Combined aerobic exercise and high-intensity respiratory muscle training in patients surgically treated for non-small cell lung cancer: a pilot randomized clinical trial. Home-based exercise: promising rehabilitation for symptom relief, improved functional status and quality of life for post-surgical lung cancer patients. Outcomes of Pulmonary Rehabilitation After Treatment for Non-Small Cell Lung Cancer Stages I to IIIa: AN OBSERVATIONAL STUDY Cardiopulmonary exercise tests and lung cancer surgical outcome. The lung cancer exercise training study: a randomized trial of aerobic training, resistance training, or both in postsurgical lung cancer patients: rationale and design Perioperative rehabilitation in operation for lung cancer (PROLUCA) – rationale and design Stereotactic body radiation therapy for early-stage non-small cell lung cancer: Executive Summary of an ASTRO Evidence-Based Guideline. Effect of postoperative physical training on activity after curative surgery for non-small cell lung cancer: a multicentre randomised controlled trial. Comparison of clinical outcome of stage I non-small cell lung cancer treated surgically or with stereotactic radiotherapy: results from propensity score analysis. Preoperative Exercise Vo2 Measurement for Lung Resection Candidates: Results of Cancer and Leukemia Group B Protocol 9238 Multimodality therapy in the treatment of lung cancer. Perioperative Rehabilitation in Operable Lung Cancer Patients (PROLUCA) Relationship of shuttle walk test and lung cancer surgical outcome. Clinical Staging of Stage I Non-Small Cell Lung Cancer in the Netherlands-Need for Improvement in an Era With Expanding Nonsurgical Treatment Options: Data From the Dutch Lung Surgery Audit. POSITIVE study: physical exercise program in non-operable lung cancer patients undergoing palliative treatment Clinical effectiveness of first-line chemoradiation for adult patients with locally advanced non-small cell lung cancer: a systematic review. Exercise in patients with non-small cell lung cancer. The extent of lung parenchyma resection significantly impacts long-term quality of life in patients with non-small cell lung cancer. Stereotactic body radiotherapy versus surgery for medically operable Stage I non-small-cell lung cancer: a Markov model-based decision analysis. Postoperative adjuvant chemotherapy for stage I non-small cell lung cancer. Too Sick Not to Exercise: Using a 6-Week, Home-Based Exercise Intervention for Cancer-Related Fatigue Self-management for Postsurgical Non–Small Cell Lung Cancer Patients Effects of exercise training on exercise capacity in patients with non-small cell lung cancer receiving targeted therapy Treatment of stage III non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.
BACKGROUND Lung resection surgery further decreases exercise capacity and negatively affects respiratory muscle function in patients with non-small cell lung cancer ( NSCLC ) . The best design for exercise interventions in these patients has not been determined yet . AIM To assess the impact of aerobic exercise and high-intensity respiratory muscle training on patient outcomes following lung cancer resection surgery . DESIGN Prospect i ve , single-blind , pilot r and omized controlled trial . SETTING Outpatient cardiopulmonary rehabilitation unit of two university hospitals . POPULATION Thirty-seven patients with NSCLC after tumor resection . METHODS Patients were r and omly assigned to exercise training or usual post-operative care . The training program consisted of aerobic exercises and high-intensity respiratory muscle training ( 24 supervised sessions , 3 per week , 8 weeks ) . Primary outcome was exercise capacity assessed with peak oxygen uptake ( VO2peak ) during cardiopulmonary exercise test . Secondary outcomes included changes in respiratory muscle strength , levels of serum insulin growth factor I ( IGF-I ) and IGF binding protein 3 ( IGFBP-3 ) , and quality of life assessed with the European Organization for Research and Treatment of Cancer ( EORTC QLQ-C30 ) question naire . RESULTS The 8-week training program was associated with significant improvement in VO2peak ( 2.13 mL/Kg/min [ 95%CI 0.06 to 4.20 ] ) , maximal inspiratory and expiratory pressures ( 18.96 cmH2O [ 95 % CI 2.7 to 24.1 ] and 18.58 cmH2O [ 95 % CI 4.0 to 33.1 ] , respectively ) and IGFBP-3 ( 0.61 µg/mL [ % 95 CI 0.1 to 1.12 ] ) . No significant differences were observed in the EORTC QLQ-C30 . CONCLUSIONS An 8-week exercise program consisting of aerobic exercise and high-intensity respiratory muscle training improved exercise capacity , respiratory muscle strength , and serum IGFBP-3 levels in NSCLC patients after lung resection . There was no impact on the other outcomes assessed . CLINICAL REHABILITATION IMPACT A combination of aerobic exercise and respiratory muscle training could be included in the rehabilitation program of deconditioned patients with NSCLC after lung resection surgery BACKGROUND Post-thoracotomy non-small cell lung cancer ( NSCLC ) patients report cancer-related fatigue ( CRF ) as a severe symptom that may increase the occurrence and severity of other symptoms while decreasing functional status and quality of life ( QOL ) . The aim of this pilot study was to describe the effects of a home-based rehabilitative exercise intervention on CRF , other symptoms , functional status , and QOL for post-surgical NSCLC patients starting within days after hospital discharge . METHODS Seven post-thoracotomy NSCLC patients completed the  Brief Fatigue Inventory ( BFI ) measuring CRF severity , and the  M.D. And erson Symptom Inventory measuring symptom severity at pre- and post-surgery , and at the end of each week of the six-week intervention . Additionally , the Medical Outcomes Short-Form-36 measuring physical and mental functional status ; and the Quality of Life Index ( QLI ) measuring QOL were completed pre- and post-surgery , after week 3 , and at the end of the intervention ( week 6 ) . RESULTS Participants had a mean age of 65 years , a mean of 6 co-morbid conditions , and initiated the intervention within 4 days after hospital discharge . Participants ' CRF severity scores were reduced to mild levels while the mean number of symptoms decreased from 10.4 post-surgery to 7.0 at week 6 with lower levels of severity and interference . Likewise , participants ' post-intervention functional status and QOL improved to near or above pre-surgical levels . CONCLUSIONS The exercise intervention for post-surgical NSCLC patients showed promising preliminary efficacy in improving CRF , other symptom severity , functional status , and QOL . Further testing via a two-arm r and omized controlled trial is being conducted PURPOSE : Although rehabilitation after treatment for non-small cell lung cancer ( NSCLC ) was found to have a beneficial effect on exercise capacity in a number of studies , insight into its effect on quality of life ( QoL ) and fatigue is limited . The aim of this study was to examine the outcome of pulmonary rehabilitation ( PR ) regarding fatigue , QoL , and exercise capacity in adult patients curatively treated for NSCLC stages I to IIIa . METHODS : Study data were prospect ively and routinely gathered in daily practice in patients taking part in an outpatient PR program after treatment for NSCLC stages I to IIIa . PR consisted of 12 weeks of supervised exercises 3 times a week , supplemented with scheduled visits with members of a multidisciplinary team . Data were gathered at initial assessment and discharge . Outcomes included fatigue ( the Functional Assessment of Cancer Therapy-Fatigue and the fatigue domain of the Chronic Respiratory Disease Question naire ) ; QoL ( total CRQ score ) , Functional Assessment of Cancer Therapy-Lung , and the Short Form 36 ; and exercise capacity ( cardiopulmonary exercise testing ) . RESULTS : Fifty patients started the program out of the 70 patients referred to PR and 43 ( 86 % ) completed the program . Significant ( P ⩽ .01 ) and clinical ly relevant improvements were observed for all outcome measures . CONCLUSIONS : Rehabilitation after treatment for NSCLC stages I to IIIa showed promising improvements regarding patient fatigue , QoL , and exercise capacity . PR should be considered for patients after treatment for NSCLC stages I to IIIa 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 Background The Lung Cancer Exercise Training Study ( LUNGEVITY ) is a r and omized trial to investigate the efficacy of different types of exercise training on cardiorespiratory fitness ( VO2peak ) , patient-reported outcomes , and the organ components that govern VO2peak in post-operative non-small cell lung cancer ( NSCLC ) patients . Methods / Design Using a single-center , r and omized design , 160 subjects ( 40 patients / study arm ) with histologically confirmed stage I-IIIA NSCLC following curative-intent complete surgical resection at Duke University Medical Center ( DUMC ) will be potentially eligible for this trial . Following baseline assessment s , eligible participants will be r and omly assigned to one of four conditions : ( 1 ) aerobic training alone , ( 2 ) resistance training alone , ( 3 ) the combination of aerobic and resistance training , or ( 4 ) attention-control ( progressive stretching ) . The ultimate goal for all exercise training groups will be 3 supervised exercise sessions per week an intensity above 70 % of the individually determined VO2peak for aerobic training and an intensity between 60 and 80 % of one-repetition maximum for resistance training , for 30 - 45 minutes/session . Progressive stretching will be matched to the exercise groups in terms of program length ( i.e. , 16 weeks ) , social interaction ( participants will receive one-on-one instruction ) , and duration ( 30 - 45 mins/session ) . The primary study endpoint is VO2peak . Secondary endpoints include : patient-reported outcomes ( PROs ) ( e.g. , quality of life , fatigue , depression , etc . ) and organ components of the oxygen cascade ( i.e. , pulmonary function , cardiac function , skeletal muscle function ) . All endpoints will be assessed at baseline and postintervention ( 16 weeks ) . Sub studies will include genetic studies regarding individual responses to an exercise stimulus , theoretical determinants of exercise adherence , examination of the psychological mediators of the exercise - PRO relationship , and exercise-induced changes in gene expression . Discussion VO2peak is becoming increasingly recognized as an outcome of major importance in NSCLC . LUNGEVITY will identify the optimal form of exercise training for NSCLC survivors as well as provide insight into the physiological mechanisms underlying this effect . Overall , this study will contribute to the establishment of clinical exercise therapy rehabilitation guidelines for patients across the entire NSCLC continuum . Trial Registration 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 PURPOSE This guideline presents evidence -based recommendations for stereotactic body radiation therapy ( SBRT ) in challenging clinical scenarios in early-stage non-small cell lung cancer ( NSCLC ) . METHODS AND MATERIAL S The American Society for Radiation Oncology convened a task force to perform a systematic literature review on 4 key questions addressing : ( 1 ) application of SBRT to operable patients ; ( 2 ) appropriate use of SBRT in tumors that are central ly located , large , multifocal , or unbiopsied ; ( 3 ) individual tailoring of SBRT in " high-risk " clinical scenarios ; and ( 4 ) SBRT as salvage therapy after recurrence . Guideline recommendations were created using a predefined consensus-building methodology supported by American Society for Radiation Oncology-approved tools for grading evidence quality and recommendation strength . RESULTS Although few r and omized trials have been completed for SBRT , strong consensus recommendations based on extensive , consistent publications were generated for several questions , including recommendations for fractionation for central tumors and surgery versus SBRT in st and ard-risk medically operable patients with early-stage NSCLC . Lower quality evidence led to conditional recommendations on use of SBRT for tumors > 5 cm , patients with prior pneumonectomy , T3 tumors with chest wall invasion , synchronous multiple primary lung cancer , and as a salvage therapy after prior radiation therapy . These areas of moderate- and low- quality evidence highlight the importance of clinical trial enrollment as well as the role of prospect i ve data registries . CONCLUSIONS SBRT has an important role to play in treating early-stage NSCLC , particularly for medically inoperable patients with limited other treatment options . Shared decision-making with patients should be performed in all cases to ensure the patient underst and s the risks related to SBRT , the side effects , and the alternative treatments available OBJECTIVE To evaluate the effect of a combined hospital plus home exercise programme following curative surgery for non-small cell lung cancer ( NSCLC ) . DESIGN R and omised controlled trial . SETTING Teaching hospital . PARTICIPANTS One hundred and thirty-one subjects with NSCLC admitted for curative surgery . INTERVENTIONS Participants were r and omised to usual care or a hospital plus home exercise programme . OUTCOMES The primary outcome was the between-group difference in physical activity 4 weeks after surgery . Secondary outcomes were the difference in quadriceps strength , exercise tolerance and quality of life [ Short Form-36 ( SF-36 ) and European Organisation for Research and Treatment of Cancer ( EORTC ) QLQ-LC13 ] from pre-operatively ( baseline ) to 4 weeks after surgery . RESULTS The participants ( n=131 ) had a mean age of 68 [ st and ard deviation ( SD ) 11 ] years and mean forced expiratory volume in 1 second of 2.4 ( SD 1.1)l . There were no significant differences in physical activity between the groups 4 weeks after surgery [ mean difference adjusted for baseline 12minutes/day , 95 % confidence interval ( CI ) -20.2 to 44.1 ] . In addition , there were no significant differences in total SF-36 or EORTC QLQ-LC13 scores from baseline to 4 weeks after surgery . Both groups had recovered their pre-operative walking distance 4 weeks after surgery , and there were no differences between the groups ( mean difference in Incremental Shuttle Walk Test from baseline to 4 weeks after surgery ( -26 m , 95 % CI -94.2 to 42.3 ) . CONCLUSIONS A hospital plus home exercise programme showed little benefit in unselected patients with NSCLC following surgery . Regardless of group allocation , the patients had recovered their pre-operative exercise tolerance levels by 4 weeks after surgery OBJECTIVES Guideline -specified curative therapies for a clinical stage I non-small cell lung cancer ( NSCLC ) are either lobectomy or Stereotactic Ablative Radiotherapy ( SABR ) . As outcomes of prospect i ve r and omized clinical trials comparing these modalities are unavailable , we performed a propensity-score matched analysis to create two similar groups in order to compare clinical outcomes . METHODS We selected 577 patients , 96 VATS or open lobectomy were treated at Erasmus University Medical Center Rotterdam and 481 SABR patients were treated at VU University Medical Center Amsterdam with clinical stage I NSCLC . RESULTS Matching of patients according to propensity score result ed in a cohort that consisted of 73 patients in the surgery group and of 73 patients in the SABR group . Median follow-up in the surgery and SABR group was 