Short-term preoperative exercise therapy does not improve long-term outcome after lung cancer surgery: a randomized controlled study† Perioperative rehabilitation in operation for lung cancer (PROLUCA) – rationale and design Perioperative Rehabilitation in Operable Lung Cancer Patients (PROLUCA) Preoperative Exercise Vo2 Measurement for Lung Resection Candidates: Results of Cancer and Leukemia Group B Protocol 9238 Preoperative pulmonary rehabilitation versus chest physical therapy in patients undergoing lung cancer resection: a pilot randomized controlled trial. Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies. Preoperative pulmonary rehabilitation in patients undergoing lung resection for non-small cell lung cancer. Cardiopulmonary exercise tests and lung cancer surgical outcome. Short‐Term Preoperative High‐Intensity Interval Training in Patients Awaiting Lung Cancer Surgery: A Randomized Controlled Trial Preoperative exercise training prevents functional decline after lung resection surgery: a randomized, single-blind controlled trial Safety and Feasibility of an Exercise Intervention for Patients Following Lung Resection Predictors of exercise oxygen desaturation following major lung resection. Multimodality therapy in the treatment of lung cancer. Pulmonary rehabilitation programme for patients undergoing curative lung cancer surgery. Preoperative Maximal Oxygen Uptake and Exercise-induced Changes in Pulse Oximetry Predict Early Postoperative Respiratory Complications in Lung Cancer Patients Preoperative pulmonary rehabilitation in patients with non-small cell lung cancer and chronic obstructive pulmonary disease Performance at preoperative stair-climbing test is associated with prognosis after pulmonary resection in stage I non-small cell lung cancer. Stereotactic Body Radiation Therapy Versus Surgery for Early Lung Cancer Among US Veterans. Incentive spirometry does not enhance recovery after thoracic surgery [Impact and Effect of Preoperative Short-term Pulmonary Rehabilitation Training on  Lung Cancer Patients with Mild to Moderate Chronic Obstructive Pulmonary Disease:  A Randomized Trial]. Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study. Screening for Lung Cancer: U.S. Preventive Services Task Force Recommendation Statement CPAP Increases 6-Minute Walk Distance After Lung Resection Surgery
OBJECTIVES Poor aerobic fitness is a potential modifiable risk factor for long-term survival and quality of life in patients with lung cancer . This r and omized trial evaluates the impact of adding rehabilitation ( Rehab ) with high-intensity interval training ( HIIT ) before lung cancer surgery to enhance cardiorespiratory fitness and improve long-term postoperative outcome . METHODS Patients with operable lung cancer were r and omly assigned to  usual care ( UC , n = 77 ) or to intervention group ( Rehab  , n = 74 ) that entailed HIIT that was implemented only preoperatively .  Cardiopulmonary exercise testing ( CPET ) and pulmonary functional tests ( PFTs ) including forced vital capacity ( FVC ) , forced expiratory volume ( FEV 1 ) and carbon monoxide transfer factor ( KCO ) were performed before and 1 year after surgery . RESULTS During the preoperative waiting time ( median 25 days ) , Rehab patients participated to a median of 8 HIIT sessions ( interquartile [ IQ ] 25 - 75 % , 7 - 10 ) . At 1 year follow-up , 91 % UC patients and 93 % Rehab patients were still alive ( P = 0.506 ) . Pulmonary functional changes were non-significant and comparable in both groups ( FEV 1 mean -7.5 % , 95 % CI , -3.6 to -12.9 and in KCO mean 5.8 % 95 % CI 0.8 - 11.8 ) Compared with preoperative CPET results , both groups demonstrated similar reduction in peak oxygen uptake ( mean -12.2 % 95 % CI -4.8 to -18.2 ) and in peak work rate ( mean -11.1 % 95 % CI -4.2 to -17.4 ) . CONCLUSIONS Short-term preoperative rehabilitation with HIIT does not improve pulmonary function and aerobic capacity measured at 1 year after lung cancer resection . TRIAL REGISTRY Clinical Trials.gov ; No. NCT01258478 ; www . clinical trials.gov Background The purpose of the PROLUCA study is to investigate the efficacy of preoperative and early postoperative rehabilitation in a non-hospital setting in patients with operable lung cancer with special focus on exercise . Methods Using a 2x2 factorial design with continuous effect endpoint ( Maximal Oxygen Uptake ( VO2peak ) ) , 380 patients with non-small cell lung cancer ( NSCLC ) stage I-IIIa referred for surgical resection will be r and omly assigned to one of four groups : ( 1 ) preoperative and early postoperative rehabilitation ( starting two weeks after surgery ) ; ( 2 ) preoperative and late postoperative rehabilitation ( starting six weeks after surgery ) ; ( 3 ) early postoperative rehabilitation alone ; ( 4 ) today ’s st and ard care which is postoperative rehabilitation initiated six weeks after surgery . The preoperative rehabilitation program consists of an individually design ed , 30-minute home-based exercise program performed daily . The postoperative rehabilitation program consists of a supervised group exercise program comprising cardiovascular and resistance training two-hour weekly for 12 weeks combined with individual counseling . The primary study endpoint is VO2peak and secondary endpoints include : Six-minute walk distance ( 6MWD ) , one-repetition-maximum ( 1RM ) , pulmonary function , patient-reported outcomes ( PROs ) on health-related quality of life ( HRQoL ) , symptoms and side effects of the cancer disease and the treatment of the disease , anxiety , depression , wellbeing , lifestyle , hospitalization time , sick leave , work status , postoperative complications ( up to 30 days after surgery ) and survival . Endpoints will be assessed at baseline , the day before surgery , pre-intervention , post-intervention , six months after surgery and one year after surgery . Discussion The results of the PROLUCA study may potentially contribute to the identification of the optimal perioperative rehabilitation for operable lung cancer patients focusing on exercise initiated immediately after diagnosis and rehabilitation shortly after surgery . Trial Registration Introduction . Surgical resection in patients with non – small cell lung cancer ( NSCLC ) may be associated with significant morbidity , functional limitations , and decreased quality of life . Objectives . The safety and feasibility of a preoperative and early postoperative rehabilitation program in patients operated for NSCLC was determined in a nonhospital setting , with focus on high-intensity interval exercise . Methods . Forty patients with biopsy-proven NSCLC stages I to IIIa referred for surgical resection at the Department of Cardiothoracic Surgery RT , Rigshospitalet , University of Copenhagen , were r and omly assigned to 1 of 4 groups ( 3 intervention groups and 1 control group ) . The preoperative