1853.7), p = 0.84) and six months (574.0 (−1162.3 to 2310.3), p = 0.52). Conclusions: further research is required to determine patient subgroups deriving the greatest benefits from PA interventions.

Physical function and health-related quality of life in the convalescent phase in surgically treated patients with malignant pleural mesothelioma

PURPOSE

According to reports, patients with lung cancer have decreased pulmonary function and exercise capacity after surgery. However, to date, physical function and health-related quality of life (HRQOL) after surgery for malignant pleural mesothelioma (MPM) have not been evaluated in detail in the convalescent phase. This study aimed to assess physical function and HRQOL of MPM patients following pleurectomy/decortication (P/D) in the convalescent phase.

METHODS

The study included 16 male MPM patients who underwent P/D between September 2014 and August 2016. Physical function was assessed based on handgrip and knee extensor strengths, the six-minute walk distance (6MWD), and pulmonary function, including forced vital capacity (FVC) and forced expiratory volume in one second (FEV1). HRQOL was assessed using the Medical Outcome Study 36-item Short Form Health Survey (SF-36). The assessment was performed preoperatively, postoperatively, and 1-year after surgery.

RESULTS

The 6MWD, FVC, and FEV1 values 1-year postoperatively improved significantly compared with baseline (P < 0.05 all). Additionally, the scores of six of the eight SF-36 domains were significantly improved 1 year after P/D: physical functioning, body pain, general health, vitality, social functioning, and mental health (all P < 0.05). 6MWD, FVC, and FEV1 were correlated with vitality, mental health, and physical functioning (P < 0.05 all).

CONCLUSIONS

Patients with MPM who underwent P/D showed improved physical function and HRQOL compared with postoperative values in the convalescent phase. Physicians, nurses, and rehabilitation staff should note these findings, which may provide insight into the development of customized rehabilitation strategies in the convalescent phase for such patients.