Increasing Physical Activity and Exercise in Lung Cancer: Reviewing Safety, Benefits, and Application
2015; Elsevier BV; Volume: 10; Issue: 6 Linguagem: Inglês
10.1097/jto.0000000000000536
ISSN1556-1380
AutoresBrett C. Bade, D. David Thomas, JoAnn B. Scott, Gerard A. Silvestri,
Tópico(s)Nutrition and Health in Aging
ResumoLung cancer continues to be a difficult disease frequently diagnosed in late stages with a high mortality and symptom burden. In part because of frequent lung comorbidity, even lung cancer survivors often remain symptomatic and functionally limited. Though targeted therapy continues to increase treatment options for advanced-stage disease, symptom burden remains high with few therapeutic options. In the last several decades, exercise and physical activity have arisen as therapeutic options for obstructive lung disease and lung cancer. To date, exercise has been shown to reduce symptoms, increase exercise tolerance, improve quality of life, and potentially reduce length of stay and postoperative complications. Multiple small trials have been performed in perioperative non–small-cell lung cancer patients, although fewer studies are available for patients with advanced-stage disease. Despite the increased interest in this subject over the last few years, a validated exercise regimen has not been established for perioperative or advanced-stage disease. Clinicians underutilize exercise and pulmonary rehabilitation as a therapy, in part because of the lack of evidence-based consensus as to how and when to implement increasing physical activity. This review summarizes the existing evidence on exercise in lung cancer patients. Lung cancer continues to be a difficult disease frequently diagnosed in late stages with a high mortality and symptom burden. In part because of frequent lung comorbidity, even lung cancer survivors often remain symptomatic and functionally limited. Though targeted therapy continues to increase treatment options for advanced-stage disease, symptom burden remains high with few therapeutic options. In the last several decades, exercise and physical activity have arisen as therapeutic options for obstructive lung disease and lung cancer. To date, exercise has been shown to reduce symptoms, increase exercise tolerance, improve quality of life, and potentially reduce length of stay and postoperative complications. Multiple small trials have been performed in perioperative non–small-cell lung cancer patients, although fewer studies are available for patients with advanced-stage disease. Despite the increased interest in this subject over the last few years, a validated exercise regimen has not been established for perioperative or advanced-stage disease. Clinicians underutilize exercise and pulmonary rehabilitation as a therapy, in part because of the lack of evidence-based consensus as to how and when to implement increasing physical activity. This review summarizes the existing evidence on exercise in lung cancer patients. Lung cancer is the second most common cancer type, is the leading cause of cancer death, and is expected to comprise 13% of new cancer diagnoses (224,210 new cases) with 159,260 deaths in 2014.1The American Cancer Society Cancer Facts & Figures 2014. The American Cancer Society, 2014: 4-15Google Scholar Though improved understanding of cancer biology and targeted therapies is improving outcomes, 1-year and 5-year survival rates remain low at 43% and 17%, respectively.1The American Cancer Society Cancer Facts & Figures 2014. The American Cancer Society, 2014: 4-15Google Scholar Furthermore, lung cancer patients have high symptom burden including dyspnea, cough, fatigue, anxiety, depression, insomnia, and pain.2Thompson E Solà I Subirana M Non-invasive interventions for improving well-being and quality of life in patients with lung cancer—a systematic review of the evidence.Lung Cancer. 2005; 50: 163-176Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar,3Rochester CL Fairburn C Crouch RH Pulmonary rehabilitation for respiratory disorders other than chronic obstructive pulmonary disease.Clin Chest Med. 2014; 35: 369-389Abstract Full Text Full Text PDF PubMed Google Scholar Even lung cancer survivors more than 5 years from diagnosis experience quality of life (QoL) impairment in 35% of cases4Yang P Cheville AL Wampfler JA et al.Quality of life and symptom burden among long-term lung cancer survivors.J Thorac Oncol. 