intervention consisted of a home-based exercise program , while the postoperative exercise program comprised a supervised group exercise program involving resistance and high-intensity interval cardiorespiratory exercise 2 hours weekly for 12 weeks combined with individual counseling . The study endpoints were inclusion rate , adherence , and number of adverse events . Results . Forty patients ( of 124 screened ; 32 % ) were included and r and omized into the 4 groups . The postoperative exercise was completed by 73 % of the patients r and omized to this intervention . No adverse events were observed , indicating that the early postoperative exercise program is safe . The preoperative home-based exercise program was not feasible due to interfering diagnostic procedures and fast-track surgery that left only 1 to 2 weeks between diagnosis and surgery . Conclusion . The early postoperative exercise program for patients with NSCLC was safe and feasible , but in a fast-track set up , a preoperative home-based exercise program was not feasible for this population Introduction : A stepwise approach to the functional assessment of lung resection c and i date s is widely accepted , and this approach incorporates the measurement of exercise peak Vo2 when spirometry and radionuclear studies suggest medical inoperability . A new functional operability ( FO ) algorithm incorporates peak exercise Vo2 earlier in the preoperative assessment to determine which patients require preoperative radionuclear studies . This algorithm has not been studied in a multicenter study . Methods : The CALGB ( Cancer and Leukemia Group B ) performed a prospect i ve multi-institutional study to investigate the use of primary exercise Vo2 measurement for the prediction of surgical risk . Patients with known or suspected resectable non-small cell lung cancer ( NSCLC ) were eligible .  Exercise testing including measurement of peak oxygen uptake ( Vo2 ) , spirometry , and single breath diffusion capacity ( DLCO ) was performed on each patient . Nuclear perfusion scans were obtained on selected high-risk patients . After surgery , morbidity and mortality data were collected and correlated with preoperative data . Mortality and morbidity were retrospectively compared by algorithm-based risk groups . Results : Three hundred forty-six patients with suspected lung cancer from nine institutions underwent thoracotomy with or without resection ; 57 study patients did not undergo thoracotomy .  Patients who underwent surgery had a median survival time of 30.9 months , whereas patients who did not undergo surgery had a median survival time of 15.6 months . Among the 346 patients who underwent thoracotomy , 15 patients died postoperatively ( 4 % ) , and 138 patients ( 39 % ) exhibited at least one cardiorespiratory complication postoperatively . We found that patients who had a peak exercise Vo2 of < 65 % of predicted ( or a peak Vo2/kg < 16 ml/min/kg ) were more likely to suffer complications ( p = 0.0001 ) and were also more likely to have a poor outcome ( respiratory failure or death ) if the peak Vo2 was < 15 ml/min/kg ( p = 0.0356 ) . We also found a subset of 58 patients who did not meet FO algorithm criteria for operability , but who still tolerated lung resection with a 2 % mortality rate . Conclusions : Our data provide multicenter validation for the use of exercise Vo2 for preoperative assessment of lung cancer patients , and we encourage an aggressive approach when evaluating these patients for surgery OBJECTIVE To evaluate the effect of 4 weeks of pulmonary rehabilitation ( PR ) versus chest physical therapy ( CPT ) on the preoperative functional capacity and postoperative respiratory morbidity of patients undergoing lung cancer resection . DESIGN R and omized single-blinded study . SETTING A teaching hospital . PARTICIPANTS Patients undergoing lung cancer resection ( N=24 ) . INTERVENTIONS Patients were r and omly assigned to receive PR ( strength and endurance training ) versus CPT ( breathing exercises for lung expansion ) . Both groups received educational classes . MAIN OUTCOME MEASURES Functional parameters assessed before and after 4 weeks of PR or CPT ( phase 1 ) , and pulmonary complications assessed after lung cancer resection ( phase 2 ) . RESULTS Twelve patients were r and omly assigned to the PR arm and 12 to the CPT arm . Three patients in the CPT arm were not su bmi tted to lung resection because of inoperable cancer . During phase 1 evaluation , most functional parameters in the PR group improved from baseline to 1 month : forced vital capacity ( FVC ) ( 1.47L [ 1.27 - 2.33L ] vs 1.71L [ 1.65 - 2.80L ] , respectively ; P=.02 ) ; percentage of predicted FVC ( FVC% ; 62.5 % [ 49%-71 % ] vs 76 % [ 65%-79.7 % ] , respectively ; P<.05 ) ; 6-minute walk test ( 425.5±85.3 m vs 475±86.5 m , respectively ; P<.05 ) ; maximal inspiratory pressure ( 90±45.9cmH(2)O vs 117.5±36.5cmH(2)O , respectively ; P<.05 ) ; and maximal expiratory pressure ( 79.7±17.1cmH(2)O vs 92.9±21.4cmH(2)O , respectively ; P<.05 ) . During phase 2 evaluation , the PR group had a lower incidence of postoperative respiratory morbidity ( P=.01 ) , a shorter length of postoperative stay ( 12.2±3.6d vs 7.8±4.8d , respectively ; P=.04 ) , and required a chest tube for fewer days ( 7.4±2.6d vs 4.5±2.9d , respectively ; P=.03 ) compared with the CPT arm . CONCLUSIONS These findings suggest that 4 weeks of PR before lung cancer resection improves preoperative functional capacity and decreases the postoperative respiratory morbidity Complete surgical resection is the most effective curative treatment for lung cancer . However , many patients with lung cancer also have severe COPD which increases their risk of postoperative complications and their likelihood of being considered " inoperable . " Preoperative pulmonary rehabilitation ( PR ) has been proposed as an intervention to decrease surgical morbidity but there is no established protocol and no r and omized study has been published to date . We tested two preoperative PR interventions in patients undergoing lung cancer resection and with moderate-severe COPD in a r and omized single blinded design . Outcomes were length of hospital stay and postoperative complications . The first study tested 4 weeks of guideline -based PR vs. usual care : that study proved to be very difficult to recruit as patients and providers were reluctant to delay surgery . Nine patients were r and omized and no differences were found between arms . The second study tested ten preoperative PR sessions using a customized protocol with nonst and ard components ( exercise prescription based on self efficacy , inspiratory muscle training , and the practice of slow breathing ) ( n=10 ) vs. usual care ( n=9 ) . The PR arm had shorter length of hospital stay by 3 days ( p=0.058 ) , fewer prolonged chest tubes ( 11 % vs. 63 % , p=0.03 ) and fewer days needing a chest tube ( 8.8 vs. 4.3 days p=0.04 ) compared to the controlled arm . A ten-session preoperative PR intervention may improve post operative lung reexpansion evidence d by shorter chest tube times and decrease the length of hospital stay , a crude estimator of post operative morbidity and costs . Our results suggest the potential for short term preoperative pulmonary rehabilitation interventions in patients with moderate-severe COPD undergoing curative lung resection . 