# Exercise as it relates to Disease/Strength and endurance training in the treatment of advanced lung cancer

The following is a critique of the research paper 'Strength and endurance training in the treatment of lung cancer patients in stages IIIA/IIIB/IV'.

## What is the background to this research?

Lung cancer (LC) is the most commonly diagnosed form of cancer and is the leading cause of cancer-related deaths worldwide. LC is extremely deadly as it is rarely detected in its early stages due to the inability to externally examine the organs, with physical symptoms only manifesting once the cancer has reached an advanced stage. Unfortunately in its advanced stages LC is irresectable therefore palliative chemotherapy is prescribed to slow the spread of the cancer and/or reduce associated symptoms. However, the side effects of chemotherapy have a significant impact on the physical activity levels of patients - with a lack of exercise rapidly progressing muscular atrophy, therefore reducing the patients ability to perform daily activities resulting in a diminished quality of life (QOL).
Although other literature highlights the importance of exercise programs in the recovery of those with operable LC, there is little research surrounding the benefits of exercise programs for those receiving palliative treatment for the inoperable disease. This research therefore fills the gap by examining ‘the feasibility and effects of a specially designed treatment protocol for advanced LC patients on the patient’s QOL and their ability to be independent in activities of daily living during the time patients received palliative chemotherapy’. Given the commonness of lung cancer, this research is extremely important as it could improve the QOL for the millions of people around the world receiving palliative care for the disease.

## Where is this research from?

This study was predominantly conducted by researchers from the Vivantes Clinic in Neukoelln, Germany – with these authors belonging to the Departments of Internal Medicine, Hematology and Oncology; Internal Medicine, Pulmonology and Infectiology; and Radiology. All authors involved in this study are highly experienced, each involved in many published studies surrounding exercise and its impact on physical conditions and diseases.

## What kind of research was this?

This research was conducted as a randomised control trial (RCT). This form of study is considered to be the highest level of evidence as RCT’s are ‘designed to be unbiased and have less risk of systematic error’.

## What did the research involve?

This study involved 46 participants aged 18 years and over, who had been diagnosed with LC in stage IIIA/IIIB/IV and were receiving an inpatient palliative platinum-based chemotherapy treatment at the Vivantes Klinikum Neukoelln/Berlin. A computer program was used to randomly place participants in either the intervention (IG) or control group (CG), with the IG beginning with the participants first day of chemotherapy and ending after their third cycle of chemotherapy.

##### Base-line and end of study measures

All participants from both the IG and CG were tested pre and post IG using the following tests:
* The Barthel Index – The primary outcome measure used to evaluate patient’s independence in daily tasks.
* European Organization for Research and Treatment of Cancer QOL Questionnaire Core-30 – The secondary outcome measure used to evaluate patients QOL.
* 6-Minute Walk Test & Staircase walking (amount of steps) – Used to test patient endurance capacity.
* Biceps curl, triceps extension, bridging, abdominal exercise (maximum number of reps) – Use to test patient strength.

##### Breathing Techniques

Breathing techniques were used in both the IG and CGs and included the active cycle of breathing technique (ACBT).

##### IG

The IG group completed endurance training and breathing techniques five days a week and strength training every other day.
Endurance The endurance training consisted of two separate exercises, a 6 minute walk in the hallway (5 days a week) and a 2 minute stair walk. In the hallway walk, the training intensity was determined using the Modified Borg Scale (MBS) and a pre-calculated heart rate reserve (HRR), with participants training anywhere from 50-60% of HRR. In the stair walk, each participant had 2 minutes to walk up and down as many stairs as possible, with the amount of stairs walked in the time period recorded.
Strength In each strength training session, the participant completed three sets (1 minute rest in-between) at 50% of their pre-determined maximum rep range of each of the following; a bridging exercise, abdominal exercise, bicep curl exercise and triceps extension exercise, with the arm exercises completed using a medium resistance Thera-band.

##### CG

The CG only received conventional physiotherapy. Therefore, the participants received controlled breathing techniques and/or manual therapy techniques which included massage and muscle stretching, distraction and traction, and joint manipulation and mobilisation.