2012; 7: 64-70Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar and report lower physical and health scores compared with healthy patients.5Ostroff JS Krebs P Coups EJ et al.Health-related quality of life among early-stage, non-small cell, lung cancer survivors.Lung Cancer. 2011; 71: 103-108Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Interestingly, the patients who experience QoL improvement after therapy (15%) have no change in symptom burden, suggesting an adaptation to chronic symptoms.4Yang P Cheville AL Wampfler JA et al.Quality of life and symptom burden among long-term lung cancer survivors.J Thorac Oncol. 2012; 7: 64-70Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Lung cancer patients are in a uniquely difficult situation in that their disease, their comorbidities, and their treatment may all lead to worsened symptomatology.6Pujol JL Quantin X Chakra M Cardiorespiratory fitness in patients with advanced non-small cell lung cancer: why is this feature important to evaluate?.Can it be improved? J Thorac Oncol. 2009; 4: 565-567Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Chronic obstructive pulmonary disease (COPD) is present concomitantly in 73% of men and 53% of women with newly diagnosed primary lung cancer.7Loganathan RS Stover DE Shi W Venkatraman E Prevalence of COPD in women compared to men around the time of diagnosis of primary lung cancer.Chest. 2006; 129: 1305-1312Crossref PubMed Scopus (61) Google Scholar The diverse causes of activity limitation are listed by the 2013 American Thoracic Society/European Respiratory Society (ATS/ERS) statement on pulmonary rehabilitation (PR) and include ventilatory or gas exchange limitations, cardiac limitation, lower limb or respiratory muscle dysfunction, anxiety, depression, and poor motivation.8Spruit MA Singh SJ Garvey C ATS/ERS Task Force on Pulmonary Rehabilitation et al.An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation.Am J Respir Crit Care Med. 2013; 188: e13-e64Crossref PubMed Scopus (221) Google Scholar Chemotherapy-induced anemia, radiation-induced pneumonitis, and lung resection-related impairment are frequently seen and likely contribute to dyspnea and fatigue.6Pujol JL Quantin X Chakra M Cardiorespiratory fitness in patients with advanced non-small cell lung cancer: why is this feature important to evaluate?.Can it be improved? J Thorac Oncol. 2009; 4: 565-567Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,9Nezu K Kushibe K Tojo T Takahama M Kitamura S Recovery and limitation of exercise capacity after lung resection for lung cancer.Chest. 1998; 113: 1511-1516Crossref PubMed Google Scholar,10Feinstein MB Krebs P Coups EJ et al.Current dyspnea among long-term survivors of early-stage non-small cell lung cancer.J Thorac Oncol. 2010; 5: 1221-1226Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar With significant cancer burden and rising cancer costs (estimated $86.6 billion in 2009),1The American Cancer Society Cancer Facts & Figures 2014. The American Cancer Society, 2014: 4-15Google Scholar an inexpensive cancer therapy to relieve symptoms and improve QoL is appealing. Inactivity and low-exercise tolerance are increasingly recognized in chronically ill patients. Multiple studies show lower activity and daily step counts in COPD, peripheral vascular disease, and non–small-cell lung cancer (NSCLC).11Moy ML Janney AW Nguyen HQ et al.Use of pedometer and Internet-mediated walking program in patients with chronic obstructive pulmonary disease.J Rehabil Res Dev. 2010; 47: 485-496Crossref PubMed Scopus (18) Google Scholar, 12Ayabe M Brubaker PH Dobrosielski D et al.Target step count for the secondary prevention of cardiovascular disease.Circ J. 2008; 72: 299-303Crossref PubMed Scopus (26) Google Scholar, 13Richardson CR Mehari KS McIntyre LG et al.A randomized trial comparing structured and lifestyle goals in an internet-mediated walking program for people with type 2 diabetes.Int J Behav Nutr Phys Act. 2007; 4: 59Crossref PubMed Scopus (56) Google Scholar, 14Moy