4 weeks of conventional preoperative PR seems non feasible BACKGROUND The impact of short-term preoperative pulmonary rehabilitation on exercise capacity of patients with chronic obstructive pulmonary disease undergoing lobectomy for non-small cell lung cancer is evaluated . METHODS A prospect i ve observational study was design ed . Inclusion criteria consisted of an indication to lung resection because of a clinical stage I or II non-small cell lung cancer and a chronic obstructive disease on preoperative pulmonary function test . In such conditions , maximal oxygen consumption by a cardio-pulmonary exercise test was evaluated ; when this result ed as being < or = 15 ml/kg/min a pulmonary rehabilitation programme lasting 4 weeks was considered . Twelve patients fulfilled inclusion criteria , completed the preoperative rehabilitation programme and underwent a new functional evaluation prior to surgery . The postoperative record of these patients was collected . RESULTS On completion of pulmonary rehabilitation , the resting pulmonary function test and diffuse lung capacity of patients was unchanged , whereas the exercise performance was found to have significantly improved ; the mean increase in maximal oxygen consumption proved to be at 2.8 ml/kg/min ( p<0.01 ) . Eleven patients underwent lobectomy ; no postoperative mortality was noted and mean hospital stay was 17 days . Postoperative pulmonary complication was recorded in 8 patients . CONCLUSIONS Short-term preoperative pulmonary rehabilitation could improve the exercise capacity of patients with chronic obstructive pulmonary disease who are c and i date s for lung resection for non-small cell lung cancer STUDY OBJECTIVES Surgical resection remains the treatment of choice for anatomically resectable non-small cell lung cancer . However , the presence of associated comorbid conditions increases the risk of death and surgical complications . Several studies have evaluated the usefulness of preoperative exercise testing for predicting postoperative morbidity and mortality . The aim of this study was to establish whether exercise testing could predict poor surgical outcome in lung cancer surgery and whether the absolute value or percentage of predicted value is the better predictor of the surgical outcome . DESIGN The study was design ed as a prospect i ve study . PATIENTS AND SETTING One hundred thirty patients with potentially operable lung cancer at Papworth Hospital over 2 years were recruited ; of these , 101 underwent curative surgery .  INTERVENTIONS Spirometry and cardiopulmonary exercise tests were performed for every patient ( n = 99 ) , except for two patients with back problems . We also recorded the outcome of surgery , in particular , complications and mortality . MEASUREMENTS AND RESULTS Mean maximum oxygen transport at peak exercise ( Vo(2)peak ) was 18.3 mL/kg/min ( SD , 4.7 mL/kg/min ) , and mean percentage of predicted Vo(2)peak value was 84.4 % ( SD , 30 % ) . Poor surgical outcome was significantly related to Vo(2)peak percentage of predicted ( p < 0.01 ) but not to the actual oxygen uptake value . CONCLUSIONS The use of the percentage of predicted Vo(2)peak value would be a better indicator of surgical outcome , since it predicts the surgical outcome better , and corrects for normal physiologic ranges . The threshold of Vo(2)peak for surgical intervention could be set between 50 % and 60 % of predicted without excess surgical mortality Introduction : Impairment in aerobic fitness is a potential modifiable risk factor for postoperative complications . In this r and omized controlled trial , we hypothesized that a high‐intensity interval training ( HIIT ) program enhances cardiorespiratory fitness before lung cancer surgery and therefore reduces the risk of postoperative complications . Methods : Patients with operable lung cancer were r and omly assigned to usual care ( UC ) ( n = 77 ) or preoperative rehabilitation based on HIIT ( Rehab ) ( n = 74 ) .  Maximal cardiopulmonary exercise testing and the 6‐minute walk test were performed twice before surgery . The primary outcome measure was a composite of death and in‐hospital postoperative complications . Results : The groups were well balanced in terms of patient characteristics . During the preoperative waiting period ( median 25 days ) , the peak oxygen consumption and the 6‐minute walking distance increased ( median + 15 % , interquartile range , 25th to 75 percentile [ IQR25%–75 % , % ] = + 9 % to + 22 % , p = 0.003 and + 15 % , IQR25%–75 % = + 8 % to + 28 % , p < 0.001 , respectively ) in the Rehab group , whereas peak oxygen consumption declined in the UC group ( median –8 % , IQR25%–75 % = –16 % to 0 % ] , p = 0.005 ) . The primary end point did not differ significantly between the two groups : at least one postoperative complication developed in 27 of the 74 patients ( 35.5 % ) in the Rehab group and 39 of 77 patients ( 50.6 % ) in the UC group ( p = 0.080 ) . Notably , the incidence of pulmonary complications was lower in the Rehab compared with in the UC group ( 23 % versus 44 % , p = 0.018 ) , owing to a significant reduction in atelectasis ( 12.2 % versus 36.4 % , p < 0.001 ) , and this decrease was accompanied by a shorter length of stay in the postanesthesia care unit ( median –7 hours , IQR25%–75 % = –4 to –10 ) . Conclusions : In this r and omized controlled trial , preoperative HIIT result ed in significant improvement in aerobic performances but failed to reduce early complications after lung cancer resection Objectives : To investigate the effects of a preoperative pulmonary rehabilitation programme in patients with lung cancer undergoing video-assisted thoracic surgery .  Design : R and omized , single-blind controlled trial . Setting : Teaching hospital . Subjects : Patients with suspected or confirmed lung cancer undergoing video-assisted thoracic surgery .  Intervention : Participants were r and omized  to either a prehabilitation group or a control group .  