Intensive rehab benefits lung cancer patients undergoing surgery

A rehabilitation programme comprising intensive perioperative pulmonary rehabilitation (PR) and standard of care (SC) led to improved exercise capacity and tolerance in individuals with early-stage non-small-cell lung cancer (NSCLC) who are undergoing lung resection, the PUREAIR trial suggests.

Patients may have impaired function and quality of life as well as overall deconditioning after lung resection. [J Clin Oncol 2008;26:233-241; Chest 2013;143:e166S-e190S] Old age and frailty may also factor in the recovery process. [J Geriatr Oncol 2015;6:38-45; Thorax 2004;59:602-607] To help patients improve their clinical and functional status prior to and after surgery, intensive perioperative PR – a comprehensive pre- and postop intervention comprising exercise training, education, and behavioural changes – is recommended. [Am J Respir Crit Care Med 2013;188:e13-e64; Chest 2018;154:986; Eur Respir J 2009;34:17-41]

A total of 140 participants (mean age 67 years, 61 percent male, 18 percent with chronic obstructive pulmonary disease) were randomized 1:1 to receive SC either alone or with intensive perioperative PR. [Eur J Phys Rehabil Med 2021;57:1002-1011]

SC comprised therapeutic educational sessions on admission (ie, counselling and self-care management, preparing patients for postop phase, highlighting breathing exercises, sputum clearance tech­niques, pain control strategies), plus daily early inpatient postop rehab (ie, breathing exercises) from day 1 following surgery until discharge.

Intensive perioperative PR included 14 preop sessions (outpatient and homebased), and 39 postop sessions (outpatient and homebased) a month following surgery which ran for 2 months (comprising aerobic and resistance training, Respiratory Muscle Training [RMT], scar massage, and group bodyweight exercise training). Following which, continuation of aerobic training and RMT until the 6-month follow-up was recommended.

Six months following surgery, walking distance significantly increased by 48.9 metres on average among patients in the PR arm, as opposed to a reduction by 7.5 metres observed among those who only received SC (difference, +56.4 metres; p<0.001).

“The primary outcome of our study … has been achieved … The [difference] is well over the minimal clinically important difference [of] 25 metres,” said the researchers. “This remarkable result … has been obtained despite a dropout rate that was higher than anticipated (40 percent observed vs 10 percent expected).”

There was also a minimal decrease in walking distance in the PR vs the SC arm at 1 month postop (–3.0 vs –30.1 metres). A comparison between arms also yielded a significant difference (+27.1 metres; p=0.025).

There were fewer complications in the PR vs the SC arm during the first few months following surgery (n=24 vs 41) and at 6 months (n=5 vs 9). There were also fewer adverse events in the PR vs the SC arm (n=30 vs 54).

“[Taken together, our study shows that] comprehensive PR improves exercise capacity at 1 and 6 months after surgery … [Our findings] highlight the importance of combined pre- and postop rehabilitation in reducing physical deconditioning in lung cancer patients undergoing surgery,” they said.

The researchers called for future trials to evaluate the effects of exercise training on other outcomes, as “cancer patients have several unmet needs, and rehab interventions should be part of a multidimensional approach offered by a multidisciplinary team.”

Services for patients with mobility issues and those living far from treatment centres should also be explored in future studies. These include telerehabilitation or remote evaluations and community physiotherapy services that can help facilitate rehab sessions for this patient subgroup.