ML Danilack VA Weston NA Garshick E Daily step counts in a US cohort with COPD.Respir Med. 2012; 106: 962-969Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 15Granger CL Denehy L McDonald CF Irving L Clark RA Physical activity measured using global positioning system tracking in non-small cell lung cancer: an observational study.Integr Cancer Ther. 2014; 13: 482-492Crossref PubMed Scopus (3) Google Scholar In COPD, for example, physical inactivity is often seen during exacerbation and a predictor of poor outcome.16Ehsan M Khan R Wakefield D et al.A longitudinal study evaluating the effect of exacerbations on physical activity in patients with chronic obstructive pulmonary disease.Ann Am Thorac Soc. 2013; 10: 559-564Crossref PubMed Scopus (7) Google Scholar,17Waschki B Kirsten A Holz O et al.Physical activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study.Chest. 2011; 140: 331-342Crossref PubMed Scopus (191) Google Scholar The same pattern is seen in pulmonary hypertension, interstitial lung disease, and lung cancer.3Rochester CL Fairburn C Crouch RH Pulmonary rehabilitation for respiratory disorders other than chronic obstructive pulmonary disease.Clin Chest Med. 2014; 35: 369-389Abstract Full Text Full Text PDF PubMed Google Scholar,18Jones LW Hornsby WE Goetzinger A et al.Prognostic significance of functional capacity and exercise behavior in patients with metastatic non-small cell lung cancer.Lung Cancer. 2012; 76: 248-252Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Adding to their burden, functional capacity significantly declines after lung cancer diagnosis.19Douglas E Exercise in cancer patients.Phys Therapy Rev. 2005; 10: 71-88Crossref Google Scholar,20Hummler S Thomas M Hoffmann B et al.Physical performance and psychosocial status in lung cancer patients: results from a pilot study.Oncol Res Treat. 2014; 37: 36-41Crossref Scopus (1) Google Scholar In a recent longitudinal trial, 36% of lung cancer patients (all stages) were noted to reduce or stop walking exercise over the course of 6 months.21Lin YY Liu MF Tzeng JI et al.Effects of walking on quality of life among lung cancer patients: a longitudinal study.Cancer Nurs. 2014; Google Scholar The term "dyspnea spiral" has been utilized to describe the development of dyspnea, activity avoidance to prevent further dyspnea, and resultant further loss of function. Some estimates suggest up to 1 of 3 of loss in functional capacity in cancer patients is because of prolonged physical inactivity.19Douglas E Exercise in cancer patients.Phys Therapy Rev. 2005; 10: 71-88Crossref Google Scholar Historically, providers and caring family members have contributed to physical inactivity by recommending rest to reduce symptom burden, leading to further deconditioning.22Schwartz AL Fatigue mediates the effects of exercise on quality of life.Qual Life Res. 1999; 8: 529-538Crossref PubMed Scopus (108) Google Scholar Lung cancer patients with lower exercise tolerance have worse surgical outcomes, chemotherapy response and tolerance, and survival.3Rochester CL Fairburn C Crouch RH Pulmonary rehabilitation for respiratory disorders other than chronic obstructive pulmonary disease.Clin Chest Med. 2014; 35: 369-389Abstract Full Text Full Text PDF PubMed Google Scholar In the last 20 years, increasing physical activity has shown great promise for cancer and chronic lung disease therapy. Because of the significant overlap between lung cancer and chronic lung disease (namely COPD), lung cancer patients may benefit from physical activity more than other cancer patients. Indeed, exercise therapy represents a low-cost way to improve symptoms and potentially outcomes in lung cancer. Given the potential benefit of exercise in this population coupled with the lack of clear recommendations for clinicians providing care, we will review the literature to date on exercise, physical activity, and lung cancer. Before summarizing the literature, a distinction between "physical activity" and "exercise" should be made. Caspersen et al.23Caspersen CJ Powell KE Christenson GM Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research.Public Health Rep. 1985; 100: 126-131PubMed Google Scholar defined and distinguished these terms