Participants in the prehabilitation group underwent a combination of moderate endurance and resistance training plus breathing exercises three to five times per week . Main measures : The primary outcome of the study was exercise capacity . Secondary outcomes were muscle strength ( Senior Fitness Test ) , health-related quality of life ( Short-Form 36 ) and the postoperative outcomes . Patients were evaluated at baseline ( before r and omization ) , presurgery ( only the prehabilitation group ) , after surgery and three months post-operatively . Results : A total of 40 patients were r and omized and 22 finished the study ( 10 in the prehabilitation group and 12 in the control group ) . Three patients were lost to follow-up at three months . After the training , there was a statistically significant improvement in exercise tolerance ( + 397 seconds , p = 0.0001 ) , the physical summary component of the SF-36 ( + 4.4 points , p = 0.008 ) and muscle strength ( p < 0.01 ) . There were no significant differences between groups after surgery . However , three months postoperatively , significant differences were found in the mean change of exercise capacity ( p = 0.005 ) , physical summary component ( p = 0.001 ) and upper and lower body strength ( p = 0.045 and p = 0.002 ) . Conclusions : A pulmonary rehabilitation programme before video-assisted thoracic surgery seems to improve patients ’ preoperative condition and may prevent functional decline after surgery . Clinical Registration Number : NCT01963923 ( Registration date 10/10/2013 Purpose . Following surgical lung resection , patients frequently suffer functional decline and reduced activity levels . Despite this exercise interventions are not routinely provided . This study aim ed to establish the safety and feasibility of exercise administered following lung resection in an Australian setting . Method . Pilot r and omized controlled trial . Fifteen individuals ( 53 % male ) , mean ± st and ard deviation age 65.5 ± 16.1 years , undergoing surgery for suspected lung cancer . R and omization occurred postoperatively . Control arm received protocol ized inpatient respiratory physiotherapy . Intervention arm additionally received twice daily exercise until discharge home and twice weekly as outpatient for 8 weeks . Outcome measures ( safety , feasibility , functional capacity , functional mobility , and health-related quality of life [ HRQoL ] ) were assessed preoperatively and 2 and 12 weeks postoperatively . Results . Fifteen participants ( lung cancer n = 10 ) were assigned to control ( n = 8) and intervention ( n = 7 ) groups . Inpatient exercise was delivered on 71 % of occasions ( 35 out of 49 planned sessions ) . Four participants attended outpatient exercise sessions and these participants attended sessions on 81 % of occasions ( 52 out of 64 planned sessions ) . No adverse events occurred . There was a significant between group difference in 6-Minute Walk Test ( 6MWT ; P = .024 ) . In both groups the 6MWT declined from baseline to 2 weeks postoperative and then improved up to 12 weeks ; improvements were greater in the intervention group . Intervention was associated with positive trends of improvement in some HRQoL domains . Conclusions . Exercise intervention performed in the inpatient and outpatient setting s for individuals following lung resection  was safe and feasible . The uptake rate for outpatient exercise was 57 % , similar to previous trials ; however , adherence was excellent within the subgroup of participants who attended . Further research is required to investigate the best setting of exercise delivery and explore ways to improve the uptake rate OBJECTIVE To identify predictors of postoperative exercise oxygen desaturation ( EOD ) in patients su bmi tted to lobectomy or pneumonectomy for lung carcinoma . PATIENTS AND METHODS A consecutive series of 227 patients with non-small cell lung cancer su bmi tted to lobectomy or pneumonectomy from January 2000 through October 2002 were prospect ively analyzed . Maximal stair-climbing tests were performed preoperatively ( the day before the operation ) and postoperatively ( on average , 9.2 days after operation ) in room air for all patients . A fall in oxygen saturation during the exercise below 90 % was termed ' desaturation ' . Univariate and multivariate analyses were performed to identify predictors of postoperative EOD . RESULTS Thirty-five patients ( 15.4 % ) developed postoperative EOD . After multivariate analysis , the only independent predictor of postoperative EOD result ed a reduction in oxygen saturation during the preoperative exercise ( P=0.0004 ) . CONCLUSIONS Patients with a reduction in oxygen saturation during the preoperative exercise test are at increased risk to develop a postoperative EOD below 90 % . A postoperative exercise test should be performed in all these patients . Should EOD be confirmed , an intermittent home oxygen therapy is recommended in order to facilitate recovery from operation and improve the quality of life Lung cancer is the leading cause of cancer death in the world , causing more than one million deaths each year . The incidence and mortality rates are highest in the United States and Europe and continue to increase in developing nations . Non-small cell lung cancer ( NSCLC ) accounts for 80 to 85 % of all new cases of lung cancer . The majority of patients with NSCLC present with advanced disease at the time of diagnosis . Although the prognosis of advanced NSCLC is very poor , current chemotherapy combinations have been shown to improve 1-year survival and quality of life for these patients . Approximately one third of patients with NSCLC are diagnosed with locally advanced disease . Although cure rates are modest and variable in locally advanced NSCLC , multimodality therapy ( chemotherapy in combination with surgery or radiotherapy ) has result ed in statistically significant improvement in 5-year survival when compared with surgery or radiotherapy alone . Patients with early-stage NSCLC have the best long-term survival rates following surgical resection ; however , systemic recurrences remain a problem in the majority of these patients . The rationale for treating patients with early-stage NSCLC with combined-modality therapy ( chemotherapy and surgery ) is compelling , and several r and omized trials are currently in progress . Although progress has been slow , when we consider the recent advances in smoking prevention , smoking cessation , staging classification , imaging and diagnostic techniques , screening and therapeutic modalities , and multidisciplinary care , as well as in the underst and ing of the molecular pathogenesis of lung cancer , the future , in my opinion , is very promising OBJECTIVES The aim of the study was to develop a multistr and ed pragmatic rehabilitation programme for operable lung cancer patients , that looks into feasibility , process indicators , outcome measures , local adaptability , compliance and potential cost benefit . METHODS An outpatient-based complex intervention , rehabilitation for operated lung cancer ( ROC ) programme , was developed to optimize physical status , prepare for the inpatient journey and support through recovery after surgery . It includes exercise classes , smoking cessation , dietary advice and