# Exercise as it relates to Disease/Physical Activity Intervention for People with Advanced Lung Cancer

This is an analysis of the journal article "Exercise and relaxation intervention for patients with advanced lung cancer: a qualitative feasibility study" by L. Adamsen et al. (2011). Scandinavian Journal of Medicine and Science in Sports. Volume 22: 804-815

## What is the background to this research?

Lung cancer is the uncontrolled growth of abnormal cells in the lungs, which forms tumours. The growth begins in the cells of the air passages of one or both lungs, depriving the bloodstream of oxygen. There are two main types of lung cancer:
* Non-small cell lung cancer (NSCLC)
* Small cell lung cancer (SCLC)
NSCLC is the most common type and accounts for 80% of lung cancers, while SCLC accounts for the remaining 20%. Common symptoms of lung cancer include:
* Shortness of breath
* Wheezing
* Chest pain
* Coughing
* Decreased appetite
* Weight loss
* Fatigue
* Recurrent bronchitis or pneumonia
Common factors that increase the risk of lung cancer include:
* Tobacco smoking
* Exposure to second-hand smoke
* Exposure to asbestos and other occupational substances
Currently, there is no screening tool for lung cancer in Australia. Individuals with a high risk of lung cancer are adults between the ages of 55-80 with a smoking history, who are currently smoking or stopped smoking in the last 15 years. An individual’s prognosis depends on the type and stage of lung cancer, their age and health. However, only 16% of individuals survive five years after diagnosis.
Lung cancer is the leading cause of cancer deaths in Australia, accounting for one in five cancer deaths. It is the fifth most common cancer diagnosed after breast, bowel and prostate cancer and melanoma. One in seventeen Australians is diagnosed with lung cancer before 85 years of age. The incidence of lung cancer in Australia is increasing. It is estimated that there will be 12,434 new lung cancer diagnoses and 9,021 lung cancer deaths in 2017. As lung cancer is such a debilitating disease, intervention programs initiated at diagnosis and through the course of the disease, that focus on improving quality of life are necessary. This research study highlights the importance of a physical intervention program in individuals with lung cancer.

## Where is the research from?

The research was conducted at a fitness facility in the Copenhagen University Hospital, Rigshospitalet, Denmark. It was conducted by Adamsen, Stage, Laursen, Rorth and Quist. The lung cancer patients were recruited from the Department of Oncology at this hospital.
One of the authors, Professor Lis Adamsen, is the Head of Research at The University Hospitals’ Centre for Nursing and Care Research, Copenhagen, Denmark. Professor Adamsen has published many articles on the effects of physical activity in cancer patients undergoing chemotherapy.

## What kind of research was this?

The research study employed qualitative and quantitative methodology, however the article only reported the findings from the qualitative method. The qualitative method consisted of individual and group interviews of the lung cancer patients.

## What did the research involve?

The research study explored the use, benefits and barriers to exercise in previously sedentary patients with advanced lung cancer undergoing chemotherapy. The inclusion criteria consisted of:
* Advanced lung cancer (NSCLC and SCLC)
* Over 18 years of age
* Chemotherapy treatment
The first 15 lung cancer patients from the Copenhagen University Hospital who enrolled in the exercise and relaxation program and met the inclusion criteria, were selected. The 15 patients participated in two programs under the supervision of a physiotherapist and clinical nurse. The two programs were:
| Hospital-based, supervised exercise and relaxation program | Home-based, unsupervised exercise and relaxation program |
| Four hours per week (two hours Tuesday and two hours Thursday) for six weeks | Three hours per week (one hour every second day) for six weeks |
| Resistance, cardiovascular and relaxation training | Gait, respiration and relaxation training |
| 45 minutes of resistance training including: leg press, chest press, pull down, abdominal crunch, lower back extension and knee extension; 3 circuits of 5-8 repetitions at 80-90% of 1 Repetition Maximum (RM) | Performed individually at home |
| 15-20 minutes of cardiovascular training including: interval training on stationary bicycles; at 70-95% of maximal heart rate | |
| 30 minutes of relaxation training including: audiotape of progressive muscle relaxation (PMR) | |
| Mixed gender groups | |
At the end of the six week program, the patients participated in individual and focus group interviews conducted by two independent researchers.
The qualitative methodology used in the research study was appropriate and effective in obtaining results from the participants. However, as the results from the quantitative methodology were not included in this article, there is a lack of numerical data, which would support the participants’ perceptions of improvement. This research study is supported by Schmitz, et al who used qualitative and quantitative methodology to show that physical activity interventions produce a small to moderate improvement in cardiorespiratory fitness in cancer survivors.