previously. They described physical activity as "a bodily movement by skeletal muscles that results in energy expenditure." Exercise is physical activity that is planned, structured, and repetitive with the goal to obtain or maintain physical fitness.23Caspersen CJ Powell KE Christenson GM Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research.Public Health Rep. 1985; 100: 126-131PubMed Google Scholar This review's goal is to summarize the effect of increased physical activity on lung cancer outcomes. As such, studies utilizing increased physical activity, exercise regimens, or PR are often compared side-by-side. Although the methods differ in application, lung cancer patients likely benefit through increased overall physical activity rather than the regimen itself. As the reader will see, compliance is an often cited challenge in patients with chronic lung disease, and the regimen that maximizes compliance may be the most effective. Indeed, utilizing an exercise regimen or rehabilitation may have more or less benefit than simply increasing physical activity. However, these two regimens have not yet been directly compared. As such, this review will consider physical activity, exercise regimens, and PR as methods to increase physical fitness that may improve cancer outcomes. The existing literature lacks a review that includes the progression of exercise's benefit in cancer and lung disease, evaluation of both medically and surgically treated lung cancer patients, and the growing interest of pedometer/accelerometer studies in patients with exercise limitation. To address these issues cohesively, PubMed was searched for the terms "physical activity," "exercise," "lung cancer," "pedometer," and "step counts." Resulting articles were individually reviewed by B.C.B. for their applicability to the topic and included as referenced to create this narrative review. Additional articles outside the searched terms were included to appropriately summarize the existing literature or provide sufficient topical background. Growing evidence supports activity's benefit in primary and secondary cancer prevention. Much of this work has been done in colon and breast cancer. In 2009–2010, several large trials showed that cardiorespiratory fitness was associated with reduced breast cancer mortality, reduced risk of colon (and overall) cancer development, and reduced mortality with gastrointestinal cancers.24Peel JB Sui X Adams SA Hébert JR Hardin JW Blair SN A prospective study of cardiorespiratory fitness and breast cancer mortality.Med Sci Sports Exerc. 2009; 41: 742-748Crossref PubMed Scopus (20) Google Scholar, 25Peel JB Sui X Matthews CE et al.Cardiorespiratory fitness and digestive cancer mortality: findings from the aerobics center longitudinal study.Cancer Epidemiol Biomarkers Prev. 2009; 18: 1111-1117Crossref PubMed Scopus (0) Google Scholar, 26Laukkanen JA Pukkala E Rauramaa R Mäkikallio TH Toriola AT Kurl S Cardiorespiratory fitness, lifestyle factors and cancer risk and mortality in Finnish men.Eur J Cancer. 2010; 46: 355-363Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Reduced lung cancer incidence with higher activity was confirmed in a 2013 review.27Koutsokera A Kiagia M Saif MW Souliotis K Syrigos KN Nutrition habits, physical activity, and lung cancer: an authoritative review.Clin Lung Cancer. 2013; 14: 342-350Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In fact, physical activity reduces risk of cancer development in multiple cancer types (colon, breast, prostate, pancreatic, endometrial, ovarian, and lung).28Brown JC Winters-Stone K Lee A Schmitz KH Cancer, physical activity, and exercise.Compr Physiol. 2012; 2: 2775-2809PubMed Google Scholar In many cancer types, increased physical activity is also associated with reduced cancer-associated mortality. Large trials in Taiwan (n = 416,175 patients followed for ~8 years) and by the National Institutes of Health (NIH) (n = 293,511) showed exercise's association with reduced all-cause mortality,29Wen CP Wai JP Tsai MK et al.Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study.Lancet. 