patient education and was tested in an enriched cohort study within a regional thoracic unit over 18 months . RESULTS A multistr and ed pragmatic rehabilitation programme pre- and post-surgery is feasible . Fifty-eight patients received the intervention and 305 received st and ard care . Both groups were matched for age , lung function comorbidity and type of surgery . Patients in the intervention group attended exercise classes twice a week until surgery , which was not delayed . Patients attended four sessions presurgery ( range 1 - 15 ) , result ing in an improvement of 20 m ( range -73 - 195 , P = 0.001 ) in a 6-min walk test and 0.66 l in forced expiratory volume in 1 s ( range -1.85 from 1.11 , P = 0.009 ) from baseline to presurgery . Fifty-four percentage of smokers in the intervention group stopped smoking . Sixteen percentage of patients were identified as being at risk of malnourishment and received nutritional intervention . There was a trend in patients in the intervention group towards experiencing fewer postoperative pulmonary complications than those in the non-intervention group ( 9 vs 16 % , respectively , P = 0.21 ) and fewer readmissions to hospital because of complications ( 5 vs 14 % respectively , P = 0.12 ) . CONCLUSION Chronic obstructive pulmonary disease-type pulmonary rehabilitation before and after lung cancer surgery is viable , and preliminary results suggest improvement in physical measures . A multicentre , r and omized controlled trial is warranted to confirm clinical efficacy . IS RCT N REGISTRATION NUMBER IS RCT N00061628 Background : Postoperative respiratory complications often arise in lung cancer patients after lung resection , although these are often difficult to predict . We sought to identify reliable predictors of early-onset postoperative respiratory complications in lung cancer patients who had moderate-to-severe preoperative respiratory impairment . Methods : This was a prospect i ve observational study that included 107 consecutive lung cancer patients with forced expiratory volume in 1 s < 60 % of predicted who were scheduled for thoracotomy and lung resection .  Preoperative functional assessment s included pulmonary function testing by spirometry , single breath diffusion capacity of lung for carbon monoxide , and cardiopulmonary exercise testing . Risk factors for early-onset postoperative respiratory complications that occurred within 30 days postoperatively were sought from among these pulmonary function testing and cardiopulmonary exercise testing results . Results : By multivariable logistic regression , peak oxygen uptake ( V′O2max% ; p < 0.001 ) and the transcutaneous pulse oxygen saturation difference during load exercise ( ΔSPO2 % ; p < 0.001 ) were independent predictors of postoperative respiratory complications . A receiver operating characteristic curve had an area under the curve of 0.846 for the combination of V′O2max% and ΔSPO2 % , while the area under the curve with V′O2max% only was 0.726 . From this , the probability of postoperative respiratory complications was P complication = e ( 2 . 58 − 0 . 08 V ′ O 2 max % + 0 . 56 Δ SP O 2 % ) / [ 1 + e ( 2 . 58 − 0 . 08 V ′ O 2 max % + 0 . 56 Δ SP O 2 % ) ] . Pcomplication ≥ 0.202 for postoperative respiratory complications had a sensitivity of 80.8 % and a specificity of 81.5 % . Conclusions : For lung cancer patients with forced expiratory volume in 1 s < 60 % of predicted , in addition to common preoperative tests , V′O2max% and ΔSPO2 % may be an aid for predicting early-onset postoperative respiratory complications Introduction The aim of this study was to assess the effects of preoperative pulmonary rehabilitation ( PPR ) on preoperative clinical status changes in patients with chronic obstructive pulmonary disease ( COPD ) and non-small cell lung cancer ( NSCLC ) , and net effects of PPR and cancer resection on residual pulmonary function and functional capacity . Material and methods This prospect i ve single group study included 83 COPD patients ( 62 ±8 years , 85 % males , FEV1 = 1844 ±618 ml , Tiffeneau index = 54 ±9 % ) with NSCLC , on 2–4-week PPR , before resection . Pulmonary function , and functional and symptom status were evaluated by  spirometry , 6-minute walking distance ( 6MWD ) and Borg scale , on admission , after PPR and after surgery . Results Following PPR significant improvement was registered in the majority of spirometry parameters ( FEV1 by 374 ml , p < 0.001 ; VLC by 407 ml , p < 0.001 ; FEF50 by 3 % , p = 0.003 ) , 6MWD ( for 56 m , p < 0.001 ) and dyspnoeal symptoms ( by 1.0 Borg unit , p < 0.001 ) . A positive correlation was identified between preoperative increments of FEV1 and 6MWD ( r s = 0.503 , p = 0.001 ) . Negative correlations were found between basal FEV1 and its percentage increment ( r s = –0.479 , p = 0.001 ) and between basal 6MWD and its percentage change ( r s = –0.603 , p < 0.001 ) during PPR . Compared to basal values , after resection a significant reduction of most spirometry parameters and 6MWD were recorded , while Tiffeneau index , FEF25 and dyspnoea severity remained stable ( p = NS ) . Conclusions Preoperative pulmonary rehabilitation significantly enhances clinical status of COPD patients before NSCLC resection . Preoperative increase of exercise tolerance was the result of pulmonary function improvement during PPR . The beneficial effects of PPR were most emphasized in patients with initially the worst pulmonary function and the weakest functional capacity BACKGROUND This investigation evaluated whether the performance at a preoperative symptom-limited stair-climbing test was a prognostic factor in resected pathologic stage I non-small cell lung cancer ( NSCLC ) . METHODS Observational analysis was performed on a prospect i ve data base that included 296 patients who underwent pulmonary lobectomy for pathologic stage T1 N0 or T2 N0 NSCLC ( 2000 to 2008 ) . Patients who received induction chemotherapy were excluded . Survival was calculated by the Kaplan-Meyer method . The log-rank test was used to assess differences in survival between groups . The relationships between survival and baseline and clinical variables were determined by Cox multivariate analyses . RESULTS Median follow-up was 43 months . The best cutoff associated with prognosis was an 18-meter stair climb . Median ( months ) survival and 5-year survival of patients who climbed more than 18 meters were significantly longer than those who climbed less than 18 meters ( 97 vs 74 ; 77 % vs 54 % , p=0.001 ) . Cox regression model ( hazard ratio ) showed that climbing more than 18 meters ( 0.5 ; p=0.003 ) , diffusion capacity of the lung for carbon monoxide ( 0.98 ; p=0.02 ) , and pT stage ( 1.8 ; p=0.02 ) were independent prognostic factors . Patients who climbed less than 18 meters had increased deaths from cancer ( 24 % vs 15 % , p=0.1 ) or other causes ( 19 % vs 9 % , p=0.02 ) . CONCLUSIONS Preoperative cardiopulmonary fitness is a significant prognostic factor in patients after resection for early-stage NSCLC . Interventions aim ed at improving exercise tolerance can be useful to improve long-term prognosis after NSCLC operations BACKGROUND Stereotactic body radiation therapy ( SBRT ) has been proposed as a potential alternative to surgery for early lung cancer , although we lack well-powered prospect i ve r and omized data comparing these treatments , and existing studies suffer from incomplete information on confounders that can bias results . Here , we evaluated the comparative effectiveness of surgery  and  SBRT  in lung cancer treatment using a large extensively detailed data base from the Veteran 's Affairs system . METHODS We identified veterans with biopsy-proven clinical stage I non-small cell lung cancer diagnosed between 2006 and 2015 from within the Veteran 's Affairs Informatics and Computing Infrastructure . We compared cancer-specific survival among patients receiving lobectomy , sublobar resection , or SBRT  using univariable and multivariable competing risk analyses . Multivariable analyses adjusted for confounders including preoperative pulmonary function , smoking status , comorbidity , and staging workup procedures . RESULTS In all , 4,069 patients were included ( 449 SBRT , 2,986 lobectomy , 634 sublobar resection ) . Unadjusted analysis found higher immediate postprocedural mortality in the surgery groups compared with the SBRT group . The multivariable analysis considering long-term survival found higher cancer-specific mortality for SBRT compared with lobectomy ( subdistribution hazard ratio 1.45 , 95 % confidence interval : 1.09 to 1.94 , p = 0.01 ) , although no survival difference between SBRT and sublobar resection ( subdistribution hazard ratio 1.25 , 95 % confidence interval : 0.93 to 1.68 , p = 0.15 ) . CONCLUSIONS Among a large cohort of early stage lung cancer patients , we found that lobectomy had improved survival compared with SBRT , although we found no survival difference between sublobar resection and SBRT . Despite these findings , the potential for unmeasured confounding remains and prospect i ve r and omized trials are needed to better compare these treatment modalities Objective : To investigate the additional effect of incentive spirometry to chest physiotherapy to prevent postoperative pulmonary complications after thoracic surgery for lung and esophageal resections . Design : R and omized controlled trial . Setting : University hospital , intensive care unit , and surgical department . Patients : Sixty‐seven patients ( age , 59 ± 13 yrs ; forced expiratory volume in 1 sec , 93 % ± 22 % predicted ) undergoing elective thoracic surgery for lung ( n = 40 ) or esophagus ( n = 27 ) resection . Interventions : Physiotherapy ( breathing exercises , huffing , and coughing ) ( PT ) plus incentive spirometry ( IS ) was compared with PT alone . Measurements and Main Results : Lung function , body temperature , chest radiograph , white blood cell count , and number of hospital and intensive care unit days were all measured . Pulmonary function was significantly reduced after surgery ( 55 % of the initial value ) and improved significantly in the postoperative period in both groups . However , no differences were observed in the recovery of pulmonary function between the groups . The overall score of the chest radiograph , based on the presence of atelectasis , was similar in both treatment groups . Eight patients ( 12 % ) ( three patients with lobectomy and five with esophagus resection ) developed a pulmonary complication ( abnormal chest radiograph , elevated body temperature and white blood cell count ) , four in each treatment group . Adding IS to regular PT did not reduce hospital or intensive care unit stay . Conclusions : Pulmonary complications after lung and esophagus surgery were relatively low . The addition of IS to PT did not further reduce pulmonary complications or hospital stay . Although we can not rule out beneficial effects in a subgroup of high‐risk patients , routine use of IS after thoracic surgery seems to be ineffective BACKGROUND Pulmonary rehabilitation ( PR ) is proposed as an effective strategy to decrease surgical morbidity . However , appropriate rehabilitation plan , initiation time , and optimal duration of PR remain unclear . Lung cancer patients with chronic obstructive pulmonary disease ( COPD ) are considered high-risk population for postoperative pulmonary complications ( PPCs ) because of poor lung fitness and cardiopulmonary endurance . This study aims to assess the impact of a one-week , systematic and highly-intensive rehabilitation on surgical lung cancer patients with mild to moderate COPD . METHODS A r and omized controlled trial with 48 subjects was conducted ( 24 patients each for the intervention and groups ) . The intervention group received seven days of systematic , integrated and highly-intensive PR before surgical treatment , including : pharmacotherapy with atomizing terbutaline , pulmicort and infusion of ambroxol ; and physical rehabilitation with respiratory training and endurance training . The control group underwent st and ard preoperative care . RESULTS For the intervention group , the postoperative length of stay was shorter [ ( 6.17±2.91 ) d vs ( 8.08±2.21 ) d ; P=0.013 ] ; likewise for the duration of antibiotics use [ ( 3.61±2.53 ) d vs ( 5.36±3.12 ) d ; P=0.032 ] . No significant difference was found between the groups in total in-hospital cost [ ( 46,455.6±5,080.9 ) ¥ vs ( 45,536.0±4,195.8 ) ¥ , P=0.498 ] , medicine cost [ ( 7,760.3±2,366.0 ) vs ( 6,993.0±2,022.5 ) , P=0.223 ] , and material cost [ ( 21,155.5±10,512.1 ) ¥ vs ( 21,488.8±3,470.6 ) ¥ , P=0.883 ] . In the intervention group , peak expiratory flow [ ( 268.40±123.94 ) L/min vs ( 343.71±123.92 ) L/min ; P<0.001 ] , 6-min walk distance ( 6-MWD ) [ ( 595.42±106.74 ) m vs ( 620.90±99.27 ) m ; P=0.004 ] , and energy consumption [ ( 59.93±10.61 ) kcal vs ( 61.03±10.47 ) kcal ; P=0.004 ] were statistically different after the seven-day exercise , compared with those on the first day . Finally , for the intervention group the incidence of PPCs ( 8.3 % , 2/24 vs 20.8 % , 5/24 , 20.8 % ; P=0.416 ) were lower . CONCLUSIONS The systematic and highly-intensive pulmonary rehabilitation combining abdominal respiration training , respiratory exercise with incentive spirometry , and aerobic exercise could improve the cardiorespiratory endurance of lung cancer patients with mild to moderate COPD . The proposed program may be a practicable preoperative strategy . OBJECTIVE At present , even when early-stage , small-sized non-small cell lung cancers are being increasingly detected , lesser resection has not become the treatment of choice . We sought to compare sublobar resection ( segmentectomy or wedge resection ) with lobar