49 months and 28 months , respectively . Overall survival of patients who underwent surgery was 95 % and 80 % at 12 and 60 months , respectively . For the SABR group this was 94 % at 12 months and 53 % at 60 months . No statistical significant difference ( p=0.089 ) in survival was found between these groups . CONCLUSIONS In this study we found no significant differences in overall survival in propensity matched patients diagnosed with stage I NSCLC treated either surgically or with SABR . After 3 years there seems to be a trend toward improved survival in patients who were treated surgically 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 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 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 OBJECTIVE Surgery remains the treatment of choice in patients with potentially resectable lung carcinoma . Both the British Thoracic Society and American Chest Physician guidelines for the selection of patients with lung cancer surgery suggest the use of a shuttle walk test to predict outcome in patients with borderline lung function . The guidelines suggest that if the patient is unable to walk 250 m during a shuttle walk test , they are high risk for surgery . However , there is no published evidence to support this recommendation . Therefore , we undertook a prospect i ve study to examine the relationship between shuttle walk test  and surgical outcome in 139 patients undergoing assessment for possible lung cancer surgery . METHODS The shuttle walk test was performed in 139 potentially resectable patients , recruited over a 2 year period , prior to surgery . One hundred and eleven patients underwent surgery . Outcome of surgery , including duration of hospital stay , complication and mortality rates was recorded . Student 's t-test was used to compare the shuttle walk distance in patients with good and poor outcome from surgery . RESULTS Mean age of patients undergoing surgery was 69 years ( 42 - 85 ) .  Mean shuttle walk distance was 395 m ( 145 - 780 ) , with a mean oxygen desaturation of 4 % ( 0 - 14 ) during the test . Sixty nine patients had a good surgical outcome and 34 had a poor outcome . The shuttle walk distance was not statistically different in the two outcome groups . CONCLUSION Shuttle walk distance  should not be used to predict poor surgical outcome in lung cancer patients , contrary to current recommendations . It is therefore advisable to perform a formal cardiopulmonary exercise test if at all possible . The usefulness of a shuttle walk test might be improved . It could be compared to a predicted value , as for a formal cardiopulmonary exercise test BACKGROUND The clinical stage of non-small cell lung cancer ( NSCLC ) determines the initial treatment , whereas the pathologic stage best determines prognosis and the need for adjuvant treatment . In an era in which stereotactic ablative radiotherapy ( SABR ) has become an alternative modality to surgical intervention , clinical staging is even more important , because pathologic staging is omitted in the case of SABR . The objective of this study was to determine the concordance between clinical and pathologic stage in routine clinical practice for patients with early-stage NSCLC . METHODS Prospect i ve data were derived from the Dutch Lung Surgery Audit ( DLSA ) in 2013 and 2014 . Patients with clinical stage I NSCLC who underwent surgical resection and had a positron emission tomography-computed tomography ( PET-CT ) scan in their clinical workup were selected .  Clinical and pathologic TNM ( cTNM and pTNM ) stages were compared . RESULTS From a total of 1,790 patients with clinical stage I , 1,555 ( 87 % ) patients were included in this analysis . Concordance between cTNM and pTNM was 59.9 % . Of the patients with clinical stage I , 22.6 % were upstaged to pathologic stage II or higher . In total , 14.9 % of all patients with clinical stage I had nodal metastases , and 5.5 % of all patients had unforeseen N2 disease . In patients with clinical stage T2a tumors , 21.3 % had nodal metastases , 14.5 % being N1 and 6.7 % being N2 disease . CONCLUSIONS Concordance between clinical and pathologic stage is 59.9 % . In patients with clinical stage I NSCLC , 22.6 % were upstaged to pathologic stage II or higher , which is an indication for adjuvant chemotherapy . Improvement in accuracy of staging is thus needed , particularly for these patients Background Patients with advanced stage non-small cell lung cancer ( NSCLC ) or small cell lung cancer ( SCLC ) often experience multidimensional impairments , affecting quality of life during their course of disease . In lung cancer patients with operable disease , several studies have shown that exercise has a positive impact on quality of life and physical functioning . There is limited evidence regarding efficacy for advanced lung cancer patients undergoing palliative treatment . Therefore , the POSITIVE study aims to evaluate the benefit of a 24-week exercise intervention during palliative treatment in a r and omized controlled setting . Methods / design The POSITIVE study is a r and omized , controlled trial investigating the effects of a 24-week exercise intervention during palliative treatment on quality of life , physical performance and immune function in advanced , non-operable lung cancer patients . 