## What were the basic results?

The attendance rate for the hospital-based, supervised program was 76%. For a group of previously sedentary individuals, the attendance rate was high and was attributed to the set times, compulsory participation and peer expectation of the hospital-based, supervised program. The participants reported:
* Improved physical capacity
* Improved wellbeing and energy
* Positive social interactions with others in a similar situation
In contrast, the home-based, unsupervised program was ineffective. The participants reported:
* Lack of motivation to exercise alone
* Lack of energy to train without a partner
* Strong preference for the structured group training
At the interviews, the participants expressed a desire to continue the exercise and relaxation program beyond the six week period.
The researchers noted that the lung cancer participants experienced physical, functional and emotional benefits from the exercise and relaxation program. These findings are consistent with a study by Temel, et al which reported significant improvements in lung cancer symptoms as a result of a hospital-based exercise program for patients with advanced NSCLC.

## What conclusions can we take from this research?

The research showed that an exercise and relaxation program in previously sedentary patients with advanced lung cancer, can encourage increased physical activity. Increased physical activity improves well-being and breathing capacity whilst increasing muscle strength and energy. An exercise and relaxation program is therefore beneficial to individuals with advanced lung cancer who are undergoing chemotherapy treatment.
The findings from the research study closely align with other research in the area. A systematic review by Grangera, et al highlighted the positive benefits of exercise intervention in patients with NSCLC, including exercise capacity, symptoms and quality of life. Whilst a randomised control trial by Arbane, et al reported that exercise intervention increased quadriceps muscle strength which improved quality of life in NSCLC patients.

## Practical advice

Participation in a supervised, peer group exercise intervention is beneficial for individuals with lung cancer. This intervention should include:
* Resistance training using machines to involve a large number of muscle groups (both upper and lower body)
* Cardiovascular training using stationary bicycles and walking on treadmills
* Relaxation training using audiotape PMR
* Stretching exercises for the respiratory muscles
* Instruction on managing attacks of dyspnea
Regular monitoring of heart rate, blood pressure, respiration rate and temperature should be conducted throughout the exercise intervention for the health and safety of the lung cancer participants.

## Further information/resources

For further information on lung cancer and the benefits of physical activity, click on the following links below:
* Wikipedia Lung Cancer
* American Cancer Society
* Australian Government Cancer Australia
* International Association for the Study of Lung Cancer
* Dana-Farber Cancer Institute

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 L. Adamsen et al. (2011). Scandinavian Journal of Medicine and Science in Sports. Volume 22: 804-815
* 1 2 3 4 5 Cure Cancer Australia. (2017). Lung Cancer. [Internet]. Available: http://www.curecancer.com.au/what-we-do/all-cancers/lung
* 1 2 3 4 5 6 7 8 Cancer Council Australia. (2017). Lung Cancer. [Internet]. Available: http://www.cancer.org.au/about-cancer/types-of-cancer/lung-cancer.html
* 1 2 Medical News Today. (2016). Lung Cancer: Facts, Types and Causes. [Internet]. Available: http://www.medicalnewstoday.com/info/lung-cancer
* 1 2 3 4 Australian Government Cancer Australia. (2017). Lung Cancer Statistics. [Internet]. Available: https://lung-cancer.canceraustralia.gov.au/statistics
* 1 2 K.H. Schmitz, et al. (2005). Cancer Epidemiology, Biomarkers & Prevention. Volume 14: 1588-1594
* ↑ J.S. Temel, et al. (2009). Journal of Thoracic Oncology. Volume 4: 595-600
* ↑ C.L. Grangera, et al. A Systematic Review. Volume 72: 139-153
* ↑ G. Arbane, et al. (2011). Lung Cancer. Volume 71: 229-234
* ↑ M.A. Spruit, et al. (2006). Lung Cancer. Volume 52: 257-260