resection to test which one is the appropriate procedure for such lesions . METHODS From 1992 to 2001 , a nonr and omized study was performed in 3 institutes for patients with a peripheral cT1N0M0 non-small cell lung cancer of 2 cm or less who were able to tolerate a lobectomy . The results of the  sublobar resection group  enrolled preoperatively ( n = 305 ) were compared with those of the  lobar resection group ( n = 262 ) . RESULTS Except for distribution of tumor location , there were no significant differences in any variable , patient characteristics , curability , pathologic stage , morbidity , or recurrence rate . Median follow-up was more than 5 years . Disease-free and overall survivals were similar in both groups with 5-year survivals of 85.9 % and 89.6 % for the sublobar resection group and 83.4 % and 89.1 % for the lobar resection group , respectively . Multivariate analysis confirmed that the recurrence rate and prognosis associated with sublobar resection were not inferior to those obtained with lobar resection . Postoperative lung function was significantly better in patients who underwent sublobar resection . CONCLUSIONS Sublobar resection should be considered as an alternative for stage IA non-small cell lung cancers 2 cm or less , even in low-risk patients . These results could lay the foundation for starting r and omized controlled trials anew , which would bring great changes of lung cancer surgery in this era of early detection of lung cancer The U.S. Preventive Services Task Force ( USPSTF ) makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms . It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance . The USPSTF does not consider the costs of providing a service in this assessment . The USPSTF recognizes that clinical decisions involve more considerations than evidence alone . Clinicians should underst and the evidence but individualize decision making to the specific patient or situation . Similarly , the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms . Summary of Recommendation and Evidence The USPSTF recommends annual screening for lung cancer with low-dose computed tomography ( LDCT ) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years . Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery . ( B recommendation ) See the Clinical Considerations section for suggestions for implementation in practice . See the Figure for a summary of the recommendation and suggestions for clinical practice . Figure . Screening for lung cancer : clinical summary of U.S. Preventive Services Task Force recommendation . Appendix Table 1 describes the USPSTF grade s , and Appendix Table 2 describes the USPSTF classification of levels of certainty about net benefit . Appendix Table 1 . What the USPSTF Grade s Mean and Suggestions for Practice Appendix Table 2 . USPSTF Levels of Certainty Regarding Net Benefit Supplement . Consumer Fact Sheet . Rationale Importance Lung cancer is the third most common cancer and the leading cause of cancer-related death in the United States ( 1 ) . The most important risk factor for lung cancer is smoking , which results in approximately 85 % of all U.S. lung cancer cases ( 2 ) . Although the prevalence of smoking has decreased , approximately 37 % of U.S. adults are current or former smokers ( 2 ) . The incidence of lung cancer increases with age and occurs most commonly in persons aged 55 years or older . Increasing age and cumulative exposure to tobacco smoke are the 2 most common risk factors for lung cancer . Lung cancer has a poor prognosis , and nearly 90 % of persons with lung cancer die of the disease . However , early-stage nonsmall cell lung cancer ( NSCLC ) has a better prognosis and can be treated with surgical resection . Detection Most lung cancer cases are NSCLC , and most screening programs focus on the detection and treatment of early-stage NSCLC . Although chest radiography and sputum cytologic evaluation have been used to screen for lung cancer , LDCT has greater sensitivity for detecting early-stage cancer ( 3 ) . Benefits of Detection and Early Treatment Although lung cancer screening is not an alternative to smoking cessation , the USPSTF found adequate evidence that annual screening for lung cancer with LDCT  in a defined population of high-risk persons can prevent a substantial number of lung cancerrelated deaths . Direct evidence from a large , well-conducted , r and omized , controlled trial ( RCT ) provides moderate certainty of the benefit of lung cancer screening with LDCT in this population ( 4 ) . The magnitude of benefit to the person depends on that person 's risk for lung cancer because those who are at highest risk are most likely to benefit . Screening can not prevent most lung cancerrelated deaths , and smoking cessation remains essential . Harms of Detection and Early Intervention and Treatment The harms associated with LDCT screening include false-negative and false-positive results , incidental findings , overdiagnosis , and radiation exposure . False-positive LDCT results occur in a substantial proportion of screened persons ; 95 % of all positive results do not lead to a diagnosis of cancer . In a high- quality screening program , further imaging can resolve most false-positive results ; however , some patients may require invasive procedures . The USPSTF found insufficient evidence on the harms associated with incidental findings . Overdiagnosis of lung cancer occurs , but its precise magnitude is uncertain . A modeling study performed for the USPSTF estimated that 10 % to 12 % of screen-detected cancer cases are overdiagnosedthat is , they would not have been detected in the patient 's lifetime without screening . Radiation harms , including cancer result ing from cumulative exposure to radiation , vary depending on the age at the start of screening ; the number of scans received ; and the person 's exposure to other sources of radiation , particularly other medical imaging . USPSTF Assessment The USPSTF concludes with moderate certainty that annual screening for lung cancer with LDCT is of moderate net benefit in asymptomatic persons who are at high risk for lung cancer based on age , total cumulative exposure to tobacco smoke , and years since quitting smoking . The moderate net benefit of screening depends on limiting screening to persons who are at high risk , the accuracy of image interpretation being similar to that found in the NLST ( National Lung Screening Trial ) , and the resolution of most false-positive results without invasive procedures ( 4 ) . Clinical Considerations Patient Population Under Consideration The risk for lung cancer increases with age and cumulative exposure to tobacco smoke and decreases with time since quitting smoking . The best evidence for the benefit of screening comes from the NLST , which enrolled adults aged 55 to 74 years who had at least a 30 pack-year smoking