2011; 378: 1244-1253Abstract Full Text Full Text PDF PubMed Scopus (307) Google Scholar and that self-reported moderately vigorous physical activity led to lower risk of all-cause and cancer-specific mortality (colon, liver, and lung), respectively.30Arem H Moore SC Park Y et al.Physical activity and cancer-specific mortality in the NIH-AARP diet and health study cohort.Int J Cancer. 2014; 135: 423-431Crossref PubMed Google Scholar Multiple trials have also shown reduced symptom burden with increased activity. Specifically, exercise can also be used as an adjunctive therapy for cancer-related symptom relief during and after cancer treatment.28Brown JC Winters-Stone K Lee A Schmitz KH Cancer, physical activity, and exercise.Compr Physiol. 2012; 2: 2775-2809PubMed Google Scholar In a randomized, controlled trial (RCT), Segal et al.31Segal R Evans W Johnson D et al.Structured exercise improves physical functioning in women with stages I and II breast cancer: results of a randomized controlled trial.J Clin Oncol. 2001; 19: 657-665PubMed Google Scholar showed that breast cancer patients not receiving chemotherapy increased their subjective physical functioning with an exercise regimen. Interestingly, the patients who directed their own regimen appeared to have equal or better improvements. In 2005, Douglas19Douglas E Exercise in cancer patients.Phys Therapy Rev. 2005; 10: 71-88Crossref Google Scholar reviewed breast and metastatic tumors, noting that exercise benefited functional capacity, strength, hospital stay, QoL, energy, and fatigue. In hospitalized patients receiving myeloablative chemotherapy, one study found benefit symptom control, cognitive function, and psychosocial function during therapy.32Oechsle K Aslan Z Suesse Y Jensen W Bokemeyer C de Wit M Multimodal exercise training during myeloablative chemotherapy: a prospective randomized pilot trial.Support Care Cancer. 2014; 22: 63-69Crossref PubMed Scopus (8) Google Scholar A systematic Cochrane review in 2012 focused on exercise intervention and QoL in cancer patients receiving or planning active treatment. Fifty-six trials were included (4826 patients) and concluded that exercise interventions may have beneficial effects on QoL, physical function, social function, and fatigue.33Mishra SI Scherer RW Snyder C Geigle PM Berlanstein DR Topaloglu O Exercise interventions on health-related quality of life for people with cancer during active treatment.Cochrane Database Syst Rev. 2012; 8 (CD008465)Google Scholar The effects were more noticeable with the moderate and vigorous intensity programs. Some clinicians have recommended limited activity in cancer patients ostensibly to avoid worsening symptoms. To be sure, lung cancer patients limit activity to avoid the "dyspnea spiral." Similarly, supporting families often limit activity in the cancer patient to prevent acute symptoms. Before advocating more activity, the safety of increasing physical activity in lung cancer patients needs to be established. Research regarding the feasibility and safety of exercise perioperatively (see Table 1),34Granger CL Chao C McDonald CF Berney S Denehy L Safety and feasibility of an exercise intervention for patients following lung resection: a pilot randomized controlled trial.Integr Cancer Ther. 2013; 12: 213-224Crossref PubMed Scopus (6) Google Scholar,35Bradley A Marshall A Stonehewer L et al.Pulmonary rehabilitation programme for patients undergoing curative lung cancer surgery.Eur J Cardiothorac Surg. 2013; 44: e266-e271Crossref PubMed Scopus (0) Google Scholar in advanced NSCLC (see Tables 2 and 3),36Payne C Larkin PJ McIlfatrick S Dunwoody L Gracey JH Exercise and nutrition interventions in advanced lung cancer: a systematic review.Curr Oncol. 2013; 20: e321-e337Crossref PubMed Scopus (7) Google Scholar and in advanced-stage lung cancer undergoing chemotherapy37Quist M Rørth M Langer S et al.Safety and feasibility of a combined exercise intervention for inoperable lung cancer patients undergoing chemotherapy: a pilot study.Lung Cancer. 