Effects of perioperative exercise interventions on lung cancer patients: An overview of systematic reviews

The Optimal Time of High-Intensity Pre-rehabilitation for Surgical Lung Cancer Patients: A Retrospective Cohort Study with 4452 Patients

BACKGROUND

The aim of this study was to investigate the influence of the time of pre-rehabilitation (PR) combined with respiratory training and aerobic exercise on surgical patients with lung cancer.

PATIENTS AND METHODS

A retrospective study from a 5-year database of a single center, including patients with lung cancer who underwent surgery between 1 January 2016 and 31 December 2020, was conducted. The patients were divided into the PR group, in which they received the PR regimen, and the non-PR group, in which they received routine care.

RESULTS

A total of 4452 patients were retrospectively included, 684 of whom received PR regimen. A lower postoperative pulmonary complication (PPC) rate was observed in PR group than in non-PR group before or after propensity score matching (PSM) (before: 12.6% vs 18.5%, P < 0.001; after: 12.6% vs 18.7%, P < 0.001). For the PR group, a restricted cubic spline model revealed a significant nonlinear dose‒response association between PR time and the occurrence of PPCs (P for nonlinearity = 0.002). The PR time associated with the lowest occurrence of PPCs was 7 days, and the odds ratio (OR) of PPCs decreased steeply, with an OR of 0.8 [95% confidence interval (CI) 0.66-0.97] per day until 7 days, and then remained stable with a slight increase afterward with an OR of 1.11 (95% CI 0.99-1.25) per day.

CONCLUSION

The study validated the effectiveness of a pre-rehabilitation regimen for decreasing the occurrence of PPCs. A U-shaped nonlinear relationship was found between pre-rehabilitation time and the PPC rate, indicating that both excessive and insufficient pre-rehabilitation time may increase the incidence of PPCs. Registry Number: ChiCTR1800020097.

Potential Therapeutic Role of Respiratory Muscle Training in Dyspnea Management of Cancer Survivors: A Narrative Review

Dyspnea is a disabling symptom presented in approximately half of all cancer survivors. From a clinical perspective, despite the availability of pharmacotherapies, evidence-based effective treatments are limited for relieving dyspnea in cancer survivors. Preliminary evidence supports the potential of respiratory muscle training to reduce dyspnea in cancer survivors, although large randomized controlled studies are warranted. The aims of this article were to review the relevant scientific literature on the potential therapeutic role of respiratory muscle training in dyspnea management of cancer survivor, and to identify possible mechanisms, strengths and limitations of the evidence as well as important gaps for future research directions.

Physical activity for cancer prehabilitation: A scoping review

This scoping review aims to synthesize the current landscape of physical activity in cancer prehabilitation and identify knowledge gaps. We searched MEDLINE, EMBASE, SCOPUS and WEB OF SCIENCE for exercise interventions and observational studies that measured exercise or physical activity before cancer treatment from inception to January 20, 2023. Fifty-one articles from 44 unique studies were reviewed, including 32 intervention and 12 observational studies. Surgery is the only treatment modality that has been investigated. Included studies used heterogeneous exercise interventions and measures for physical activity. Colorectal and other gastrointestinal, lung, and urologic cancers are the most studied cancer types. Exercise intervention in cancer prehabilitation is highly feasible. The evidence for improved fitness, functional, psychosocial, and clinical outcomes is promising yet limited. Although research has increased recently, prehabilitation exercise remains a relatively under-investigated area in oncology. We have provided research directions towards an ideal cancer prehabilitation design in the real-world setting.

Study protocol: a core outcome set for perioperative exercise clinical effectiveness trials for lung cancer patients

BACKGROUND

Outcome assessment in perioperative exercise trials for lung cancer is heterogeneous, often omitting those that are important and patient-relevant. This heterogeneity hinders the synthesis of evidence. To address this issue, a core outcome set, an agreed-upon standardized set of outcomes to be measured and reported, is required to reduce heterogeneity among outcome measurements. This study protocol describes the methodology, aiming to develop a core outcome set for perioperative exercise intervention trials for lung cancer in clinical practice.