history and were current smokers or had quit within the past 15 years . As with all screening trials , the NLST tested a specific intervention over a finite period . Because initial eligibility extended through age 74 years and participants received 3 annual screening computed tomographic scans  , the oldest participants in the trial were aged 77 years . The USPSTF used modeling studies to predict the benefits and harms of screening programs that use different screening intervals , age ranges , smoking histories , and times since quitting . A program that annually screens adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years is projected to have a reasonable balance of benefits and harms . The model assumes that persons who achieve 15 years of smoking cessation during the screening program discontinue screening . This model predicts the outcomes of continuing the screening program used in the NLST through age 80 years . Screening may not be appropriate for patients with substantial comorbid conditions , particularly those at the upper end of the screening age range . The NLST excluded persons who were unlikely to complete curative lung cancer surgery and those with medical conditions that posed a substantial risk for death during the 8-year trial . The baseline characteristics of the NLST showed a relatively healthy sample , and fewer than 10 % of enrolled participants were older than 70 years ( 5 ) . Persons with serious comorbid conditions may experience net harm , no net benefit , or at least substantially less net benefit . Similarly , persons who are unwilling to have curative lung surgery are unlikely to benefit from a screening program . Assessment of Risk Age , total exposure to tobacco smoke , and years since quitting smoking are important risk factors for lung cancer and were used to determine eligibility in the NLST . Other risk factors include specific occupational exposures , radon exposure , family history , and history of pulmonary fibrosis or chronic obstructive lung disease . The incidence of lung cancer is relatively low in persons younger than 50 years but increases with age , especially after age 60 years . In current and former smokers , age-specific incidence rates increase with age and cumulative exposure to tobacco smoke . Smoking cessation substantially reduces a person 's risk for developing and dying of lung cancer . Among persons enrolled in the NLST , those who were at highest risk because of additional risk factors or a greater cumulative exposure to tobacco smoke experienced most of the benefit ( 6 ) . A vali date d multivariate model showed that persons in the highest 60 % of risk accounted for 88 % of all deaths preventable by screening . Screening Tests Low-dose computed tomography has shown high sensitivity and acceptable specificity for the detection of lung cancer in high-risk persons .  Chest radiography and sputum cytologic evaluation  have not shown adequate sensitivity or specificity as screening tests . Therefore , LDCT is currently the only recommended screening test for lung cancer . Treatment Surgical resection is the current st and ard of care for localized NSCLC . This type of cancer is treated with surgical resection when possible and also with radiation and chemotherapy . Annual LDCT screening may not be useful for patients with life-limiting comorbid conditions or poor functional status who may not be c and i date s for surgery . Other Approaches to Prevention Smoking cessation is the most important intervention to prevent NSCLC . Advising smokers to stop smoking and preventing nonsmokers from being exposed to tobacco smoke are the most effective ways to decrease the morbidity and mortality associated with lung cancer . Current smokers should be informed of their continuing risk for lung cancer and offered cessation treatments . Screening with LDCT should be viewed as an adjunct to tobacco cessation interventions . Useful Re sources Clinicians have many re sources to help patients stop smoking . The Centers for Disease Control and Prevention has developed a Web site with many such re sources , including information on tobacco quit lines , available in several language s ( www.cdc.gov/tobacco/campaign/tips ) . Quit BACKGROUND : The application of CPAP has been used to minimize postoperative pulmonary complications after lung resection surgery . The aim of this study was to quantify both the CPAP effects upon lung function and functional capacity in early postoperative lung resection , as well as to evaluate if CPAP prolongs air leak through the chest drain . METHODS : Thirty patients in the postoperative period of lung resection were allocated into 2 groups : an experimental group , consisting of 15 patients who underwent a 10 cm H2O CPAP  , and a  15 patient control group  , who performed breathing exercises . Arterial blood gas analysis , peak expiratory flow ( PEF ) , respiratory muscle strength , spirometry , and 6-min walk test ( 6MWT ) were assessed in the preoperative period , and repeated postoperatively on the first and on the seventh day ( 6MWT was repeated only on the seventh day ) . RESULTS : Significant increases in PEF , muscle strength , and FEV1 between the first and seventh postoperative day were observed , both in the experimental and in the control group , whereas FVC and PaO2 increased significantly between the first and seventh postoperative day only in the experimental group . The average loss in 6-min walk distance ( 6MWD ) from preoperative to postoperative day 7 in the experimental group was significantly lower than in control group . When comparing the 2 groups , only 6MWD was statistically different ( P < .001 ) . There was no air leakage increase through the drain with the early use of CPAP . CONCLUSION : When compared to breathing exercises , CPAP increases the 6MWD in postoperative lung resection patients , without prolonging air leak through the chest drain
In conclusion , preoperative exercise-based training improves pulmonary function before surgery and reduces in-hospital length of stay and postoperative complications after lung resection surgery for lung cancer
Lung cancer is the leading cause of cancer-related death worldwide .
For early stages of the disease , lung resection surgery remains the best treatment with curative intent , but significant morbidity is associated , especially among patients with poor pulmonary function and cardiorespiratory fitness .
In those cases , the implementation of a preoperative exercise-based intervention could optimize patient 's functional status before surgery and improve postoperative outcomes and enhance recovery .
The aim of this systematic review is to provide the current body of knowledge regarding the effectiveness of a preoperative exercise-based intervention on postoperative and functional outcomes in patients with lung cancer su bmi tted to lung resection surgery .