250 patients will be recruited in the Clinic for Thoracic Diseases in Heidelberg , enrolment begun in November 2013 . Main inclusion criterion is histologically confirmed NSCLC ( stage IIIa , IIIb , IV ) or SCLC ( Limited Disease-SCLC , Extensive Disease-SCLC ) not amenable to surgery . Patients are r and omized into two groups . Both groups receive weekly care management phone calls ( CMPCs ) with the goal to assess symptoms and side effects . Additionally , one group receives a combined resistance and endurance training ( 3x/week ) . Primary endpoints are quality of life assessed by the Functional Assessment of Cancer Therapy for patients with lung cancer ( FACT-L , subcategory Physical Well-Being ) and General Fatigue measured by the Multidimensional Fatigue Inventory ( MFI-20 ) . Secondary endpoints are physical performance ( maximal voluntary isometric contraction , 6-min walk distance ) , psychosocial ( depression and anxiety ) and immunological parameters and overall survival . Discussion The aim of the POSITIVE trial is the evaluation of effects of a 24-week structured and guided exercise intervention during palliative treatment stages . Analysis of various outcomes ( such as quality of life , physical performance , self-efficacy , psychosocial and immunological parameters ) will contribute to a better underst and ing of the potential of exercise in advanced lung cancer patients . In contrast to other studies with advanced oncological patients the POSITIVE trial provides weekly phone calls to support patients both in the intervention and control group and to segregate the impact of physical activity on quality of life . Trial registration Clinical Trials.gov NCT02055508 ( Date : December 12 , 2013 BACKGROUND The National Institute for Health and Clinical Excellence has issued guidelines on the treatment of non-small cell lung cancer ( NSCLC ) and recommends that patients with stage IIIA-IIIB disease who are not amenable to surgery be treated with potentially curative chemoradiation ( CTX-RT ) . This review was conducted as part of a larger systematic review of all first-line chemotherapy ( CTX ) and CTX-RT treatments for patients with locally advanced or metastatic NSCLC . However , it was considered that patients with potentially curable disease ( e.g. stage IIIA ) are different from those with advanced disease , who are suitable for palliative treatment only , and therefore the results should be reported separately . OBJECTIVE To evaluate the clinical effectiveness of first-line CTX in addition to radiotherapy ( RT ) ( CTX-RT vs CTX-RT ) for adult patients with locally advanced NSCLC who are suitable for potentially curative treatment . DATA SOURCES Three electronic data bases ( MEDLINE , EMBASE and The Cochrane Library ) were search ed from January 1990 to September 2010 . REVIEW METHODS Inclusion criteria comprised adult patients with locally advanced NSCLC , trials that compared any first-line CTX-RT therapy ( induction , sequential , concurrent and consolidation ) and outcomes of overall survival ( OS ) and /or progression-free survival ( PFS ) . The results of clinical data extraction and quality assessment were summarised in tables and with narrative description . Direct meta-analyses using OS data were undertaken where possible : sequential CTX-RT compared with concurrent CTX-RT ; sequential CTX-RT compared with concurrent/consolidation CTX-RT ; and sequential CTX-RT compared with concurrent CTX-RT with or without consolidation . There were not sufficient data to perform meta- analysis on PFS . RESULTS Of the 240 potentially relevant studies that were published post 2000 , 19 met the inclusion criteria and compared CTX-RT with CTX-RT . The results from the OS meta- analysis comparing sequential CTX-RT with concurrent CTX-RT appear to show an OS advantage for concurrent CTX-RT arms over sequential arms ; this result is not statistically significant [ hazard ratio ( HR ) 0.79 ; 95 % confidence interval ( CI ) 0.50 to 1.25 ) ] . The results from the OS meta- analysis comparing sequential CTX-RT with concurrent/consolidation CTX-RT appear to show a statistically significant OS advantage for concurrent/consolidation CTX-RT treatment over sequential treatment ( HR 0.68 ; 95 % CI 0.55 to 0.83 ) . The results from the OS meta- analysis comparing sequential CTX-RT with concurrent CTX-RT with or without consolidation appear to show a statistically significant OS advantage for concurrent CTX-RT with or without consolidation over sequential treatment ( HR 0.72 ; 95 % CI 0.61 to 0.84 ) . LIMITATIONS This report provides a summary and critical appraisal of a comprehensive evidence base of CTX-RT trials ; however , it is possible that additional trials have been reported since our last literature search . It is disappointing that the quality of the research in this area does not meet the accepted quality st and ards regarding trial design and reporting . CONCLUSIONS This review identified that the research conducted in the area of CTX-RT was generally of poor quality and suffered from