PUREAIR protocol: randomized controlled trial of intensive pulmonary rehabilitation versus standard care in patients undergoing surgical resection for lung cancer

Effects of exercise prehabilitation and/or rehabilitation on health-related quality of life and fatigue in patients with non-small cell lung cancer undergoing surgery: A systematic review

BACKGROUND

This systematic review aimed to appraise the current available evidence regarding the effects of exercise prehabilitation and rehabilitation on perceived health-related quality of life (HRQoL) and fatigue in patients undergoing surgery for non-small cell lung cancer (NSCLC).

METHODS

Studies were selected according to Cochrane guidelines and assessed for methodological quality and therapeutic quality (the international CONsensus on Therapeutic Exercise aNd Training (i-CONTENT)). Eligible studies included patients with NSCLC performing exercise prehabilitation and/or rehabilitation and postoperative HRQoL and fatigue up to 90-days postoperatively.

RESULTS

Thirteen studies were included. Exercise prehabilitation and rehabilitation significantly improved postoperative HRQoL in almost half of the studies (47%), although none of the studies demonstrated a decrease in fatigue. Methodological quality and therapeutic quality were poor in respectively 62% and 69% of the studies.

CONCLUSION

There was an inconsistent effect of exercise prehabilitation and exercise rehabilitation on improving HRQoL in patients with NSCLC undergoing surgery, with no effect on fatigue. Due to the low methodological and therapeutic quality of included studies, it was not possible to identify the most effective training program content to improve HRQoL and reduce fatigue. It is recommended to investigate the impact of a high therapeutic qualified exercise prehabilitation and exercise rehabilitation on HRQoL and fatigue in larger studies.

Evidence base for exercise prehabilitation suggests favourable outcomes for patients undergoing surgery for non-small cell lung cancer despite being of low therapeutic quality: a systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review was to evaluate whether exercise prehabilitation programs reduce postoperative complications, postoperative mortality, and length of hospital stay (LoS) in patients undergoing surgery for non-small cell lung cancer (NSCLC), thereby accounting for the quality of the physical exercise program.

METHODS

Two reviewers independently selected randomized controlled trials (RCTs) and observational studies and assessed them for methodological quality and therapeutic quality of the exercise prehabilitation program (i-CONTENT tool). Eligible studies included patients with NSCLC performing exercise prehabilitation and reported the occurrence of 90-day postoperative complications, postoperative mortality, and LoS. Meta-analyses were performed and the certainty of the evidence was graded (Grading of Recommendations Assessment, Development and Evaluation (GRADE)) for each outcome.

RESULTS

Sixteen studies, comprising 2,096 patients, were included. Pooled analyses of RCTs and observational studies showed that prehabilitation reduces postoperative pulmonary complications (OR 0.45), postoperative severe complications (OR 0.51), and LoS (mean difference -2.46 days), but not postoperative mortality (OR 1.11). The certainty of evidence was very low to moderate for all outcomes. Risk of ineffectiveness of the prehabilitation program was high in half of the studies due to an inadequate reporting of the dosage of the exercise program, inadequate type and timing of the outcome assessment, and low adherence.

CONCLUSION

Although risk of ineffectiveness was high for half of the prehabilitation programs and certainty of evidence was very low to moderate, prehabilitation seems to result in a reduction of postoperative pulmonary and severe complications, as well as LoS in patients undergoing surgery for NSCLC.

Investigating the Physiological Mechanisms between Resistance Training and Pain Relief in the Cancer Population: A Literature Review

This literature review examines the mechanisms of how exercise, specifically in the form of resistance training, may lead to pain relief in the cancer population. Primary data from three different cancer populations: breast, prostate, and lung, will be examined. A number of experimental studies have been conducted to confirm the effectiveness of resistance training on pain relief as well as the biochemical pathways that relate to this process. In this review, we will examine 5 randomized controlled trials. For the purposes of this review, pain is defined as physical suffering or discomfort associated with illness. Pain is the body's natural signal, bringing attention to damage that has been sustained by tissues. However, chronic pain is common in the cancer population, and often serves no good purpose but instead will negatively impact both physical and mental health. The three types of pain: nociceptive, neuropathic, and inflammatory pathways have been investigated, and the knowledge of pain mechanisms allows for the understanding of how it is associated with pain. The purpose of this exploratory literature review is to give insight on how to maximize pain-relieving effects of resistance training. Research has indicated that resistance training modulates pain pathways by upregulating the release of pain-relieving substances including beta-endorphins, anti-inflammatory cytokines, and endocannabinoids. Understanding of the benefits of resistance training may be useful in relieving cancer pain, and reproducing effects of pain-relieving strategies while minimizing the symptoms related to cancer and its treatment.