METHODS

The project will follow the standard methodology recommended by the Core Outcome Measures in Effectiveness Trials (COMET) initiative, which is divided into four steps. Stage I: Conducting a scoping review of outcomes reported in clinical trials and protocols to develop a list of potential outcome domains. Stage II: Conducting semi-structured interviews to obtain important outcomes for patients. Stage III: Choosing the most important outcomes by conducting two rounds of the Delphi exercise. Stage IV: Achieving a consensus in a face-to-face meeting to discuss the final core outcome set.

DISCUSSION

This is the first project identified for the core outcome set of perioperative exercise trials in lung cancer, which will enhance the quality, comparability, and usability of future trials and positively impact perioperative exercise and the care of patients with lung cancer.

TRIALS REGISTRATION

Core Outcome Measurement in Effectiveness Trials (COMET) Initiative database registration: https://www.comet-initiative.org/Studies/Details/2091.

Rehabilitation outcomes for people with lung cancer (UNITE): protocol for the development of a core outcome set

INTRODUCTION

With treatment-related improvements in survival, rehabilitation is essential to improve function and health-related quality of life and manage the high symptom burden associated with lung cancer. Despite this, significant heterogeneity exists in the outcomes and instruments used to evaluate lung cancer rehabilitation programme impact. This study aims to develop a core set of clinically relevant lung cancer rehabilitation outcomes for use in clinical practice.

METHODS AND ANALYSIS

An international Delphi consensus study involving consumer, healthcare professional and researcher stakeholders to determine which outcomes to include and how to measure these. Stage 1 (preliminary): mixed methods to develop the potential list of outcomes (1) overview of systematic reviews of lung cancer exercise interventions and (2) focus groups and individual interviews with people with lung cancer. Stage 2: outcomes were grouped according to the International Classification of Functioning, Disability and Health domains. Stage 3: to determine priority outcomes for core outcome set (COS) inclusion participants will rate each outcome's importance (one-nine-point Likert scale) over two-three survey rounds. Stage 4: following review by the steering committee, a consensus meeting will be held if agreement on the COS has not been reached.Stage 5: recommendations will be made regarding a single instrument for measuring each COS outcome by reviewing existing resources where consensus has already been reached. Where resources do not exist the quality and feasibility of potential measurement instruments will be appraised, and the Delphi consensus survey and meeting process outlined in stages 3-4 will be repeated.This protocol adheres to the COS-Standardised Protocol statement and will be conducted and reported according to the COS-Standards for Development recommendations and the COS-Standards for Reporting.

ETHICS AND DISSEMINATION

Ethics approval (20/9/22, University of Melbourne ID 2022-24839-32231-3). Dissemination in peer-reviewed journals and conference presentations.

Exercise across the Lung Cancer Care Continuum: An Overview of Systematic Reviews

BACKGROUND

Growing evidence supports exercise for people with lung cancer. This overview aimed to summarise exercise intervention efficacy and safety across the care continuum.

METHODS

Eight databases (including Cochrane and Medline) were searched (inception-February 2022) for systematic reviews of RCTs/quasi-RCTs. Eligibility: population-adults with lung cancer; intervention: exercise (e.g., aerobic, resistance) +/- non-exercise (e.g., nutrition); comparator: usual care/non-exercise; primary outcomes: exercise capacity, physical function, health-related quality of life (HRQoL) and post-operative complications. Duplicate, independent title/abstract and full-text screening, data extraction and quality ratings (AMSTAR-2) were completed.