a lack of reporting of all important clinical findings , including OS . The 19 trials included in the systematic review were too disparate to form any conclusions as to the effectiveness of individual CTX agents or types of RT . The focus of primary research should be good method ological quality ; appropriate allocation of concealment and r and omisation , and comprehensive reporting of key outcomes , will enable meaningful synthesis and conclusions to be drawn . FUNDING The National Institute for Health Research Health Technology Assessment programme PURPOSE This study aim ed to evaluate the safety , feasibility , and effects of an 8-wk combined resistance and endurance exercise program in patients with advanced non-small cell lung cancer ( NSCLC ) during in- and outpatient care . METHODS In this intervention study , 40 patients with predominantly advanced NSCLC receiving simultaneous or sequential radiochemotherapy or chemotherapy alone were enrolled . For a period of 8 wk , patients were instructed to exercise at least five times per week during the inpatient setting and at least three times per week in the outpatient setting . Physical performance status ( endurance capacity : 6-min walk test ; strength capacity : h and held dynamometry ) , quality -of-life ( Functional Assessment of Cancer Therapy-Lung ) , fatigue ( Multidimensional Fatigue Inventory ) , and depression ( Patient Health Question naire ) were assessed at baseline ( T0 ) , after the exercise intervention ( T1 ) , and at a follow-up time point 8 wk later ( T2 ) . The primary end point was adequate adherence ( feasibility ) defined as completing at least two training sessions per week during a minimum of 6 wk . RESULTS Of 40 patients , 31 ( 77.5 % ) completed the postexercise assessment ( T1 ) and 22 ( 55 % ) completed follow-up ( T2 ) . The stages were IIA ( 5 % ) , IIIA ( 8 % ) , IIIB ( 20 % ) , and IV ( 67 % ) , and the median age was 63 yr ( range = 22 - 75 yr ) . Overall , adherence was 82 % for those patients who completed T1 , and 55 % of the 40 participating patients fulfilled the adequate adherence criterion . Those who completed the intervention showed a significant improvement in the 6-min walk distance and in knee , elbow , and hip muscle strength after the intervention ( T1 ) . Quality of life , fatigue , and depression scores remained stable or declined slightly . Significant improvements in knee-muscle strength were also observed at T2 . CONCLUSIONS Exercise training is feasible in advanced and metastatic NSCLC patients during anticancer treatment . In this pilot study , endurance and strength capacity improved over time , indicating the rehabilitative importance of the applied intervention . To investigate the potential impact of exercise training in this patient group , a larger r and omized trial is warranted BACKGROUND Secondary to clinical outcome , health-related quality of life ( QOL ) after resection of non-small cell lung cancer ( NSCLC ) is of particular interest . However , few studies have explored QOL following lung resection . METHODS Between January 1998 and December 2004 , a total of 159 patients with NSCLC underwent surgical resection and were enrolled in this prospect i ve study . QOL and clinical data were assessed prior to resection and for up to 24 months after surgery by applying the European Organization for Research and Treatment of Cancer core question naire and the lung-specific question naire , the European Organization for Research and Treatment of Cancer lung-specific module . QOL was calculated , and QOL following bilobectomy/lobectomy was compared with QOL after pneumonectomy . RESULTS Overall , the 5-year survival rate was 42 % . Mean survival of the pneumonectomy group was slightly lower than that of the bilobectomy/lobectomy group , although the difference was not statistically significant ( p = 0.058 ) . The rate of complications was not significantly different between the two groups . After a postoperative drop , most QOL indicators remained near baseline for up to 24 months , with the exception of physical function ( p < 0.001 ) , pain ( p = 0.034 ) , and dyspnoea ( p < 0.001 ) , which remained significantly impaired . QOL was significantly better ( difference > 10 points ) after bilobectomy/lobectomy than after pneumonectomy . However , differences were statistically significant only with regards to physical function ( at 3 months ) , social function ( at 3 and 6 months ) , role function ( at 3 , 6 , and 12 months ) , global health ( at 3 and 6 months ) , and pain ( at 6 months ) . CONCLUSIONS Patients who underwent lung resection for NSCLC failed to make a complete recovery after 24 months . Patients who underwent pneumonectomy had significantly worse QOL values and a decreased tendency to recover , compared with patients who underwent bilobectomy/lobectomy . Therefore , major lung resection has a much more serious impact on the QOL of affected patients than does major visceral surgery PURPOSE To compare the quality -adjusted life expectancy and overall survival in patients with Stage I non-small-cell lung cancer ( NSCLC ) treated with either stereotactic body radiation therapy ( SBRT ) or surgery .  