#### Methodological review

This study has a good RCT methodology, with a computer being used to randomly assign participants to either group - therefore removing the chance for any bias to occur. The exclusivity of participants accepted into this study also ensures any outcome is due only to the variable (exercise), for example, LC patients suffering other conditions such as cardiovascular diseases were excluded. This study does however have its limitations, one of which being that only 29 of the initial 46 participants completed the trial. 10 of those who dropped out of the trial did so due to non-compliance, therefore leading to the question of whether the methodology was too intense for some.

## What were the basic results?

This study found significant improvements in the IG across all tests, with the key results as follows:
* There was a significant difference between both groups in the Barthel Index post-intervention. The IG had was significantly more independent in daily activities post-intervention, whilst CG was significantly worse.
* There was a significant difference between both groups in the QOL measures, with IG significantly improving physical functioning; haemoptysis; pain in arms/shoulders; peripheral neuropathy and cognitive functioning.
* The strength and endurance significantly improved in the IG post-intervention (even after three rounds of chemotherapy), and there was a significant decrease in dyspnoea amongst the IG during sub-maximal walking activities.

##### Results review

The authors of this study appropriately interpreted the results, establishing through significant statistical differences between the IG and CG the training program has had a positive impact on the patients independence in carrying out daily tasks and the patients strength and endurance, with single factors relating to QOL also improved.

## What conclusions can we take from this research?

It can be concluded from this study that LC patients receiving palliative chemotherapy treatment should also undergo a physical activity intervention in order to counteract the inability to complete daily tasks and diminished QOL associated with advanced LC and chemotherapy. This conclusion aligns with other research relating to physical activity interventions in the palliative treatment of other forms of advanced cancer.

## Practical advice

Those involved in prescribing palliative treatment for advanced LC patients should consider the patients ability to perform endurance and strength based exercises and if possible implement some combination of these exercises as part of the patients treatment plan. However, given the health risks that accompanies advanced LC and chemotherapy, exercise training programs should only be prescribed and supervised by a trained health professional.

## Further information/sources

* Further information regarding LC from the Cancer Council:
https://www.cancer.org.au/cancer-information/types-of-cancer/lung-cancer
* If you have been diagnosed with cancer and need support:
https://www.cancer.org.au/cancer-information/after-a-diagnosis/coping-with-a-cancer-diagnosis
* If someone you know has been diagnosed with cancer:
https://www.cancer.org.au/assets/pdf/caring-for-someone-with-cancer#_ga=2.255355019.2040694170.1599448859-2041275608.1568335855

## References

* 1 2 3 4 Henke C, Cabri J, Fricke L, Pankow W, Kandilakis G, Feyer P et al. Strength and endurance training in the treatment of lung cancer patients in stages IIIA/IIIB/IV. Supportive Care in Cancer. 2013;22(1):95-101.
* 1 2 Blandin Knight S, Crosbie P, Balata H, Chudziak J, Hussell T, Dive C. Progress and prospects of early detection in lung cancer. Open Biology. 2017;7(9):170070.
* ↑ Walters S, Maringe C, Coleman M, Peake M, Butler J, Young N et al. Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, 2004–2007. Thorax. 2013;68(6):551-564.
* ↑ Cancer Council NSW. Palliative Treatment for Lung Cancer | Cancer Council NSW [Internet]. Cancer Council NSW. 2020 [cited 7 September 2020]. Available from: https://www.cancercouncil.com.au/lung-cancer/treatment/palliative-treatment/
* ↑ Peterson M, Rhea M, Sen A, Gordon P. Resistance exercise for muscular strength in older adults: A meta-analysis. Ageing Research Reviews. 2010;9(3):226-237.
* ↑ Kosmidis P. Quality of Life as a New End Point. Chest. 1996;109(5):110S-112S.
* ↑ Burns P, Rohrich R, Chung K. The Levels of Evidence and Their Role in Evidence-Based Medicine. Plastic and Reconstructive Surgery. 2011;128(1):305-310.
* 1 2 Hariton E, Locascio J. Randomised controlled trials - the gold standard for effectiveness research. BJOG: An International Journal of Obstetrics & Gynaecology. 2018;125(13):1716-1716.
* ↑ Albrecht T, Taylor A. Physical Activity in Patients With Advanced-Stage Cancer: A Systematic Review of the Literature. Clinical Journal of Oncology Nursing. 2012;16(3):293-300.
* ↑ Edbrooke L, Granger C, Denehy L. Physical activity for people with lung cancer. Australian Journal of General Practice. 2020;49(4):175-181.