Effects of exercise training in people with non-small cell lung cancer before lung resection: a systematic review and meta-analysis

INTRODUCTION

Exercise training before lung resection for non-small cell lung cancer is believed to decrease postoperative complications (POC) by improving cardiorespiratory fitness. However, this intervention lacks a strong evidence base.

AIM

To assess the effectiveness of preoperative exercise training compared with usual care on POC and other secondary outcomes in patients with scheduled lung resection.

METHODS

A systematic search of randomised trials was conducted by two authors. Meta-analysis was performed, and the effect of exercise training was estimated by risk ratios (RR) and mean differences, with their CIs. Clinical usefulness was estimated according to minimal important difference values (MID).

RESULTS

Fourteen studies involving 791 participants were included. Compared with usual care, exercise training reduced overall POC (10 studies, 617 participants, RR 0.58, 95% CI 0.45 to 0.75) and clinically relevant POC (4 studies, 302 participants, Clavien-Dindo score ≥2 RR 0.42, 95% CI 0.25 to 0.69). The estimate of the effect of exercise training on mortality was very imprecise (6 studies, 456 participants, RR 0.66, 95% CI 0.20 to 2.22). The main risks of bias were a lack of participant blinding and selective reporting. Exercise training appeared to improve exercise capacity, pulmonary function and also quality of life and depression, although the clinical usefulness of the changes was unclear. The quality of the evidence was graded for each outcome.

CONCLUSION

Preoperative exercise training leads to a worthwhile reduction in postoperative complications. These estimates were both accurate and large enough to make recommendations for clinical practice.

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.

The Effect of Comedy Films on Postoperative Pain and Anxiety in Surgical Oncology Patients

Objectives: To determine the effect of watching Turkish comedy films on postoperative pain and anxiety in oncology surgical patients. Design: This study was conducted using a pre- and post-test randomized controlled trial model. Materials and Methods: The study was conducted in a general surgery clinic of a hospital in eastern Turkey between January 2016 and January 2017. The sample of the study consisted of 88 patients (44 test, 44 control) selected by using the randomized sampling method. In the experimental group, funny videos from Turkish old comedy movies were watched for 10 min before surgery. Anxiety, measured by the State-Trait Anxiety Inventory, and vital signs were measured before and after the experimental protocol. In the analysis of the data, descriptive statistics, χ2 and t test were used. Results: The state-trait anxiety pre- and post-test mean score of the experimental group was found to be 39.59 ± 3.66 and 37.54 ± 3.52 before and after watching the video, respectively, indicating a statistically significant difference between these two values (p ≤ 0.05). No statistically significant difference was found between the pre- and post-test state-trait anxiety scores of the patients in the control group. The decrease from the pre- to post-test mean pain score was determined as 0.65 ± 1.05 in the experimental group and 0.11 ± 0.96 in the control group. A statistically significant difference was found between the groups’ post-test mean pain scores (p ≤ 0.05). Conclusion: The study results suggest that watching Turkish comedy movie videos has a positive effect on postoperative pain and anxiety in surgical oncology patients.

Feasibility of an eight-week outpatient-based pulmonary rehabilitation program for advanced lung cancer patients undergoing cytotoxic chemotherapy in Korea

The scientific evidence supporting pulmonary rehabilitation (PR) for lung cancer patients undergoing cytotoxic chemotherapy is accumulating; however, the feasibility of outpatient-based PR in these patients has not yet been evaluated in Korea. We conducted an eight-week outpatient-based PR feasibility study in a tertiary referral hospital setting. Patients with advanced lung cancer (non-small cell lung cancer IIIB-IV and small-cell lung cancer extensive disease) scheduled to undergo first-line cytotoxic chemotherapy underwent PR consisting of 60-minute sessions twice a week under the guidance and supervision of a physical therapist, for a total of eight weeks. Feasibility was assessed based on completion of the PR program. In total, 12 patients (median age 68 years) were enrolled; 11 (91.7%) were male with a history of smoking. Among these 12 patients, 9 (75%) completed the eight-week outpatient-based PR program. Three patients could not complete the PR program: two were unwilling and one died from complications of lung cancer. This study showed a 75% completion rate of an eight-week outpatient-based PR program for advanced lung cancer patients undergoing cytotoxic chemotherapy, which supports its feasibility.