2012; 75: 203-208Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar has been performed and is reviewed here.TABLE 1Surgical Studies (n = 22)AuthorPatientsRegimenNResultSekine et al.68Sekine Y Chiyo M Iwata T et al.Perioperative rehabilitation and physiotherapy for lung cancer patients with chronic obstructive pulmonary disease.Jpn J Thorac Cardiovasc Surg. 2005; 53: 237-243Crossref PubMed Google ScholarNSCLC with COPD undergoing lobectomyPreoperative-PR (2 weeks) with postoperative CPT22FEV1 preservation, shorter LoS, fewer pulmonary complicationsSpruit et al.50Spruit MA Janssen PP Willemsen SC Hochstenbag MM Wouters EF Exercise capacity before and after an 8-week multidisciplinary inpatient rehabilitation program in lung cancer patients: a pilot study.Lung Cancer. 2006; 52: 257-260Abstract Full Text Full Text PDF PubMed Scopus (105) Google ScholarNSCLC and SCLC pts after treatment (9 surgeries; 1 chemoradiation)Posttreatment PR (8 weeks; inpatient)10Improved 6MWD and cycle ergometryCesario et al.51Cesario A Ferri L Galetta D et al.Pre-operative pulmonary rehabilitation and surgery for lung cancer.Lung Cancer. 2007; 57: 118-119Abstract Full Text Full Text PDF PubMed Scopus (70) Google ScholarLung cancer, preoperativePreoperative-PR (4 weeks)8Improved operabilityJones et al.54Jones LW Peddle CJ Eves ND et al.Effects of presurgical exercise training on cardiorespiratory fitness among patients undergoing thoracic surgery for malignant lung lesions.Cancer. 2007; 110: 590-598Crossref PubMed Scopus (136) Google ScholarSuspected stages I–IIIA NSCLCPreoperative cycle ergometry for 5 sessions20Improved 6MWD and VO2Bobbio et al.66Bobbio A Chetta A Ampollini L et al.Preoperative pulmonary rehabilitation in patients undergoing lung resection for non-small cell lung cancer.Eur J Cardiothorac Surg. 2008; 33: 95-98Crossref PubMed Scopus (102) Google ScholarNSCLC (stage I or II), COPD, and VO2 15 ml/kg/minPehlivan et al.56Pehlivan E Turna A Gurses A Gurses HN The effects of preoperative short-term intense physical therapy in lung cancer patients: a randomized controlled trial.Ann Thorac Cardiovasc Surg. 2011; 17: 461-468Crossref PubMed Scopus (14) Google ScholarNSCLC (stages I–IIIB)Preoperative physical therapy60Improved LOS, SaO2, exercise capacity, V/Q distributionArbane et al.57Arbane G Tropman D Jackson D Garrod R Evaluation of an early exercise intervention after thoracotomy for non-small cell lung cancer (NSCLC), effects on quality of life, muscle strength and exercise tolerance: randomised controlled trial.Lung Cancer. 2011; 71: 229-234Abstract Full Text Full Text PDF PubMed Scopus (45) Google ScholarNSCLC referred for VATSPostoperative exercise regimen (12 weeks, inpatient and outpatient)53No change in QoL or 6MWD. Reduction in quadriceps strength lossBenzo et al.69Benzo R Wigle D Novotny P et al.Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies.Lung Cancer. 2011; 74: 441-445Abstract Full Text Full Text PDF PubMed Scopus (35) Google ScholarLung cancer and moderate/severe COPDPreoperative-PR (10 sessions)194 weeks of preoperative-PR difficult to implement; shorter chest tube times and nonsignificant reduced LOSGranger et al.34Granger CL Chao C McDonald CF Berney S Denehy L Safety and feasibility of an exercise intervention for patients following lung resection: a pilot randomized controlled trial.Integr Cancer Ther. 2013; 12: 213-224Crossref PubMed Scopus (6) Google ScholarAdults undergoing lung resection for suspected lung cancerPostoperative, twice daily sessions as inpatient and twice weekly sessions as outpatient (8 weeks)15 (LC 10)Exercise was safe and feasible. 57% of patients participated outpatient therapyDivisi et al.52Divisi D Di Francesco C Di Leonardo G Crisci R Preoperative pulmonary rehabilitation in patients with lung cancer and chronic obstructive pulmonary disease.Eur J Cardiothorac Surg. 2013; 43: 293-296Crossref PubMed Scopus (11) Google ScholarNSCLC (stage I) and COPDPreoperative-PR (4 weeks)27Improved PaO2, VO2, and FEV1. Reduced inoperabilityStigt et al.60Stigt JA Uil SM van Riesen SJ et al.A randomized controlled trial of postthoracotomy pulmonary rehabilitation in patients with resectable lung cancer.J Thorac Oncol. 