RESULTS

Thirty systematic reviews involving between 157 and 2109 participants (n = 6440 total) were included. Most reviews (n = 28) involved surgical participants. Twenty-five reviews performed meta-analyses. The review quality was commonly rated critically low (n = 22) or low (n = 7). Reviews commonly included combinations of aerobic, resistance and/or respiratory exercise interventions. Pre-operative meta-analyses demonstrated that exercise reduces post-operative complications (n = 4/7) and improves exercise capacity (n = 6/6), whilst HRQoL findings were non-significant (n = 3/3). Post-operative meta-analyses reported significant improvements in exercise capacity (n = 2/3) and muscle strength (n = 1/1) and non-significant HRQoL changes (n = 8/10). Interventions delivered to mixed surgical and non-surgical populations improved exercise capacity (n = 3/4), muscle strength (n = 2/2) and HRQoL (n = 3). Meta-analyses of interventions in non-surgical populations demonstrated inconsistent findings. Adverse event rates were low, however, few reviews reported on safety.

CONCLUSIONS

A large body of evidence supports lung cancer exercise interventions to reduce complications and improve exercise capacity in pre- and post-operative populations. Additional higher-quality research is needed, particularly in the non-surgical population, including subgroup analyses of exercise type and setting.

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.

Effects of exercise-based home pulmonary rehabilitation on patients with chronic obstructive pulmonary disease: An overview of systematic review

BACKGROUND

Clinical research on exercise-based home pulmonary rehabilitation (HPR) effectiveness in chronic obstructive pulmonary disease (COPD) treatment is rising, as are associated systematic reviews/meta-analyses (SRs/MAs). However, different SRs/MAs vary in outcome indicators, analysis methodologies, literature quality, and findings. This overview aimed to describe the findings of these SRs/MAs and assess their methodological quality.

METHODS

From inception until April 2022, we searched PubMed, Web of Science, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), and Wan Fang. Two researchers searched these SRs/MAs separately, collected the data, and cross-checked it using predetermined rules. The Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR 2) was used to evaluate the methodological quality of each contained SR/MA. The evidence was assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 (PRISMA-2009). The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) was used to determine the validity of the results.

RESULTS

A total of 433 records were found, with 44 chosen for full-text review. There were 11 SRs/MAs that matched the inclusion criteria. Our overview included studies published from 2010 to 2022. According to the AMSTAR 2 tool, one had low methodological quality, while the other 10 SRs/MAs had very low quality. The PRISMA statement revealed a low rate of complete reporting for eight items. The GRADE tool, on the other hand, revealed that the evidence quality for most outcomes was very low to moderate.

CONCLUSION

According to current research, exercise-based HPR may benefit COPD patients. Nevertheless, this finding is restricted by the low quality of the included SRs/MAs. And more high-quality and large-sample studies are needed in the future.

PROSPERO

ID: CRD42022322768. https://www.crd.york.ac.uk/prospero/#recordDetails.

Telehealth exercise to Improve Physical function and frailty in patients with multiple myeloma treated with autologous hematopoietic Stem cell transplantation (TIPS): protocol of a randomized controlled trial

BACKGROUND

Advances in autologous hematopoietic stem cell transplantation (HSCT) and supportive care have led to marked improvements in survival for patients with multiple myeloma. Despite these improvements, patients with multiple myeloma remain at high risk of physical dysfunction and frailty due to HSCT and its associated exposures. Although traditional supervised exercise programs can improve frailty in cancer patients and survivors, rehabilitation facilities are typically far from a patient's residence, are offered on fixed days/hours, contain uniform activities for everyone, and carry a higher risk of contact cross-infection due to immunosuppression, which can be barriers to exercise participation. Innovative personalized interventions are needed to overcome the limitations of traditional exercise interventions. The purpose of this study is to determine the efficacy and sustainability of a telehealth exercise intervention on physical function and frailty in patients with multiple myeloma treated with HSCT.

METHODS

This randomized controlled trial will assess the efficacy of an 8-week telehealth exercise intervention in 60 patients with multiple myeloma who underwent autologous HSCT (30-180 days post-transplant) and are pre-frail or frail. There will be 30 intervention participants and 30 delayed controls. We will administer remote baseline assessments (week 0), followed by an 8-week telehealth intervention (week 1-8), post assessment (week 9), and an additional follow-up assessment (week 17). Our primary endpoint will be improved physical function, as assessed by the Short Physical Performance Battery test. Our secondary endpoint will be a decrease in frailty characteristics such as gait speed, strength, and fatigue. We will also evaluate the sustainability of improved physical function and frailty at week 17. Participants randomized to the intervention group will perform at least 90 min of exercise per week throughout the 8 weeks.