METHODS AND MATERIAL S We constructed a Markov model to describe health states after either SBRT or lobectomy for Stage I NSCLC for a 5-year time frame . We report various treatment strategy survival outcomes stratified by age , sex , and pack-year history of smoking , and compared these with an external outcome prediction tool ( Adjuvant ! Online ) . RESULTS Overall survival , cancer-specific survival , and other causes of death as predicted by our model correlated closely with those predicted by the external prediction tool . Overall survival at 5 years as predicted by baseline analysis of our model is in favor of surgery , with a benefit ranging from 2.2 % to 3.0 % for all cohorts . Mean quality -adjusted life expectancy ranged from 3.28 to 3.78 years after surgery and from 3.35 to 3.87 years for SBRT . The utility threshold for preferring SBRT over surgery was 0.90 . Outcomes were sensitive to quality of life , the proportion of local and regional recurrences treated with st and ard vs. palliative treatments , and the surgery- and SBRT-related mortalities . CONCLUSIONS The role of SBRT in the medically operable patient is yet to be defined . Our model indicates that SBRT may offer comparable overall survival and quality -adjusted life expectancy as compared with surgical resection . Well-powered prospect i ve studies comparing surgery vs. SBRT in early-stage lung cancer are warranted to further investigate the relative survival , quality of life , and cost characteristics of both treatment paradigms OBJECTIVE Surgery constitutes the mainstay of treatment in stage I non-small cell lung cancer ( NSCLC ) . However , a significant fraction of patients after surgical resection die mainly due to systemic relapse . Nonetheless , the best adjuvant treatment to improve survival and decrease relapse rate remains as an ever controversial issue . Therefore , we conducted a r and omized trial to determine whether postoperative adjuvant chemotherapy is beneficial in prolonging survival and decreasing recurrence in patients with completely resected stage I NSCLC . METHODS It was design ed as a r and omized , prospect i ve two-armed study with  surgery only ( control group , 59 patients ) versus surgery plus adjuvant MVP ( mitomycin C , vinblastin and cisplatin ) chemotherapy ( study group , 59 patients ) . RESULTS Data for all the patients were complete . Twenty-four patients in the control group and nine patients in the study group experienced tumor recurrence during the follow-up . Neither histological type nor surgical extent correlated with recurrence . However , the addition of adjuvant MVP chemotherapy could decrease the rate of recurrence and the incidence of cancer-related death after surgery in the patients of stage I NSCLC ( P<0.05 ) . We followed up at least 5 years , and the duration of mean follow-up was 7.3 years . The rates of the loco-regional and distant metastases were 3.4 and 40.7 % in the control group , and 3.4 and 11.9 % in the study group , respectively . The 5- and 10-year survival rates were 74.6 and 56.3 % in the control group , and 81.4 and 65.0 % in the study group , respectively ( P=0.19 , log-rank test ) . The 5- and 10-year disease-free survival rates were 64.8 and 54.8 % in the control group , and 88.8 and 76.8 % in the study group , respectively ( P=0.002 , log-rank test ) . CONCLUSIONS Our results suggest that the addition of adjuvant MVP chemotherapy may reduce the incidence of distant metastasis and prolong the disease-free survival of the patients with stage I NSCLC after surgery Background : Two prevalent unmet supportive care needs reported by the non – small cell lung cancer ( NSCLC ) population include the need to manage fatigue and attain adequate exercise to meet the physical dem and s of daily living . Yet , there are no guidelines for routine rehabilitative support to address fatigue and exercise for persons with NSCLC during the critical transition from hospital to home after thoracotomy . Objective : The objective of this study was to evaluate the feasibility , acceptability , safety , and changes in study end points of a home-based exercise intervention to enhance perceived self-efficacy for cancer-related fatigue ( CRF ) self-management for persons after thoracotomy for NSCLC transitioning from hospital to home . Interventions / Methods : Guided by the principles of the Transitional Care Model and the Theory of Symptom Self-management , a single-arm design composed of 7 participants with early-stage NSCLC performed light-intensity walking and balance exercises in a virtual reality environment with the Nintendo Wii Fit Plus . Exercise started the first week after hospitalization for thoracotomy and continued for 6 weeks . Results : The intervention positively impacted end points such as CRF severity ; perceived self-efficacy for fatigue self-management , walking , and balance ; CRF self-management behaviors ( walking and balance exercises ) ; and functional performance ( number of steps taken per day ) . Conclusions : A home-based , light-intensity exercise intervention for patients after thoracotomy for NSCLC is feasible , safe , well tolerated , and highly acceptable showing positive changes