2013; 8: 214-221Abstract Full Text Full Text PDF PubMed Scopus (12) Google ScholarNSCLC, resectablePostoperative-PR (twice/week for 12 weeks)49No change in QoL. Exercise tolerance improved. More reported pain and limitationsCoats et al.87Coats V Maltais F Simard S et al.Feasibility and effectiveness of a home-based exercise training program before lung resection surgery.Can Respir J. 2013; 20: e10-e16PubMed Google ScholarNSCLC before resectionPreoperative, home-based exercise regimen (exercise 3×/week for 4 weeks)16Improved exercise tolerance and muscle strengthSterzi et al.59Sterzi S Cesario A Cusumano G et al.Post-operative rehabilitation for surgically resected non-small cell lung cancer patients: serial pulmonary functional analysis.J Rehabil Med. 2013; 45: 911-915Crossref PubMed Scopus (3) Google ScholarNSCLC undergoing resectionPostoperative PR, inpatient for 3weeks110Improved exercise tolerance (through 6MWT)Stefanelli et al.67Stefanelli F Meoli I Cobuccio R et al.High-intensity training and cardiopulmonary exercise testing in patients with chronic obstructive pulmonary disease and non-small-cell lung cancer undergoing lobectomy.Eur J Cardiothorac Surg. 2013; 44: e260-e265Crossref PubMed Scopus (5) Google ScholarNSCLC (stages I and II) and COPDPreoperative-PR (3 weeks)40Improved VO2 and maintained after surgeryHoffman et al.86Hoffman AJ Brintnall RA Brown JK et al.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.Cancer Nurs. 2013; 36: 175-188Crossref PubMed Scopus (8) Google ScholarNSCLC undergoing thoracotomy (stages I–IIIA)Light intensity walking and balance (Wii; Nintendo, Redmond, WA) for 6 weeks7Feasible. Improved cancer-related fatigue, walking, balance, and # steps/day)Bradley et al.35Bradley A Marshall A Stonehewer L et al.Pulmonary rehabilitation programme for patients undergoing curative lung cancer surgery.Eur J Cardiothorac Surg. 2013; 44: e266-e271Crossref PubMed Scopus (0) Google ScholarPresumed lung cancer undergoing curative surgeryPreoperative and postoperative rehabilitation program, multidisciplinary58Feasible. Improvement in 6MWD and FEV1 (Preoperative portion). 54% quit smokingMorano et al.55Morano MT Mesquita R Da Silva GP et al.Comparison of the effects of pulmonary rehabilitation with chest physical therapy on the levels of fibrinogen and albumin in patients with lung cancer awaiting lung resection: a randomized clinical trial.BMC Pulm Med. 2014; 14: 121Crossref PubMed Scopus (1) Google ScholarNSCLC undergoing resection and abnormal spirometryPreoperative-PR (4 weeks)24Preoperative-PR reduced fibrinogen and improved functionality and QoLBrocki et al.89Brocki BC Andreasen J Nielsen LR Nekrasas V Gorst-Rasmussen A Westerdahl E Short and long-term effects of supervised versus unsupervised exercise training on health-related quality of life and functional outcomes following lung cancer surgery—a randomized controlled trial.Lung Cancer. 2014; 83: 102-108Abstract Full Text Full Text PDF PubMed Google ScholarLung cancer patients after chest surgeryOutpatient weekly sessions for 10weeks78No QoL or symptom benefit after 1 year (pain benefit at 4 months)Arbane et al.58Arbane G Douiri A Hart N et al.Effect of postoperative physical training on activity after curative surgery for non-small cell lung cancer: a multicentre randomised controlled trial.Physiotherapy. 2014; 100: 100-107Abstract Full Text Full Text PDF PubMed Google ScholarNSCLC undergoing resectionPostoperative inpatient exercise (for 4 weeks) and recommended outpatient regimen131No change in physical activity, strength, or QoL. If airflow obstruction, QoL improvementChang et al.80Chang NW Lin KC Lee SC Chan JY Lee YH Wang KY Effects of an early postoperative walking exercise programme on health status in lung cancer patients recovering from lung lobectomy.J Clin Nurs. 2014; 23: 3391-3402Crossref PubMed Scopus (3) Google ScholarNSCLC undergoing lobectomyPostoperative walking (12 weeks)66Improved FEV1, FVC, and 6MWTHoffman et al.79Hoffman AJ Brintnall RA von Eye A et al.Home-based exercise: promising rehabilitation for symptom relief, improved functional status and quality of life for post-surgical lung cancer patients.J Thorac Dis. 2014; 6: 632-640PubMed Google ScholarNSCLC undergoing thoracotomy and chemotherapyWalking and balance exercises (Wii) for 16 weeks5Trends toward symptom, functionality, and QoL improvementMujovic et al.70Mujovic N Mujovic N Subotic D et al.Preoperative pulmonary rehabilitation in patients with non-small cell lung cancer and chron
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