DISCUSSION

This study will help optimize the delivery of safe, low-cost, and scalable telehealth exercise interventions to improve health outcomes in patients with multiple myeloma, an understudied population at high risk for physical dysfunction and frailty. Our study may provide the foundation for sustainable telehealth exercise interventions to improve physical function and frailty for other hematologic cancer patients (e.g., acute leukemia, lymphoma) as well as any other cancer population of interest.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05142371 . This study was retrospectively registered on December 2nd, 2021, and is currently open to accrual.

"All Hands on Deck": Psychological Characteristics of Women with Experience of Oncological Disease Participating in Sailing Cruise-A Pilot Study

BACKGROUND

In addition to searching for effective methods of treatment, interventions are sought to support well-being, quality of life, mental health, and recovery. Sailing has its specific features, including task orientation, challenges, contact with people, and nature. This specificity may be treated as a potential therapeutic factor, but it is also likely that people with certain psychological characteristics are involved in it. Therefore, the study aimed to assess some psychological features of women with cancer experience who decided to take part in the Onco-Cruise (Polish: Onko-Rejs).

METHODS

Participants were 56 women (M = 46.73; SD = 9.21). We used NEO-FFI, the Zimbardo Time Perspective Inventory, and The Multidimensional Health Locus of Control Scale.

RESULTS

Onco-Cruises participants were characterized by a high level of extraversion (M = 32.48; SD = 7.02; sten score M = 7.21; Mo = 7), openness (M = 31.50; SD = 6.31; sten score M = 7.41; Mo = 8), low neuroticism (M = 21.62; SD = 9.33; sten score M = 4.96), predominance of present hedonistic (M = 12.55, SD = 1.46) and future time perspective (M = 11.39; SD = 2.67), and the internal health locus of control (M = 23.25, SD = 5.43).

CONCLUSION

Group sailing can be favorable for broadly understood health and cancer recovery, but people who choose this activity have certain psychological predispositions, especially indicating high needs for stimulation. Permanent features should be taken into account when proposing various interventions for oncology patients to best suit them to their natural possibilities and preferences and, thus, make them most effective.

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 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.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Cost-effectiveness analysis of home-based rehabilitation compared to usual care for people with inoperable lung cancer

OBJECTIVE

Few economic evaluations of lung cancer rehabilitation exist. The aim of this study was to assess the cost-effectiveness of providing home-based rehabilitation for inoperable lung cancer.

METHODS

A cost-utility analysis alongside a randomised controlled trial (RCT) of rehabilitation compared with usual care. The primary outcome was quality-adjusted life years (QALYs) gained. The incremental cost-effectiveness ratio [ICER (95% CI)] and the net monetary benefit are reported. Value of information (VOI) analysis assessed the need/value of more research.

RESULTS

Seventy participants (34 intervention and 36 usual care), average (SD) age 63.0 (12.0) years, 32 (45.7%) stage IV. The average intervention cost was AU$3421 (AU$5352 usual care), and effect (QALY) was 0.30 (0.31 usual care). The ICER was AU$228,197 (-1,173,194 to 1,101,450) per QALY gained. The net monetary benefit was AU$1508, favouring the intervention. The probability that the intervention was more cost-effective than usual care, at a willingness to pay threshold of AU$50,000, was 75%. VOI analysis showed that additional research to resolve decision uncertainty is potentially worthwhile.

CONCLUSION

A high degree of uncertainty exists regarding the cost-effectiveness of lung cancer rehabilitation. Further RCTs, powered for economic evaluations and utilising rehabilitation sensitive outcomes, are required to support translation of evidence into clinical practice.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.