in CRF self-management . Implication s for Practice : Beginning evidence suggests that a light-intensity in-home walking and balance intervention after hospitalization for thoracotomy for NSCLC is a potentially effective rehabilitative CRF self-management intervention . Next steps include testing of this health-promoting self-management intervention in a larger-scale r and omized controlled trial Purpose Peak oxygen consumption ( VO2peak ) is an important predictive factor for long-term prognosis in patients with non-small cell lung cancer ( NSCLC ) . The purpose of this study was to investigate whether 8 weeks of exercise training improves exercise capacity , as assessed by VO2peak , and other related factors in patients with NSCLC receiving targeted therapy . Methods A total of 24 participants with adenocarcinoma were r and omly assigned to either the control group ( n = 11 ) or the exercise group ( n = 13 ) . Subjects in the exercise group participated in individualized , high-intensity aerobic interval training of exercise . The outcome measures assessed at baseline and after 8 weeks were as follows : VO2peak and the percentage of predicted VO2peak ( % predVO2peak ) , muscle strength and endurance of the right quadriceps , muscle oxygenation during exercise , insulin resistance as calculated by the homeostasis model , high-sensitivity C-reactive protein , and quality of life ( QoL ) question naire inventory . Results No exercise-related adverse events were reported . After exercise training , VO2peak and % predVO2peak increased by 1.6 mL kg−1 min−1 and 5.3 % ( p < 0.005 ) , respectively ; these changes were associated with improvements in circulatory , respiratory , and muscular functions at peak exercise ( all p = 0.001 ) . The exercise group also had less dyspnea ( p = 0.01 ) and favorably lower fatigue ( p = 0.05 ) than baseline . Conclusions Patients with NSCLC receiving targeted therapy have quite a low exercise capacity , even with a relatively high QoL. Exercise training appears to improve exercise capacity and alleviate some cancer-related symptoms OBJECTIVES Stage III non-small cell lung cancer ( NSCLC ) describes a heterogeneous population with disease presentation ranging from apparently resectable tumors with occult microscopic nodal metastases to unresectable , bulky nodal disease . This review up date s the published clinical trials since the last American College of Chest Physicians guidelines to make treatment recommendations for this controversial subset of patients . METHODS Systematic search es were conducted through MEDLINE , Embase , and the Cochrane Data base for Systematic Review up to December 2011 , focusing primarily on r and omized trials , selected meta-analyses , practice guidelines , and review s. RESULTS For individuals with stage IIIA or IIIB disease , good performance scores , and minimal weight loss , treatment with combined chemoradiotherapy results in better survival than radiotherapy alone . Consolidation chemotherapy or targeted therapy following definitive chemoradiation for stage IIIA is not supported . Neoadjuvant therapy followed by surgery is neither clearly better nor clearly worse than definitive chemoradiation . Most of the arguments made regarding patient selection for neoadjuvant therapy and surgical resection provide evidence for better prognosis but not for a beneficial impact of this treatment strategy ; however , weak comparative data suggest a possible role if only lobectomy is needed in a center with a low perioperative mortality rate . The evidence supports routine platinum-based adjuvant chemotherapy following complete resection of stage IIIA lung cancer encountered unexpectedly at surgery . Postoperative radiotherapy  improves local control without improving survival . CONCLUSIONS Multimodality therapy is preferable in most subsets of patients with stage III lung cancer . Variability in the patients included in r and omized trials limits the ability to combine results across studies and thus limits the strength of recommendations in many scenarios . Future trials are needed to investigate the roles of individualized chemotherapy , surgery in particular cohorts or setting s , prophylactic cranial radiation , and adaptive radiation
Preliminary work from this review suggests that exercise intervention compared with usual care both pre and post-surgery is associated with improved cardiopulmonary exercise capacity , increased muscle strength and reduced fatigue , post-operative complications and hospital length of stay .
BACKGROUND Surgery remains the best curative option for appropriately selected patients with lung cancer .
Evidence suggests that improving cardiovascular fitness and functional capacity can accelerate post-surgery recovery and reduce mortality .
However , the effect of exercise intervention for patients surgically treated for Non-Small Cell Lung Cancer [ NCSLC ] has not been fully examined .
PURPOSE This review examines the literature regarding exercise intervention for patients who are surgically treated for NSCLC focussing on three key areas : method ological quality , intervention design ( e.g. duration , frequency , type ) and outcomes measured .